Citation Nr: 22018484 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 17-45 371 DATE: March 29, 2022 REMANDED Service connection for a right shoulder disability, to include as secondary to service-connected cervical spondylosis with radiculopathy. REASONS FOR REMAND The Veteran served on active duty from August 1976 to August 1979, from December 1979 to November 1987, from January 2003 to November 2003, and from September 2005 to September 2006. The Veteran had additional service with the Maryland Army National Guard (ARNG). The case is on appeal from an April 2015 rating decision. In an August 2017 VA Form 9, the Veteran requested a live videoconference Board hearing before a Veterans Law Judge. Accordingly, the Veteran was scheduled for a Board hearing in March 2022. However, that same month, through his representative, voluntarily withdrew his hearing request. Thus, the hearing request is considered withdrawn. See 38 C.F.R. § 20.704(e). Service connection for a right shoulder disability, to include as secondary to service-connected cervical spondylosis with radiculopathy. In his August 2015 notice of disagreement (NOD), the Veteran clarified that he seeks service connection for a right shoulder disability as secondary to his service-connected cervical spine disability and not his lower back disability with radiculopathy. The Veteran contended the error incurred by the RO in mischaracterizing his claim. Thus, the Board has recharacterized the Veteran's claim as one of service connection for a right shoulder disability, to include as secondary to cervical spine spondylosis with radiculopathy. The Veteran's service treatment records (STRs) are silent for complaints or treatment sought or received for a right shoulder disability during service. The Veteran underwent a VA examination in connection with his claim for a cervical spine in April 2007. At that time, the VA examiner noted that the Veteran's neck pain "also refers to bilateral shoulder blades with constant pain described as a 10 out of 10. Post-service treatment records show that in November 2008, a VA provider referred the Veteran to physical therapy for cervical strengthening and "shoulder stabilization" as a result of the Veteran's cervical spine disabilities. See November 20, 2008 progress notes. The Veteran was afforded a VA examination in connection with this claim in April 2015. The Veteran reported that he developed his shoulder problems in 1983 and that he believed it is the result of his "back problems." He further noted that a January 2015 MRI performed by a private provider revealed ligament tears in his shoulders. The VA examiner did not provide a specific diagnosis for the claimed disability. The examiner opined that the claimed disability was less likely than not incurred in or caused by the claimed in-service injury, event. In support of his opinion, the examiner stated that musculoskeletal shoulder conditions are not known to medical science to be proximately caused by "chronic low back lumbar disc herniation at L4-5 with radiculopathy." The Board finds that the April 2015 VA opinion is inadequate to decide the Veteran's claim. The opinion appears to have been based solely on the Veteran's lumbar spine disability, whereas the claimed underlying condition, as the Veteran clarified in his August 2015 NOD, is his upper/cervical spine disabilities. Given the post-service medical evidence suggesting a potential relationship between the Veteran's cervical spine disabilities and his right shoulder disability, and because the April 2015 VA examiner failed to address the possible connection between the two, a remand is warranted for a new VA examination and opinion to comment on the nature and etiology of the claimed disability. In light of the remand, updated VA and private treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain any updated VA treatment records dated since November 2017. 2. Request from the Veteran, and assist in obtaining, any updated private treatment records in connection with this claim, to include records pertaining to a right shoulder surgery undergone in 2015. 3. Thereafter, schedule the Veteran for a VA examination by a qualified medical professional with respect to his right shoulder claim. The examiner should first identify any right shoulder disabilities, which may include a ligament tear. (i) Thereafter, the examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any identified right shoulder disability had its onset, or is otherwise related to the Veteran's military service. (ii) If not to (i), the examiner is then asked to provide an opinion as to whether any identified right shoulder disability is at least as likely as not (50 percent or greater probability) caused by, or aggravated by, a service-connected disability, to include his service-connected cervical spine spondylosis with radiculopathy. Aggravation is an increase in severity beyond the natural progress of the disease. (Continued on the next page) Consideration should be given to: (1) the April 2007 VA examination report indicating that neck pain also refers to bilateral shoulder blades with constant pain; and (2) the Reasons for Remand set forth above. A complete rationale must be provided for any opinion reached. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board William Pagan, 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.