Citation Nr: 22015895 Decision Date: 03/20/22 Archive Date: 03/20/22 DOCKET NO. 17-24 629 DATE: March 20, 2022 ORDER Entitlement to service connection for a left shoulder disability is denied. FINDING OF FACT The Veteran's current left shoulder disability was not incurred in service, arthritis was not manifested within one year of service discharge, and the left shoulder disability is not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1979 to September 1980. The Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference during an August 2021 Board of Veterans' Appeals (Board) hearing. A transcript of the hearing is included in the claims file. Service Connection Entitlement to service connection for a left shoulder disability The Veteran asserts that his left shoulder disability had its onset during service. During his August 2021 Board hearing, the Veteran testified that he injured his shoulder while stationed in Germany in 1979. He testified he was sleeping on top of the gun and he fell about 10 feet, breaking his arm, hand, and dislocating his shoulder. The Veteran stated that he was treated by a field medic and then transported to a hospital, where they put his arm in a cast and then popped his shoulder into place. He also stated that he did not get medical attention or "really think about [his shoulder] again" until his shoulder locked up in 2005. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The Board has carefully reviewed the evidence of record and finds that the evidence persuasively weighs against the claim for service connection for a left shoulder disability. The reasons follow. As to evidence of a current disability, a March 2018 VA medical treatment record notes a distal left clavicle cortex irregularity and apparent erosion of the superior left humeral anatomic neck may represent osteoarthritis or inflammatory arthritis. Thus, there is evidence of a current disability, and the first element of a service-connection claim is met. As to evidence of a disease or injury in service, within the April 2017 Notice of Disagreement, the Veteran reported that the time he injured his left hand in 1979 was the same time he injured his left shoulder. He stated that his left hand was broken and that he dislocated his left shoulder, which continued to be a problem. At the August 2021 hearing, the Veteran stated that the left shoulder was injured at the same time he broke his left hand. He stated he had fallen asleep and fell about 10 feet and broke his arm and hand and dislocated his shoulder. He stated it was memorable because he had to get the cast on his arm first before they could pop his shoulder back into place. He said that he woke 200 people up because he screamed when his shoulder was popped back into place. The Veteran testified that he had not thought about the incident until his left shoulder locked up on him in 2005. There is no service treatment record documenting the in-service injury to the left arm, left hand, and left shoulder. However, the August 1980 Report of Medical Examination at service discharge shows the examiner documented that the Veteran had a cast on his left lower arm. On the August 1980 Report of Medical History, it shows that the examiner documented that the Veteran currently had a cast due to fracture of the right fifth metacarpal. (The examiner appears to have gotten the wrong hand.) While there is no service treatment record documenting the injury, the Board finds that there was an injury that caused the Veteran to have his left lower arm/hand in a cast, as the August 1980 Reports of Medical Examination and History support an injury to the left hand. However, the Board finds that the Veteran did not injure his left shoulder at that time, which is explained below. Initially, the Board notes that both the "June 1980" Reports of Medical Examination and Medical History show a date of June 4, 1980, where the date in the Report of Medical Examination is crossed out. On the second page of both documents, there is a date stamp of August 27, 1980. Thus, the Board finds the August 1980 date is the accurate date that these forms were completed. In the August 1980 Report of Medical History, the Veteran specifically denied a history of painful or trick shoulder. This is an important fact because at the hearing, the Veteran claimed that when his shoulder was popped back in place, he screamed so loudly, that he woke up 200 people. It is reasonable to conclude that if the Veteran's left shoulder was injured at the time he broke his hand, he would have reported a positive history involving his shoulder, particularly because he claimed that his shoulder being popped back into place caused him a lot of pain. The Report of Medical History shows that the Veteran checked yes to multiple medical symptoms within the form, which would show that he read through the symptoms and checked yes to those he had experienced and no to those he had not experienced. This would have been an opportunity for the Veteran to report an injury to his left shoulder and/or that he experienced left shoulder pain, as he had the thought process to report a hospitalization from when he was 14 years old and other musculoskeletal pain he had experienced during service, such as the fracture to his hand. His denial of a history of a painful shoulder is evidence against a left shoulder injury during service. Additionally, the August 1980 Report of Medical Examiner shows that, other than the cast on the lower left arm, clinical evaluation of the Veteran's upper extremities was normal. The Board finds that there was no disease or injury involving the left shoulder in service, and the Veteran's allegation of an in-service left shoulder injury, at the same time he injured his left hand, is not credible. The Veteran was evaluated in September 1980 to remove his left arm cast. During the medical visits, the Veteran did not report a left shoulder injury and/or pain to his left shoulder. The examiner documented, "No lifting or strenuous [left] hand activity x 2 weeks." The examiner's documentation within the treatment records is consistent with the Veteran's left hand injury. All of these facts support the Veteran injuring his left hand, but do not support an injury to the left shoulder. Accordingly, the evidence persuasively weighs against a disease or injury involving the left shoulder during service, and the second element of a service-connection claim is not met. There is no competent evidence that arthritis of the left shoulder manifested within one year following service discharge. Thus, the evidence persuasively weighs against the award of service connection on a presumptive basis for a chronic disease. The Board also finds that the evidence persuasively weighs against a nexus between the current left shoulder disability and service. The post-service records reflect that the Veteran did not complain of or seek treatment for a left shoulder disability until approximately 2017, which is more than 35 years following service discharge and does not lend to a finding of the onset of a left shoulder disability during service. A June 2015 VA Substance Abuse Psychosocial Assessment notes that when the Veteran was asked about his physical pain, he stated that he was at a three or four out of 10, due to his arthritis. He was asked about medical conditions that interfered with his life, and he listed arthritis, bursitis in his knees, prostate issues, and Hepatitis C. In March 2016, the Veteran was there to establish care at a VA facility. When addressing his medical history, he reported osteoarthritis, Hepatitis C, and opiate/heroin addiction. The examiner documented that the Veteran's only complaint at that time was right wrist pain and stiffness. The examiner documented that the Veteran reported that he had a "ped[estrian] struck accident" in September 2015 that resulted in a broken wrist/hand and a left hip hematoma. Otherwise, the Veteran had no complaints at the March 2016 visit. In October 2016, the Veteran was seen with a cough and minor congestion for the last three days. The Veteran reported that he was a food worker at a place and needed a note to state that he was okay to continue working. The examiner performed a physical examination and wrote that the Veteran's extremities were "pretty well perfused." In a November 2016 treatment record, the examiner noted the Veteran had a history of "pedestrian-automobile accident" in September 2015, and that the Veteran presented with continuing pain in his right wrist with a new onset of pain and swelling in the right knee. A physical examination was performed at that time, and the examiner wrote the Veteran had normal range of motion and 5 out of 5 strength in his upper extremities. Additionally, at a January 2017 VA primary care visit, the Veteran was found to have normal strength in his upper extremities. The evidence within the file shows that the Veteran filed for Social Security Administration (SSA) disability in October 2016; indicating that he became unable to function or work in January 2011. The Veteran initially filed for SSA disability due to PTSD; depression; anxiety; arthritis in hips, hands, spine, knees, and legs; chronic wrist pain; chronic hip pain; and Hepatitis C. This list of disabilities did not include a left shoulder disability. Then in a December 2016 filing, the Veteran added that he had arthritis in his shoulders, hips, hands, knees; carpal tunnel syndrome in his right wrist; and broke both hips over 30 years ago. At this point, the Veteran had been out of service for more than 35 years and began seeking treatment from VA since 2016 and was not reporting left shoulder pain. The Veteran has claimed that he forgot about the in-service left shoulder injury until something happened to his shoulder in 2005. However, by the time he sought treatment from VA approximately 10 years later, he was not reporting left shoulder problems. It is reasonable to expect that at the March 2016 VA medical treatment appointment, when the Veteran was there to establish care, he would have disclosed all medical conditions for which treatment is needed and past medical conditions. The Veteran reported experiencing right hand and right knee pain, for which he subsequently received treatment and reported a past medical history of Hepatitis C, but the March 2016 and the subsequent records are silent for left shoulder symptoms. All of these facts do not support a left shoulder disability having its onset in service. At the present time, there is no competent evidence of the Veteran's left shoulder disability being related to service. The Veteran was not afforded a VA examination or medical opinion in connection with the claim. The Board finds that the facts of this case do not establish entitlement to a VA examination or medical opinion. For example, VA must provide a medical examination or opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds as fact that the record does not show evidence establishing that an event, injury, or disease related to the left shoulder in service or that the current left shoulder disability may be related to service, which is explained above. For a VA examination and/or medical opinion to be warranted, all the criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted. For all the reasons laid out above, the Board finds the evidence persuasively weighs against the claim for service connection for a left shoulder disability. Thus, the benefit-of-the-doubt doctrine is not for application, and the claim for service connection for a left shoulder disability is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Griffin, 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.