Citation Nr: 22014932 Decision Date: 03/15/22 Archive Date: 03/15/22 DOCKET NO. 13-13 835 DATE: March 15, 2022 REMANDED Entitlement to service connection for a bilateral shoulder disability, to include as secondary to a service-connected neck disability is remanded. REASONS FOR REMAND The Veteran had active service with the Army from April 1985 to November 1992. This matter is before the Board of Veterans' Appeals (the Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In May 2016, the Veteran testified in a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the evidence of record. In September 2016, the Board granted service connection for the Veteran's neck disability and remanded his claim for service connection for the bilateral shoulders for additional development. In February 2018, the Board denied the Veteran's claim for entitlement to service for the bilateral shoulders. He subsequently appealed the February 2018 Board decision to the United States Court of Appeals for Veterans Claims (the Court). In a December 2020 order, the Court granted the parties' Joint Motion for Remand (JMR), vacating the Board's February 2018 denial of entitlement to service connection for the bilateral shoulders and remanded the appeal to the Board for readjudication consistent with the JMR. The Court determined that the Board failed to provide an adequate statement of reasons and bases. The Board needed to provide a more detailed discussion of how and why the May 2018 examination presented a "reasoned analysis" regarding the Veteran's military occupational specialty (MOS) and his contention that driving a truck in heavy terrain had an impact on his shoulders. In June 2021, the Board remanded the Veteran's claims requesting direct and secondary nexus opinions. The examiner was asked to specifically consider the Veteran's MOS of motor transport operator for seven years and two months as well as his contention that driving trucks in heavy terrain contributed to his shoulder conditions. In October 2021, the Board remanded the Veteran's claims again for an addendum opinion to clarify the causal link between his shoulder conditions and his service-connected neck disability given the July 2021 VA examiner's conclusion that both the neck and shoulder conditions had their onset at the same time. The Board regrets the delay but finds additional development is necessary prior to final adjudication of his claims. In a December 2021 VA examination, the Veteran was diagnosed with bilateral shoulder strain. Imaging of the bilateral shoulders was unremarkable. The examiner opined the claimed right shoulder condition was less likely than not proximately due to or the result of the Veteran's service-connected neck condition. The examiner could not determine the baseline level of severity of the claimed condition based upon the medical evidence of record. Regardless of the established baseline the Veteran's claimed right shoulder condition was less likely as not aggravated beyond its natural progression by his service-connected neck disability. Regarding the claimed left shoulder condition, the examiner opined it was less likely than not proximately due to or the result of the Veteran's service-connected neck condition. The examiner could not determine the baseline level of severity of the claimed condition based upon the medical evidence of record. Regardless of the established baseline the Veteran's claimed left shoulder condition was less likely as not aggravated beyond its natural progression by his service-connected neck disability. The Veteran reported a history of bilateral shoulder pain and stated it started while in service from carrying heavy military equipment. While in service he was treated on one occasion for a right shoulder issue and diagnosed with right shoulder strain. He was not seen for a left shoulder complaint while on active duty. His left shoulder condition began in 2011. The examiner noted during the current examination, the Veteran made subjective complaints of bilateral shoulder pain. However, x-rays from December 2021 were negative. This is not consistent with a shoulder condition. Since the x-rays were negative and his muscle strength in the shoulders appeared normal, it is not clear what is causing his mild decreased range of motion. The pain that the Veteran complained of appeared to be referred pain from his neck because there was no evidence of a shoulder condition causing his pain. It is a well-known medical fact that a person could perceive pain in the shoulders when it was actually neck pain. There is no evidence of a shoulder condition caused or aggravated by his neck condition. The examiner referenced "Is Your Shoulder Pain Actually a Neck Problem?" from the Cleveland Clinic. The December 2021 VA examiner's opinion contains contradictory findings. The examiner diagnosed the Veteran with bilateral shoulder strain but also opined that his shoulder condition appeared to be referred pain from his neck because there was no shoulder condition causing his pain. The record shows during the July 2021 VA examination the Veteran was diagnosed with bilateral shoulder strain, shoulder impingement syndrome, degenerative arthritis, and acromioclavicular (AC) joint sprain. The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997). To be present as a current disability, the claimed condition must be present at the time of the claim for benefits, as opposed to sometime in the distant past. Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998). The Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, an addendum opinion is necessary to clarify the causal link between the Veteran's bilateral shoulder conditions and his service-connected neck disability. The matters are REMANDED for the following action: 1. Obtain and associate any outstanding VA and non-VA treatment records with the claims file. 2. Obtain and addendum opinion from the December 2021 VA examiner regarding service connection for the bilateral shoulders to include as secondary to a service-connected neck disability. If the December 2021 VA examiner is not available, the opinion with rationale should be rendered by another qualified clinician. If, and only if, the examiner feels that a physical examination is needed, one should be scheduled. The reviewing clinician is asked to opine on the following: If it is at least as likely as not that his current bilateral shoulder disability was proximately due to or aggravated beyond its natural progression by his service-connected neck disability. If aggravation is found, the examiner should state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record as well as the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. The complete record, to include a copy of this remand and the claims folder, must be made available to and reviewed by the examiner in conjunction with the examination. The examination report must include a notation that this record review took place. 3. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for further consideration. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.L. Byers 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.