Citation Nr: 22015255 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 17-40 607 DATE: March 16, 2022 ORDER Entitlement to service connection for a left shoulder disability, to include secondary to a left knee disability, is denied. REMANDED Entitlement to service connection for a right shoulder disability, to include secondary to a left knee disability, is remanded. FINDING OF FACT The Veteran's left shoulder disability was not shown as chronic in service and did not manifest to a compensable degree within one year after separation from service; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease to include secondary to a left knee disabilty. CONCLUSION OF LAW The criteria for service connection for a left shoulder disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had served on active duty in the United States Air Force from November 11, 1971, to November 6, 1975, and from November 12, 1975, to February 29, 1992. This matter came before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. These matters were remanded for additional development in March 2019 and September 2021. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases such as arthritis, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period (1 years) following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 1. Entitlement to service connection for a left shoulder disability to include secondary to a left knee disability The Veteran contends that his left shoulder disability diagnosed as a left shoulder strain and arthritis was caused by an in-service shoulder injury. Alternatively, he contends that the left shoulder disability was caused or aggravated by a service connected left knee disabilty, when after separation from service, his left knee locked up while pedaling a bicycle causing him to fall. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of a strain and arthritis of the left shoulder and evidence shows that he was treated for left shoulder injuries and pain during active service, the evidence of record persuasively weighs against finding that the Veteran's current diagnosis of a left shoulder strain and arthritis began during service, within one year of separation from service, or is otherwise related to an in-service injury, event, or disease. A review of the service treatment records shows that the Veteran had normal upper extremities with no complaints of painful or trick shoulder in the September 1971 enlistment examination. In an August 1973 service treatment record it was noted that the Veteran injured his left shoulder. An x-ray scan of the left shoulder revealed no significant abnormalities. In August 1980, August 1983, and October 1983 periodic examinations the Veteran was noted to have normal upper extremities. In a May 1988 service treatment record, the Veteran reported left shoulder pain that he has had for about one month after trying to block a basketball pass. He was diagnosed with left shoulder pain. Post service, a June 1995 VA treatment record showed that in May 1995 the Veteran was riding his bike and he reported his service-connected left knee locked up or gave out in such a manner that he fell off of his bicycle and landed on the tip of his right shoulder. An x-rays were taking of the right shoulder which revealed a complete AC separation of the right shoulder. In a September 1997 VA treatment record, the Veteran continued to report shoulder pain after numerous bike accidents including one in which he fell off his bike. A July 2002 medical record shows that the Veteran reported bilateral shoulder pain since the 1995 bike injury. A December 2011 VA treatment record shows that he was assessed with bilateral shoulder degenerative arthritis. A July 2014 VA examination report shows that the Veteran's left shoulder was diagnosed with a strain and rotator cuff tear. The examiner opined that the Veteran's bilateral shoulder disability is less likely than not incurred in or caused by the claimed in-service injury, event, or illness suffered in August 1973, November 1976, and May 1988. The records show that his injury to shoulders occurred in May 1995. In an October 2019 VA examination, he was diagnosed with arthritis of the bilateral shoulders and rotator cuff tear of the bilateral shoulder. The examiner opined that the Veteran's bilateral shoulder disability is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also determined that a baseline level of severity of the bilateral shoulder disability could not be based upon medical evidence available prior to aggravation as the medical evidence is insufficient to support a determination of a baseline level of severity. The examiner also opined that the bilateral shoulder disability is not at least as likely as not aggravated beyond its natural progression by service-connected left knee disability. The examiner explained that the service treatment records show that he was evaluated and/or treated for a left shoulder strain in 1973 and 1988 as well as a right shoulder strain in 1976. Subsequent service treatment records are silent for any continuing shoulder complaints and the Veteran reported "no" to painful and/or trick shoulder on multiple health assessments. Subsequent records show a significant right shoulder injury with AC joint separation from a bike accident in 1995 (three years after military service) but are silent for any left shoulder or knee complaints. The examiner noted that bilateral shoulder complaints due to degenerative joint disease of both shoulders began in 2011 with bilateral rotator cuff tears noted in 2014 (almost 20 years after the bicycle accident). An October 2021 VA shoulder and arm condition disabilty benefits questionnaire (DBQ) shows that the Veteran was diagnosed with left shoulder rotator cuff tear and degenerative arthritis. After a review of the evidence of record, the examiner opined that it was less likely than not that the left shoulder disabilty was caused by or related to active service to include in-service left shoulder injuries. The examiner noted that there was no record of an ongoing treatment for the left shoulders in active service and no mention of left shoulder degenerative arthritis and rotator cuff tears of the bilateral shoulder. The examiner also opined that the while the Veteran did experience a bicycle accident in 1995 where he fell resulting in injury to right shoulder and left knee. The examiner noted that there was no evidence that the Veteran injured his left shoulder in the 1995 bicycle crash, although it was noted that a right shoulder AC separation was diagnosed. The examiner remarked that the current examination findings did not support that a rotator cuff tear and degenerative arthritis of the left shoulder had a correlation to injury sustained in 1995. Regarding aggravation by the service connected left knee disabilty, the examiner remarked that while the Veteran's injury to the right shoulder in 1995, his current diagnosed degenerative arthritis and rotator cuff tear was not related to that incident. A November 2021 addendum opinion noted that the left shoulder injury during acting service showed no abnormalities and the left shoulder pain after playing basketball, but would not change any etiological opinion. VA treatment records shows that the Veteran first reported left shoulder pain in 2002 and was first diagnosed with a left shoulder disabilty in December 2011, which is at least 10 years after separation from service. While the Veteran is competent to report having experienced symptoms of shoulder pain since separation from service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of arthritis and rotator cuff tears. The issue is medically complex, as it requires knowledge of the interaction of the musculoskeletal system and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further the October 2021 VA examiner opined that the Veteran's left shoulder disability is not at least as likely as not related to an in-service injury, event, or disease, including secondary to a left knee disability which may have caused a post service bicycle accident. The rationale cited to the contemporary medical records which showed no chronic left shoulder condition in service, and the 1995 medical evidence showing that the bicycle accident caused the Veteran to fall on his right shoulder and there was no diagnosis or self-reports of a left shoulder condition stemming from the accident. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is also no evidence showing that the left shoulder was assessed with arthritis during service or within the first year after separation from service. Accordingly, a chronic condition is not shown during service. See 38 C.F.R. § 3.303. There is no evidence of arthritis of the left shoulder dated within one year of separation from service. See 38 C.F.R. §§ 3.307, 3.309(a). The Board acknowledges that the Veteran believes left shoulder disability, diagnosed as arthritis and rotor cuff tear are related to an in-service left shoulder injury, or to his left knee disability. The Veteran in this case is not competent to provide a nexus opinion regarding this issue as to whether left shoulder pain in service could result in arthritis or a rotator cuff tear. The issue is medically complex, as it requires knowledge of development of arthritis and anatomical relationships, and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of Veteran in this case because the record does not show that he the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the most recent VA examination report of record which shows that the current left shoulder disabilities diagnosed as arthritis and rotator cuff tear are not related to the in-service reports and treatments for left shoulder strains. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran's claim for service connection for a left shoulder disability is denied. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disability to include secondary to a left knee disability is remanded. During the course of the appeal, the Veteran's right shoulder has been diagnosed with an acromioclavicular (AC) joint separation as noted in a July 2014 VA examination report. In an October 2019 VA examination, he was diagnosed with arthritis of the bilateral shoulders, AC joint separation of the right shoulder, and rotator cuff tear of the bilateral shoulder. In the most recent October 2021 VA examination report, the examiner provided adequate etiological opinions regarding the right shoulder disabilities diagnosed as arthritis and a rotator cuff tear. However, concerning the right shoulder AC joint separation, the examiner noted that the condition had resolved and therefore did not provide an etiological opinion with regards to that specific disability. The Board finds that a remand is necessary to obtain an addendum opinion to determine whether the Veteran's right shoulder AC joint separation diagnosed during the pendency of the appeal were related to service and/or was caused or aggravated by his service-connected left knee disability which was reported to be the cause of the post-service bicycle accident. The Board finds that the October 2021 examiner's opinion is inadequate as no opinion was provided as the right shoulder AC joint separation. VA must consider whether a disability may be service-connected if the disability existed at the time of filing the claim or during the pendency of that claim, even if the disability has since resolved. McClain v. Nicholson, 21 Vet. App. 319 (2007). Thus, the Board finds that a remand is necessary to obtain an addendum opinion that addresses the right shoulder AC joint separation. The matter is REMANDED for the following action: Obtain an addendum from an appropriately qualified examiner to determine the nature and etiology of any right shoulder disability to include rotator cuff tear, arthritis, and AC joint separation. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. a) The examiner must provide an opinion as to whether it is at least as likely as not (probability of approximately 50 percent) that the right shoulder disability diagnosed as rotator cuff tear, arthritis, and AC joint separation had its onset in service or is otherwise etiologically related to service. The examiner should consider a November 1975 service treatment record where, he reported right shoulder pain and was diagnosed with probable muscle strain. b) Whether it is at least as likely as not (probability of approximately 50 percent) that the Veteran's right shoulder disabilty diagnosed as rotator cuff tear, arthritis, and AC joint separation was (a) caused by or has been (b) aggravated (worsened beyond the natural progress of the disorder) by his service-connected left knee disability. The examiner must provide an opinion concerning the diagnosed right shoulder AC joint separation even though the condition may have resolved as of the October 2021 VA examination. The examiner should address the June 1995 VA treatment record wherein it was noted that in May 1995 he was riding his bike and his service-connected left knee locked up or gave out in such a manner that he fell off of his bicycle and landed on the tip of his right shoulder. See November 2019 CAPRI. The examiner is reminded that the Veteran's statement, which was close in time to the accident, is probative and credible. Additionally, the Veteran claims that he injured his bilateral shoulder from the 1995 incident. See August 2017 VA 646 Statement of Accredited Representative in Appealed Case. (Continued on the next page) A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Garrett Morales Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dworkin, 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.