Citation Nr: 22019230 Decision Date: 03/31/22 Archive Date: 03/31/22 DOCKET NO. 15-03 383 DATE: March 31, 2022 REMANDED Entitlement to service connection for a right shoulder disability, to include SLAP lesion and labrum tear status-post arthroscopic repair and arthritis, is remanded. Entitlement to service connection for a left shoulder disability, to include impingement and arthritis, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 8, 1980 through July 29, 1980; September 1986 through July 1990; January through May of 1991; January through June of 2007, to include service in Qatar from January through May of 2007; and, January 2010 through April 2013. The Veteran testified during a May 2015 Board hearing. A transcript is of record. A February 2022 letter notified the Veteran that the Veterans Law Judge who presided over her May 2015 hearing is no longer employed at the Board. She was advised that she had 30 days from the date of the letter to request a new hearing before a current sitting Board member. A timely reply has not been received from the Veteran. The issues on appeal were remanded previously by the Board in July 2018. The agency of original jurisdiction (AOJ) has taken steps to perform the development ordered by the Board. The matter now returns to the Board for review. This appeal previously included issues concerning the Veteran's entitlement to service connection for low back, right knee, and left knee disabilities. Those issues were granted to the Veteran by the AOJ in rating decisions issued to the Veteran in June 2020 and July 2020 and no longer remain on appeal. Entitlement to service connection for disabilities of the bilateral shoulders is remanded. The Veteran contends on appeal that she is entitled to service connection for disabilities in both shoulders. In an October 2011 statement, she asserts that the conditions in her shoulder resulted from repetitive strain from frequently lifting overhead during her active service. She elaborated in her May 2015 Board hearing testimony that she performed duties during service primarily as an aeromedical evacuation technician and described that her duties required her to frequently lift, carry, and load patients from on and off aircraft and to lift frequently above her shoulder height. Treatment records in the claims file include January 2004 right shoulder x-rays that showed narrowing of the acromioclavicular (AC) joint and slight upward translation of the clavicle. A right shoulder MRI conducted in October 2004 showed degenerative changes in the AC joint with a small inferiorly projecting spur, inferiorly projecting acromion indenting the lateral aspect of the supraspinatus tendon associated with impingement, and a labral cyst adjacent to the anterior superior labrum. Operative reports in the claims file from First State Surgery Center show that the Veteran underwent arthroscopic repair for a right shoulder SLAP lesion and labrum tear in December 2004 and manipulation and steroid injection for right shoulder adhesive capsulitis in April 2005. A December 2011 shoulder examination revealed findings that were consistent with degenerative joint disease and strain. Relative to the Veteran's left shoulder, x-rays taken in January 2003 showed a small cystic formation in the distal clavicle. The December 2011 shoulder examination also noted objective and x-ray findings that were consistent with diagnoses for degenerative joint disease and strain in the left shoulder. Pursuant to the Board's July 2018 remand, the Veteran was afforded an October 2019 shoulder examination. Again, physical and radiological findings during the examination were interpreted by the examiner as showing degenerative or traumatic arthritis. Based on documented history, the examiner also diagnosed right shoulder labral and SLAP tear and left shoulder impingement syndrome. The examiner offered conflicting etiology opinions for the Veteran's shoulder disability. In that regard, he states that the Veteran's shoulder conditions clearly and unmistakably pre-existed the Veteran's active service, but at the same time states in his rationale that the evidence does not document that the Veteran's conditions existed prior to her active service. To the extent that the examiner suggests the opinion that the Veteran's shoulder did or did not exist prior to active service and that he believes that the Veteran incurred both shoulder disabilities after active service, the examiner did not identify or delineate which periods of service were pre-existed by the Veteran's shoulder disabilities, or, which period of service preceded the Veteran's shoulder injuries. Hence, it remains unclear as to whether the examiner was aware of the Veteran's active duty dates and had a clear understanding of when the Veteran's injuries occurred relative to her documented periods of service. Further, to the extent that the examiner concluded that the Veteran's shoulder disabilities were not aggravated during service, the examiner provided no explanation or rationale for that opinion. For these reasons the findings and conclusions expressed by the October 2019 examiner are incomplete. The AOJ also obtained a June 2020 medical opinion as part of the post-remand development. Although the reviewing clinician opined that it is less likely than not that the Veteran's shoulder disabilities were incurred during service or caused by the Veteran's active service, he states incorrectly that the record contains no documentation of the Veteran's 2004 right shoulder SLAP tear repair or 2005 right shoulder procedure. To the extent that those records may have informed the reviewing clinician's opinion, his opinion is incomplete. Moreover, although the reviewing clinician appears to conclude that the Veteran's shoulder problems began in 2004 while she was not on active duty, he does not acknowledge the Veteran's periods of active service from January through June of 2007 and from January 2010 through April 2013. The reviewing clinician provides no opinion as to whether the Veteran's pre-existing shoulder problems were aggravated during those periods of service. For these reasons, the June 2020 medical opinion is also incomplete. In a February 2022 brief, the Veteran's representative notes that the October 2019 examiner failed to delineate in his opinion and rationale whether the degenerative joint disease in the Veteran's shoulders are separate and distinct conditions from the Veteran's other shoulder diagnoses and, if so, whether the degenerative joint disease in the Veteran's shoulders is related etiologically to the Veteran's active service. The Board agrees that such an opinion would be of assistance here. Lastly, the Veteran's service personnel records show that she served in Qatar from January through May of 2007. Service connection may be presumed in the case of a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability (includes an undiagnosed or medically unexplained chronic multi-symptom illness) that became manifest during active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2026. 38 C.F.R. § 3.317(a)(1). A Persian Gulf veteran is defined as a veteran who served on active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Southwest Asia theater of operations includes Qatar. 38 C.F.R. § 3.317(e)(2). The period of the Persian Gulf War extends from August 2, 1990 to the present. 38 C.F.R. § 3.2(i). For purposes of 38 C.F.R. § 3.317, the regulations recognize three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). A MUCMI is defined by a cluster of signs or symptoms, and specifically includes joint pain. 38 C.F.R. § 3.317(a)(2)(ii). It means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. MUCMIs of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Given the Veteran's service in the Southwest Asia theater of operations and documented shoulder pain symptoms and degeneration, an opinion as to whether the degenerative joint disease in the Veteran's shoulders are manifestations of a MUCMI attributable to the Veteran's service in Qatar would also be of assistance. Given the breadth of the deficiencies in the October 2019 examination and June 2020 medical opinion, the Veteran should be scheduled to undergo a new examination of her shoulders to determine the nature and etiology of all disabilities diagnosed in both shoulders. The matters are REMANDED for the following action: Schedule the Veteran for an examination to determine the nature and etiology of any disabilities in her shoulders. The claims file should be reviewed by the examiner in conjunction with the examination. The examiner should conduct all necessary tests and studies and provide a diagnosis for all identified disabilities in the Veteran's right and left shoulders. The examiner should provide the following medical opinions: A) Is the etiology of the Veteran's shoulder disabilities (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. B) Is the pathophysiology of the Veteran's shoulder disabilities (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. If not, then provide the following medical opinions as well: C) Does the Veteran's diagnosis of arthritis or degenerative joint disease of the shoulders constitute a separate and distinct condition? D) If so, did the Veteran's arthritis or degenerative joint disease clearly and unmistakably pre-exist any of her periods of active service? E) If arthritis or degenerative joint disease in the Veteran's shoulders clearly and unmistakably pre-existed any of the Veteran's periods of active service, were the Veteran's arthritis and degenerative joint disease clearly and unmistakably not aggravated beyond its natural progression during one of her subsequent periods of active service? F) For all shoulder disabilities other than arthritis or degenerative joint disease, did the disability clearly and unmistakably pre-exist any of the Veteran's periods of active service? G) If so, was the disability clearly and unmistakably not aggravated beyond its natural progression during one of her subsequent periods of active service? H) For any shoulder disability other than arthritis or degenerative joint disease that did not clearly and unmistakably pre-exist service or was not clearly and unmistakably not aggravated by service, is it at least as likely as not that the disability was incurred during one of the Veteran's periods of active service or resulted from an injury, illness, or disease that occurred during one of her periods of active service? The examiner should provide a complete rationale for all opinions, to include a discussion of the facts and medical principles involved in forming those opinions. The opinion must address the Veteran's contention that her current shoulder disabilities are related to her in-service duties as an aeromedical evacuation technician, which required her to frequently lift, carry, and load patients on and off of aircraft and to lift frequently above her shoulder height. If an opinion cannot be given without resorting to mere speculation, the examiner must provide a complete explanation for why the opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. The examiner should provide a detailed rationale that explains fully all the reasons for the given opinions. T. J. ANTHONY Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Lee 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.