Citation Nr: 22063294 Decision Date: 11/10/22 Archive Date: 11/10/22 DOCKET NO. 20-29 654 DATE: November 10, 2022 REMANDED Entitlement to service connection for neck disability is remanded. Entitlement to service connection for right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1962 to September 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision. In December 2020, the Board denied reopening the Veteran's previously denied claims of service connection for neck and right shoulder disabilities. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a November 2021 order, the Court granted the parties' November 2021 Joint Motion for Partial Remand (JMPR) and remanded the issues of whether there was new and material evidence sufficient to reopen the Veteran's previously denied claims of service connection for neck and right shoulder disabilities to the Board for readjudication. In March 2022, the Board reopened the Veteran's previously denied claims of service connection for neck and right shoulder disabilities. The Board then remanded the claims for service connection for neck and right shoulder disabilities for additional development. 1. Entitlement to service connection for neck disability is remanded. 2. Entitlement to service connection for right shoulder disability is remanded. In March 2022, the Board remanded this matter to obtain VA medical opinion regarding whether the Veteran's neck and right shoulder disabilities are related to service. In August 2022, a VA contract examiner opined that the Veteran's neck and right shoulder strains are less likely than not incurred in or related to service. However, the examiner relied on the lack of documentation of neck and right shoulder complaints in service without adequately addressing the Veteran's reports that he injured his neck and right shoulder in a 1964 in-service truck accident and has had pain since that time. See Miller v. Wilkie, 32 Vet. App. 249 (2020); Dalton v. Nicholson, 21 Vet. App. 23 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). November 1964 service treatment records show sutures for large laceration to the scalp in the emergency room and the Veteran reported that this scalp laceration was from being thrown from a truck during a training drill earlier that day and that his neck and right shoulder hurt from the fall. The examiner also did not address the Veteran's contention that his current neck and right shoulder strains are from performing as an aircraft repairman during combat operations in Vietnam during the Vietnam War. The Veteran reported that he self-treated and did not seek treatment since he was in the field. In light of the above, remand is warranted to obtain additional VA medical opinion regarding whether the Veteran's current neck and right shoulder strains are related to service. In the March 2022 remand, the Board also directed that the Regional Office take appropriate efforts to obtain any 1964 service treatment records from the medical facility at Fort Leonard Wood, Missouri, to include hospital records pertaining to the Veteran's claimed motor vehicle accident injury. The Regional Office requested records from General Leonard Wood Army Community Hospital and no additional records were found. However, the Veteran responded by noting that his service records misspelled his name. The Board notes that the Veteran's service personnel records and service treatment records (including the November 1964 service treatment records for the scalp laceration and sutures which the Veteran reported were for treatment following a truck accident) misspell the Veteran's name. Accordingly, while this matter is on remand, the Regional Office shall take any additional actions deemed appropriate to obtain records in light of this information regarding the misspelling of the Veteran's name during service. The matters are REMANDED for the following action: 1. Take any actions deemed appropriate to obtain 1964 records from General Leonard Wood Army Community Hospital in light of the misspelling of the Veteran's name during service. 2. After outstanding records are obtained to the extent possible, ask the appropriate examiner to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's right shoulder and neck disabilities are related to service. The Veteran reports that he injured his neck and right shoulder in a 1964 in-service truck accident and has had pain since that time. He reported that while serving at Fort Riley, Kansas in 1964 he was sent on a training exercise called Goldfire which involved time in Missouri. He reported that while in Missouri, his truck overturned and he was thrown from the vehicle and knocked unconscious. He reported that when he became conscious he was laying in the road and bleeding from his head and that his neck and right shoulder hurt. He reported he went by ambulance to Fort Leonard Wood Army Hospital where he received sutures on his head. November 1964 service treatment records show sutures for large laceration to the scalp in the emergency room and reference exercise Goldfire. The Veteran also asserts that his current neck and right shoulder strains are from performing as an aircraft repairman during combat operations in Vietnam during the Vietnam War. The Veteran reported that he self-treated and did not seek treatment since he was in the field. The examiner should consider all medical and lay evidence of record, including the November 1964 Authorization for Administration of Anesthesia and for Performance of Operations and Other Procedures signed by the Veteran at the U.S. Army Hospital at Fort Leonard Wood, Missouri; the November 1964 service treatment records showing laceration to the scalp with sutures and mentioning exercise Goldfire; the December 1964 in-service report of medical history noting the Veteran was treated for cuts from a car wreck; the picture the Veteran submitted to show where he received stitches during service; and the July 1969 post-service private examination noting sutures from an auto accident. The examiner should address the Veteran's reports detailing in-service events and chronicity of pain since service. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Purcell, 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.