Citation Nr: 22011944 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 17-55 706 DATE: March 2, 2022 REMANDED Entitlement to service connection for a right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1983 to August 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2021, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record. 1. Entitlement to service connection for a right shoulder disability is remanded. The Veteran contends that a right shoulder disability is a direct result of service. Specifically, he claims as a parachute rigger he was required to maintain qualification for hazard pay and on jump status, and he had to jump at least three times every 90 days. During several of those jumps, the Veteran has stated that he injured the right shoulder, causing it to dislocate. At a September 2021 Hearing, the Veteran testified that a shoulder problem started in service and had gotten worse through the years. He described the first time he injured the right shoulder was during a combat jump when he landed and was unable to engage one of his quick releases and his parachute inflated and dragged him at least 50 yards. The Veteran described the drop zone as very rocky, and that "either a rock or some hard protrusion" in the ground hit his right shoulder causing it to dislocate. A service member reset his shoulder in the field. After some rest, the medic advised him to return to duty. The Veteran testified he was placed on a 30-day profile. The Veteran also testified about another jump where his parachute was caught in some trees and he was dangling about 25 to 30 feet in the air. While trying to maneuver out of the harness, his right shoulder dislocated. The Veteran was finally able to descend using the left arm, where he was met by a service member who reset his arm. When the Veteran went to get checked out, he was given Motrin and an arm sling, and assigned to a two-week profile. The Veteran also testified that in May 1985 on his day off, he was called to report to duty. While on his way to the barracks on a motorcycle, he was hit from behind by a vehicle and fell, landing on the right shoulder, injuring the right shoulder and scraping his body. Once at the barracks, he was checked out and given Motrin, an arm sling, treated for road rash, and placed on a two-week profile. In addition, the Veteran testified that following service, he worked at McDonnell Douglas and was electrocuted causing him to fall back into a workbench and dislocate his right shoulder. Subsequently, the Veteran filed a worker's compensation case. A corresponding June 1991 X-ray found a right shoulder defect consistent with a prior injury. Those examiners determined that the Veteran had a preexisting shoulder injury from a previous trauma. The service medical records note an April 1985 Screening Note of Acute Medical Care reported the Veteran was in a "cycle accident" with injury to the left shoulder and left knee. At the September 2021 Hearing, the Veteran testified that the information in the report was wrong because he fell onto his right side and shoulder. The Veteran indicated that different people were involved in writing that report as was apparent by the different types of handwriting within the document. The Veteran testified that the specialists were foreign nationals who did not speak English that well and it was difficult for them to fill out some of the forms manually. At an October 2017 VA shoulder examination, the examiner diagnosed arthritic conditions of the right shoulder and noted a 1988 diagnosis of a glenohumeral joint dislocation. The examiner opined the Veteran's current right shoulder disability was not due to service but more likely than not due to a 1995 job-related right shoulder dislocation which produced the current shoulder problem. The examiner considered the Veteran's Military Occupational Specialty (MOS) and parachute badge medal. However, the examiner noted there was no evidence of a shoulder condition in service. The examiner explained that despite a history of airborne activities in service, there was no service treatment evidence of injury or limitation of the right shoulder. The examiner concluded that it was most likely that the current shoulder diagnosis was due to the Veteran's history of dislocation in 1995 at his job, and not due to service. The Veteran's initial range of motion had a flexion to 90 degrees; abduction to 60 degrees; external rotation to 70 degrees; and internal rotation to 60 degrees. Because the examiner did not consider the Veteran's lay reports of right shoulder trauma in service, and that a motorcycle injury was to the right shoulder, not the left shoulder, the Board finds the October 2017 examination to be incomplete. The Board also finds that the examiner, in attributing the current right shoulder issue to a worker's compensation injury, did not discuss the significance of the worker's compensation medical examination that attributed a significant portion of the right shoulder disability to a preexisting injury. Based on the testimony from the September 2021 Board hearing, and the incomplete findings of the October 2017 examination, the Board finds that remand is necessary to obtain a VA examination to determine etiology of a right shoulder disability. Remand by the Board imposes upon VA a duty to ensure compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268 (1998). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Request the Veteran identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who provided treatment for all claimed disabilities. After securing the necessary releases, attempt to obtain all copies of pertinent treatment records identified by the Veteran that are not currently of record. 2. Then, schedule the Veteran for a VA examination with medical doctor who has not previously examined the Veteran in conjunction with this claim, to identify and determine the etiology of any right shoulder disability. The examiner must review the claims file, to include this Remand and the September 2021 hearing transcript, and must note that review in the report. All indicated tests and studies should be accomplished and the findings reported in detail. A clearly stated rationale for each opinion offered must be provided and cannot be based solely on the lack of any in-service records. After a review of the evidence, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any right shoulder disability is related to service. The examiner must consider the circumstances of the Veteran's service and involvement in parachute jumps during service. The examiner must consider the Veteran's lay statements regarding injuries to the right shoulder during parachute jumps in service. The examiner should also examine the Veteran's left shoulder and determine whether it is at least as likely as not that a motorcycle injury was of the right shoulder, rather than the left shoulder as documented, as the Veteran contends that the documented injury was to the actually to the right shoulder. The examiner should also discuss the significance of the worker's compensation findings that a significant portion of the right shoulder injury was attributable to a preexisting injury. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sonya S. Tsao, 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.