Citation Nr: 21040387 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 16-53 049 DATE: July 3, 2021 REMANDED Entitlement to service connection for a left wrist disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2001 to July 2013. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned in March 2019. In January 2020, the Board remanded these claims for additional development. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). 1. Entitlement to service connection for a left wrist disorder is remanded. The Veteran seeks service connection for a left wrist disorder. In January 2020, the Board remanded this claim so that a VA examination could be provided. A VA wrist conditions examination was completed in January 2021. At that time, the Veteran reported bilateral wrist pain and x-ray images confirmed a diagnosis of bilateral wrist arthritis. The VA examiner noted the Veteran's wrist condition was onset in 2005. He observed the Veteran experienced a right wrist injury while doing physical training and his left wrist pain was more recently onset. The examiner did not state when the Veteran initially experienced left wrist symptomatology. He opined the left wrist arthritis was less likely than not causally related to the Veteran's active service because no left wrist complaints were included in the service treatment records. This examination report does not fully describe the onset and history of the Veteran's left wrist arthritis and symptoms. Moreover, it appears the examiner may have dismissed reports of in-service left wrist pain because they were not documented in contemporaneous medical records. The examination report and etiology opinion are inadequate to evaluate the claim. See Stefl, supra; see also Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). 2. Entitlement to service connection for a left shoulder disorder is remanded. The Veteran seeks service connection for a left shoulder disability. In January 2020, the Board noted October 2012 and March 2014 VA shoulder examinations were inadequate to evaluate the claim. The Board remanded this claim so that an additional VA examination could be provided. A new VA shoulder conditions examination was completed in January 2021. The examiner did not diagnose any left shoulder condition and he did not identify any left shoulder functional impairment. He opined a left shoulder disorder was less likely than not related to the Veteran's active service because "[n]o medical records could be found of left shoulder pain complaints" and there was no current report of left shoulder functional loss. The Board notes February 2018 VA treatment records include a note to schedule an evaluation of bilateral shoulder pain. Thus, it appears the examiner may not have considered whether a left shoulder disability or functional loss was present at any time over the appeal period. The examination report is inadequate to evaluate the claim. See Stefl, supra. In addition, the examiner may have impermissibly dismissed the Veteran's reports of left shoulder symptoms solely because they were not supported by contemporaneous medical records. See Dalton supra. Additionally, the Veteran's form DD 214 reflects service in Iraq and Kuwait. He is a Persian Gulf veteran. Service connection may be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A "qualifying chronic disability" for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). Accordingly, if a left shoulder condition is not diagnosed or if left shoulder functional loss is not attributed to the Veteran's active service, an additional examination must be provided to evaluated whether the Veteran's left shoulder condition is a chronic disability resulting from an undiagnosed illness. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for left wrist arthritis. The examiner must review the claims file. The examiner should also obtain information from the Veteran as to the onset of his left wrist symptoms. The examiner is asked to provide a response to the following: Is left wrist arthritis at least as likely as not related to the Veteran's active service, including any reports of left wrist pain during active service? Is it at least as likely as not that the left wrist arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? A complete rationale must be provided for all opinions expressed. The examiner is advised that the Veteran is competent to report his experience of pain or other observable symptomatology. If the examiner dismisses any reported pain (or other observable symptomatology), a complete rationale for doing so must be provided. The absence of contemporaneous medical records, without additional rationale, is insufficient to support dismissing the Veteran's lay reports of observable symptomatology. 2. Schedule the Veteran for an appropriate examination to determine the nature and etiology of his left shoulder condition. The examiner must review the entire claims file, including a copy of this remand. The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if possible The examiner should also obtain information from the Veteran as to the onset of his left shoulder symptoms. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. Is the left shoulder functional loss at least as likely as not related to service, including any reports of left shoulder pain during active service? If left shoulder arthritis is diagnosed, is it at least as likely as not that the arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? A complete rationale must be provided for all opinions expressed. The examiner is advised that the Veteran is competent to report his experience of pain or other observable symptomatology. If the examiner dismisses any reported pain (or other observable symptomatology), a complete rationale for doing so must be provided. The absence of contemporaneous medical records, without additional rationale, is insufficient to support dismissing the Veteran's lay repots of observable symptomatology. If a positive etiology opinion is not offered for a left shoulder condition or functional loss after the analysis required above, the examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. (Continued on the next page) C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Celtnieks, Jeanne 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.