Citation Nr: 22020135 Decision Date: 04/04/22 Archive Date: 04/04/22 DOCKET NO. 17-18 234 DATE: April 4, 2022 REMANDED Entitlement to service connection for a right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1976 to July 1985, with additional service in the United States Army Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The issue of entitlement to service connection for a right shoulder condition was initially denied in a March 1986 rating decision, upon a finding that the condition had resolved during service and there was no current disability. In a January 2011 rating decision, the RO found that new and material evidence had not been submitted sufficient to reopen the previously-decided claim. In the February 2015 rating decision here on appeal, the Agency of Original Jurisdiction (AOJ) reopened the issue, but confirmed and continued the denial. The Board has reviewed the evidence submitted in support of the Veteran's request to reopen the issue of entitlement to service connection for a right shoulder disability, and finds that new and material evidence has been submitted; and the claim may thus be reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998); Barnett v. Brown, 8 Vet. App. 1 (1995) (the Board has an obligation to make an independent determination of its jurisdiction regardless of findings or actions by the RO), aff'd, 83 F.3d 1380 (Fed. Cir. 1996). In November 2021, the Veteran presented testimonial evidence at a virtual Board hearing held before the undersigned Veterans Law Judge. The transcript of the hearing is associated with the record. Entitlement to service connection for a right shoulder disability is remanded. Further development is found warranted prior to adjudication of the present appeal. Specifically, action must be taken to ensure that all relevant service treatment records (STRs) from the Veteran's reserve service are obtained and associated with the file, and to obtain an adequate examination and medical opinion. The Veteran asserts that he suffers from a current right shoulder disability relating to right shoulder injuries he sustained during his period of active duty in the U.S. Army. At the Board hearing, he described overuse injuries from carrying and throwing heavy para cable wires as part of his military occupational specialty as a switchboard operator and wire installer, as well as a training injury from falling and hitting the backside of his shoulder. He described experiencing a constant, nagging pain during service that continued after leaving the Army, until the present. Service treatment records from the Veteran's period of active duty document right shoulder symptoms and a diagnosis of bursitis. However, a January 1986 report of medical examination in connection with the Veteran's earlier claim for service connection found that the Veteran's right shoulder was unremarkable; and the report states that although the Veteran was reluctant to exert the right shoulder for fear of recurrence of the bursitis, it was not actually painful or limiting at that time. Review of the electronic claims file reveals that relevant service treatment records from the Veteran's period of Army Reserve service may be in the custody of the Federal Government, but are not yet of record. In an earlier application for compensation and pension, the Veteran indicated that he served with the Army Reserve from August 1985 to May 1995. While it appears that the Veteran has submitted select STRs from this period, there is no indication that the AOJ has attempted to obtain the Veteran's complete STRs from his period of reserve service. This should be completed, on remand. The Veteran was previously provided with a VA examination of the right shoulder in December 2014. The examination report states that the Veteran noticed right shoulder pain in 1995 while drilling a hole, and underwent surgical correction of a diagnosed right rotator cuff tear, and subsequently fell in 2011 or 2012, suffering another rotator cuff injury. The examiner stated an opinion that the Veteran's right shoulder condition was less likely than not incurred in or caused by his in-service injury, event, or illness, stating a rationale that the Veteran reported having bursitis in 1978 after lifting weights, but his symptoms resolved, and the Veteran did not have any recurrence of symptoms before he left the military. The Board notes, however, that service treatment records from February 1981 indicate injury to the right shoulder 7 months prior with continued pain and jointline tenderness to the touch, with a diagnosis of bursitis, and an October 1983 STR notes complaints of a sore right shoulder following a motor vehicle accident. Inasmuch as the examiner's conclusion is based on an inaccurate factual premise, it lacks probative value and is found to be inadequate for adjudicatory purposes. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). When VA provides an examination or obtains a medical opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, a supplemental medical opinion should be sought which considers the full evidence of record. In finding that an additional medical opinion is needed, the Board recognizes that following the hearing, the Veteran submitted a letter from a private physician stating that "[the Veteran's] shoulder injury occurred while he was in active duty." While supportive of the Veteran's claim, such opinion is found insufficient to support a grant of service connection, as it is purely conclusory in nature and does not reflect consideration of evidence of intervening injuries to the right shoulder documented in record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning and that it must be clear that the medical expert applied valid medical analysis to the significant facts of a particular case); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that "the mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion"). Of note, a December 1993 private physical and occupational therapy treatment record, submitted by the Veteran, indicates that the Veteran was seen for neck and bilateral shoulder pain/tendonitis present since a motor vehicle accident in October 1993. The treatment record indicates that the Veteran had a previous history of right shoulder pain, but that symptoms had resolved at the time of the recent motor vehicle accident. A probative etiological opinion, at the very least, should reflect awareness of this history of intercurrent injury to the right shoulder. The matter is REMANDED for the following action: 1. Obtain the Veteran's complete service treatment and service personnel records from his period of Army Reserve service (August 1985 to May 1995). All requests and responses should be documented for the file. If unsuccessful, a Formal Finding of Unavailability should be prepared, and the Veteran notified. 2. After associating all records responsive to the above with the claims file, refer the claims file to a suitably qualified medical professional for a supplemental medical opinion concerning the nature and etiology of the Veteran's right shoulder disability. The claims file should be made available to the clinician for review in connection with providing the following opinion. If additional examination is found needed, the Veteran should be scheduled for an examination and provided with sufficient notice. Based on review of the record, the clinician is asked to state an opinion as to whether it is at least as likely as not that the Veteran's current right shoulder disability arose during or is otherwise related to his active service (January 1976 to July 1985). In providing the requested opinion, the clinician should consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. The clinician's attention is directed to (but should not be limited to) the following evidence of record: - February 1981 STR: noting continued pain and jointline tenderness of the right shoulder following injury to the shoulder while doing pushups 7 months previously; - February 1981 STR: noting pain to the right shoulder for two days, and assessing bursitis; - October 1983 STR: documenting motor vehicle accident with complaint of sore right shoulder; - January 1986 Report of Medical Examination: noting right shoulder injury while lifting weights in 1978, but finding the right shoulder unremarkable at the time of the January 1986 examination; - October 1992 radiology report of right shoulder showing no significant osseous or joint pathology, following Veteran's report of right glenohumeral joint pain increased as work; - December 1993 private physical therapy note documenting bilateral shoulder tendonitis with upper back/shoulder pain present since October 1993 motor vehicle accident, includes a previous history of right shoulder pain and bilateral shoulder tendonitis, with notation that symptoms had resolved at the time of the recent motor vehicle accident; - March 2012 shoulder MRI noting old rotator cuff repair approximately 10 years ago, with acute injury and fall in December 2011; - November 2021 Veteran's hearing testimony that he sustained right shoulder injuries during active service carrying and throwing heavy para cable wires, falling and hitting the backside of his shoulder during training, and continual overexertion despite the constant, nagging pain, with symptoms continuing to the Present; - February 2022 opinion statement from the Veteran's physician that the Veteran's shoulder injury occurred while he was in active duty. The clinician must provide a clear rationale for any opinion or conclusion stated. 3. After completing the above, and conducting any further development deemed necessary in light of the expanded record, readjudicate the claim for service connection for a right shoulder disability. If the benefits sought remain denied, issue the Veteran and his representative a supplemental statement of the case and allow them an opportunity to respond before returning the case to the Board for further appellate review, if in order. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Solomon, 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.