Citation Nr: 21040995 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 19-00 497A DATE: July 7, 2021 REMANDED Entitlement to service connection for a left shoulder condition is remanded. Entitlement to service connection for a lumbosacral and thoracic sprain is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1977 to November 1987. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from an August 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2020, the Board issued a decision denying service connection for a left shoulder condition and a lumbosacral and thoracic sprain. The Veteran appealed the matter to the Court of Appeals for Veterans Claims (Court), which partially vacated the May 2020 Board decision, pursuant to a February 2021 Joint Motion for Partial Remand (JMPR). The Court remanded the matter for action consistent with the terms of the JMPR. The Board notes that the May 2020 decision also remanded the issues of entitlement to service connection for tension headaches and an increased evaluation for right shoulder rotator cuff tendonitis. In a November 2020 rating decision, the RO granted service connection for tension headaches, constituting a full grant of the Veteran's claim. In November 2020, the RO issued a Supplemental Statement of the Case (SSOC) denying an increased evaluation for the Veteran's right shoulder rotator cuff tendonitis. After the November 2020 SSOC, the Veteran's attorney filed a request for higher level review, requesting that the claim be considered under the Appeals Modernization Act (AMA). Accordingly, the Veteran's claim for an increased evaluation for right shoulder rotator cuff tendonitis will be considered under the AMA and therefore is not ripe for Board adjudication at this juncture. In the February 2021 JMPR, the parties agreed that the Board erred in failing to provide adequate reasons and bases for its decision and failing to ensure that VA met its duty to assist in providing the Veteran with adequate examinations. 1. Entitlement to service connection for a left shoulder condition is remanded. In a February 1986 treatment record, the Veteran complained that he experienced left shoulder pain for four months. See STR Medical, p. 21. In July 2017, a VA examiner issued an opinion regarding the Veteran's left shoulder condition. The examiner found that the Veteran's left shoulder symptoms onset in 1987 and noted the Veteran's contention that the condition began due to "wear and tear of doing push-ups." See Nov. 2017 Statement in Support of Claim. The examiner further stated that the Veteran's complaint of shoulder pain in 1986 did not include an examination or diagnosis and the examiner highlighted the lack of evidence or treatment for a left shoulder condition in service or following separation. The examiner noted the Veteran's complaints of four months of shoulder pain in service but noted the complaints as "a single encounter" and failed to address the history of symptoms. The examiner opined that it was less likely than not that the Veteran's left shoulder condition was incurred in or caused by service. However, the parties agreed that a new examination was warranted in order to address the Veteran's lay statements regarding his left shoulder condition. 2. Entitlement to service connection for a lumbosacral and thoracic sprain is remanded. The Veteran first complained of back pain in April 1983 and noted that it began four to five days prior. See STR Medical, p. 59. In September 2016, he reported back pain during a medical consult and further explained that he marched four to five miles per day with approximately 55 to 70 pounds in his duffle bag. See Jul. 2020 CAPRI, pp. 157-158. In July 2017, a VA examiner also issued an opinion regarding the Veteran's lumbosacral and thoracic sprain. The examiner found that the condition onset in 1977 and noted the Veteran's contention that the condition was a result of service-related physical training in military gear. See Nov. 2017 Statement in Support of Claim. The examiner further stated that the Veteran's service treatment records were silent for low back pain, except for the April 1983 record noted above. The examiner ultimately opined that it was less likely than not that the Veteran's back condition was incurred in or caused by his active duty service. Regarding rationale, the examiner stated that "given the time interval between the initial injury and subsequent complaint, there is insufficient evidence to connect his current back condition to his claimed in-service injury." The parties agreed that the July 2017 back opinion was inadequate as it relied on an absence of records and did not consider the Veteran's lay statements regarding the condition. Specifically, the examiner relied on a lack of medical records after the Veteran's service in concluding that his back condition was not related to service. Accordingly, as the parties agreed that the July 2017 opinion was inadequate, the matter must be remanded to afford the Veteran a new examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left shoulder condition. The clinician must (a) identify all current diagnoses relating to the Veteran's left shoulder and (b) opine whether it is at least likely as not that such diagnoses were incurred or aggravated in service. The clinician must specifically discuss the February 1986 service treatment note indicating that the Veteran experienced left shoulder pain for four months and the Veteran's contentions that the condition was caused by physical training performed while in service. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any back condition. The clinician must (a) identify all current diagnoses relating to the Veteran's back and (b) opine whether it is at least likely as not that such diagnoses were incurred or aggravated in service. The clinician must specifically discuss the Veteran's April 1983 in-service reports of back pain and his contentions that the condition was caused by physical training performed while in service. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries and that his reports must be taken into account in formulating the requested opinions. (Continued on the next page) The examiner must provide rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Watkins, 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.