Citation Nr: 21041441 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 15-44 035 DATE: July 9, 2021 REMANDED Entitlement to service connection for a left shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from February 1966 to November 1967, to include service in the Republic of Vietnam. His decorations include the Vietnam Service Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in New Orleans, Louisiana. This case was previously before the Board in July 2019. The Board reopened the Veteran's previously denied claim for service connection for left shoulder dislocation and remanded the underlying claim for service connection to the agency of original jurisdiction for additional development. Entitlement to service connection for a left shoulder disorder is remanded. Following the Board's remand, the Veteran was provided a VA examination of the left shoulder in December 2019. The examiner concluded that the Veteran's diagnosed degenerative arthritis of the left shoulder "was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." By way of rationale, the examiner explained: He was seen and treated for left shoulder pulled muscle during service. The weight of medical literature is against a direct relationship between muscle strain and degenerative arthritis. Veteran has a history of left shoulder rotator cuff injury with repair in 1987. Diagnosis of left shoulder degenerative arthritis was made in 1999. Medical literature indicates a connection between long standing rotator cuff injury and development of degenerative arthritis due to inability of torn rotator cuff to hold the head of humerus in glenoid socket. This causes the humerus to move upward and rub against the acromion. This damages the surface of the bones causing arthritis. See December 2019 VA opinion. The examiner's opinion does not address the Veteran's primary contention that the January 1987 left shoulder injury and resulting surgery were, in fact, the result of his in-service injury. Significantly, in reviewing contemporaneous VA treatment records from 1987, the Veteran consistently reported to the treating provider that he had reinjured the shoulder, explaining that he had dislocated it many times prior to the January 1987 injury. See, e.g., January 1987 VA treatment report (noting "Hx of old injury to C6 + dislocation of the Lt. shoulder. No recent trauma. App[arrantly] had recurrent dislocation of left shoulder. I[njury] 1 week ago" and assessing "R[ule] O[ut] recurrent dislocation of Lt. shoulder"); January 1987 VA treatment record (noting that he "injured L shoulder on 1-6-87 'dislocating'? his L shoulder for the 'Fifth time.'"); February 1987 VA treatment record ("S[tatus] p[ost] 5th dislocation L shoulder [with] radial & ulnar N[erve] residual"). Because the examiner did not address this favorable evidence or discuss whether the post-service 1987 rotator cuff surgery itself was a continuation of or otherwise related to the claimed in-service injury, the rationale for the existing opinion is incomplete. A remand is required for a clarifying addendum opinion. Additionally, while the case is in remand status, the Veteran should be provided an opportunity to submit, or to submit a release for, potentially relevant outstanding private treatment records, including those he identified from Dr. Trax and Dr. Smith in the 1970s; from Dr. Creel prior to 1987; from the chiropractor who he stated "put [his dislocated left shoulder] back in" in January 1987; and possibly records relating to an employment physical when he was denied a job in the oil industry because of his left shoulder. See May 1987 VA Form 9 ("I was treated by Drs. [Trax and Smith] in 1970 and 1971 for the left shoulder condition.); January 1987 VA treatment record (noting that ten days ago, he pulled the left shoulder "out of socket" "Chiropractor" in Jena, Louisiana, "put it back in."), January 1987 VA treatment record ("P[atien]t reports reduction per chiropractor at that arm" after he reportedly dislocated his left shoulder for the fifth time); February 1987 initial claim for service connection (also identifying private treatment by Dr. Trax, Dr. Smith, and Dr. Creel); December 2015 statement ("When I was home [after service], I wanted to work off-shore in the oil industry because I could make a lot of money. But I could not pass the physical because of my shoulder injury.") This matter is REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for any outstanding private treatment records, including but not necessarily limited to, those from Dr. Trax, Dr. Smith, Dr. Creel, the chiropractor who "put [his dislocated left shoulder] back in," and from a failed oil industry physical. Make two requests for the authorized records from any identified private treatment providers unless it is clear after the first request that a second request would be futile. 2. After completing the foregoing development to the extent possible, obtain an addendum medical opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran's January 1987 left shoulder injury, which resulted in his rotator cuff surgery and is the reported cause of his currently diagnosed degenerative arthritis, is related to service, including the reported left shoulder injury during service. In doing so, please address the January 1987 VA treatment records that reflect a history of several prior dislocations, as well as the lay statements of an initial in-service injury to the shoulder made by the Veteran and a fellow servicemember. See January 1987 VA treatment records; October 1966 service treatment report; July 2012 statement from J.A., noting the Veteran's continuing left shoulder complaints following a fight in Fort Lewis in October 1966. A complete rationale for all opinions expressed must be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Gielow, 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.