Citation Nr: 21040318 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 18-01 565 DATE: July 3, 2021 ORDER Entitlement to service connection for right shoulder rotator cuff tendonitis, rotator cuff tear, and impingement syndrome is granted. Entitlement to service connection for low back degenerative disc disease with bilateral lower extremity radiculopathy is granted. FINDINGS OF FACT 1. The Veteran's right shoulder rotator cuff tendonitis, rotator cuff tear, and impingement syndrome are related to an injury incurred during active service. 2. The Veteran's low back degenerative disc disease with bilateral lower extremity radiculopathy is related to an injury incurred during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for right shoulder rotator cuff tendonitis, rotator cuff tear, and impingement syndrome are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for low back degenerative disc disease with bilateral lower extremity radiculopathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1977 to September 1979. The Veteran testified at a March 2021 hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. Service Connection 1. Entitlement to service connection for right shoulder rotator cuff tendonitis, rotator cuff tear, and impingement syndrome is granted. 2. Entitlement to service connection for low back degenerative disc disease with bilateral lower extremity radiculopathy is granted. The Veteran asserts that his right shoulder disorder and low back disorder with radiculopathy are the result of a fall during service. Board Hearing Transcript (T.) at 3-5. The Board concludes that the Veteran has a current diagnosis of a right shoulder disorder and a low back disorder with radiculopathy that is related to an in-service injury or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). In a March 1977 service treatment record (STR), the Veteran received emergency treatment for a splinter in the right arm and leg as a result of being a field wireman and pole climbing. The medical provider treated the Veteran with splinter removal, four sutures, and dressing the injury. In a June 1978 STR, the Veteran received follow-up treatment for the right shoulder. The medical provider observed the Veteran to have mild edema in the trapezius of the right shoulder. The medical provider assessed the Veteran to have a right shoulder contusion and prescribed the use of a sling and no use of the right arm for five days. On the November 2016 private shoulder disability benefit questionnaire (DBQ), the medical provider indicated the Veteran has diagnoses of right shoulder impingement syndrome, right shoulder rotator cuff tendonitis, and right rotator cuff tear. The Veteran stated in 1977 he fell from a telephone pole onto his right shoulder during service. He stated currently experiences pain daily. The medical provider, Dr. R.M., opined that the Veteran's right shoulder disorder is due to military service. Dr. R.M. reasoned that the Veteran fell 18 feet from a pole and there is record showing that large splinters were removed, and the Veteran was placed in a sling. Dr. R.M. stated that this fall was enough to initiate degeneration in the right shoulder and back. On the November 2016 private back DBQ, the medical provider indicated the Veteran has degenerative disc disease, facet joint arthropathy, right leg sciatica, and bilateral lower extremity radiculopathy. The Veteran again reported the 1977 in-service fall. He stated he currently experience severe pain every day. Dr. R.M. opined that the Veteran's low back disorder is caused by service. Dr. R.M. reasoned that that the 1977 fall initiated the Veteran's low back degeneration and thoracic scoliosis. On the March 2017 VA shoulder examination, the examiner found the Veteran to have right shoulder subacromial/subdeltoid bursitis. The examiner opined that the Veteran's right shoulder disorder is less likely than not caused by service. The examiner reasoned that the Veteran is shown to have only an acute injury to the right shoulder upper trapezius area in service. The examiner stated there is no indication the Veteran had chronic or recurrent problems with the right shoulder in service and that the presentation today is different from that in 1978. In an April 2021 statement, fellow service member R.T. stated that in 1977 he was stationed with the Veteran. He observed the Veteran at that time to be bandaged on his arms and legs and walking with crutches. R.T. stated the Veteran told him he fell from a telephone pole to the ground. In an April 2021 private medical opinion, Dr. M.B.S. opined that the Veteran's right shoulder rotator cuff tendonitis, rotator cuff tear, and impingement syndrome disorder and his low back disorder with radiculopathy are more likely than not caused by an in-service fall. Dr. M.B.S. reasoned that in 1977 the Veteran fell from a wooden pole and injured his shoulder, back, and had large splinters removed. The STRs demonstrate that the Veteran received emergency care and follow-up care in 1978, where he was still observed to have edema. The Veteran stated he treated his pain with over-the-counter mediation and other self-treatment. Dr. M.B.S. found the Veteran's assertions to be consistent with the medical records and experience with similar orthopedic patients. Dr. M.B.S. stated that significant research has been done to substantiate that vertical compression injures result in significant trauma to the body and it is well-settled medical principle that the simple act of jumping or falling, or any downward deviation from any height, can result in vertebral compression. Further, Dr. M.B.S. found that current medical literature supports that degeneration occurs anywhere from two to 20 years post trauma. Dr. M.B.S. concluded that as the Veteran has been diagnosed with significant degenerative conditions of the low back and right shoulder and his medical records are devoid of any degenerative conditions in other parts of the body, and there is a report of ongoing pain and discomfort in the same area of injury, it is at least as likely as not that the Veteran's degenerative right shoulder disorder and low back disorder are a direct result of the in-service injury. The Board finds that the March 2017 VA shoulder opinion is less probative as the examiner did not address the 1978 STR showing follow-up treatment to the shoulder with findings of continued edema and the need for a sling. This demonstrates ongoing treatment for the 1977 fall. Further, the examiner did not address the Veteran's continuing complaints of shoulder pain after the fall. Therefore, the Board finds that this opinion is less probative. The Board finds that the April 2021 private medical opinion to be more persuasive as the medical provider reviewed the claims file, the Veteran's statements, and medical literature in the opinion. Therefore, the Board finds this opinion to be more persuasive. Based on the Veteran's assertion, R.T.'s lay statement, STRs demonstrating injury, examination, and the April 2021 private medical opinion, the Board finds that the Veteran's right shoulder disorder and low back degenerative disc disease with bilateral lower extremity radiculopathy was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Therefore, service connection for right shoulder rotator cuff tendonitis, rotator cuff tear, and impingement syndrome and for low back degenerative disc disease with bilateral lower extremity radiculopathy is warranted. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thompson, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.