Citation Nr: 22019041
Decision Date: 03/31/22	Archive Date: 03/31/22

DOCKET NO. 12-28 120
DATE: March 31, 2022

REMAND

Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected residuals of a midline episiotomy, is remanded.

REASONS FOR REMAND

The Veteran served on active duty from June 1974 to June 1977.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) (hereinafter Agency of Original Jurisdiction (AOJ)).

The Veteran testified at a January 2017 video conference hearing before the undersigned. A transcript of the hearing has been associated with the record. 

1. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected residuals of a midline episiotomy

The Veteran contends, in part, that her current left shoulder disability is causally related to events in service, to include an undocumented injury jumping into a foxhole as well as the rigors of duties which included carrying heavy objects and laying wire.  The Board has been unable to obtain an opinion by any examiner which sufficiently discusses her testimony.  The difficulty stems from discussing an injury that is not documented.  The Board will provide more specific remand directives to assist the examiners.

Accordingly, the matter is REMANDED for the following:

1. Forward the Veteran's claims file to a qualified examiner for an addendum opinion addressing whether the Veteran's left shoulder disorder is related to event(s) in service. The examiner should answer the following questions:

(a.) Whether there is a nearly equal chance or greater (i.e., probability of nearly 50 percent or greater) that the Veteran's diagnosed left shoulder disorder began in service, was caused by service, or is otherwise etiologically related to active-duty service, to include the wear and tear of carrying heavy objects during active-duty service and the reported injury while falling into a foxhole?  

The examiner should specifically accept as true that the Veteran injured her shoulder after having to jump into a foxhole during service and carried heavy equipment and laid wire during service although such events are not documented and describe whether such duties and the mechanism of injury described by the Veteran was sufficiently strenuous/severe to result in any current abnormalities of the left shoulder.

The examiner must address the significance of the October 2011 private medical records reflecting left shoulder pain due to carrying heavy loads during service.

The examiner should note that the Veteran is competent to attest to factual matters of which she has first-hand knowledge.  If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must state this with a fully reasoned explanation.

The examiner must provide a complete rationale for any opinions provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board.  In rendering this opinion, if the examiner finds any gap in time between the Veteran's military service and the onset of the disorder to be probative, he or she should provide an explanation of its medical significance.

 

 

T. MAINELLI

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Patrick C. Brady, 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.