Citation Nr: 22048664 Decision Date: 08/26/22 Archive Date: 08/26/22 DOCKET NO. 17-05 376 DATE: August 26, 2022 REMANDED Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1977 to September 1980. This matter comes before the Board of Veterans' Appeals (Board) from a May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing with the undersigned in April 2021. A transcript of that hearing has been added to the Veteran's file. This issue was previously remanded by the Board in February 2022 and has since been returned for further adjudication. Although the Board regrets additional delay, remand is necessary to obtain an addendum opinion. In February 2022 the Board remanded this issue to obtain an opinion that addressed his in-service diagnosis of anterior glenoid labrum avulsion and his July 1980 separation examination that noted painful or "trick" left shoulder. In May 2022, a VA examiner stated that all the shoulder pain visits were within a month period of time between January to February 1980. Report of medical history for separation dated July 14, 1980, Section 8 of the exam states, "left shoulder" and Section 11 indicates "Painful or 'trick' shoulder or elbow. There were no records after that of a recurrent left shoulder pain. The symptoms of left shoulder pain were forty-two years ago with no records of chronic recurrent left shoulder pain in the years after 1980 therefore it is less likely than not that the current left shoulder pain is due to the service. The examiner failed to address that the Veteran was diagnosed with anterior glenoid labrum avulsion in January 1980 and did not provide an opinion on whether this in-service diagnosis is related to any current left shoulder injury. Additionally, the examiner is reminded that the Veteran's is competent to report symptoms as he observes them, regardless of if he sought treatment, as this requires only personal knowledge as it comes to him through his senses. Layno v. Brown,6 Vet. App. 465, 470(1994). The examiner must consider these lay assertions when formulating the requested opinion and if the Veteran's reports are discounted, the examiner should still acknowledge the lay assertions and provide a reason for discounting them. The examiner is precluded from providing a negative opinion based on a lack of treatment post service without adequately considering the Veteran's statements. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to treatment for his left shoulder. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's current left shoulder disorder is related to his active duty service. In providing this opinion, the examiner must consider the following service treatment records (STRs): STR dated January 14, 1980 showing a one-month history of shoulder pain following an injury when the Veteran fell with his humerus extended and in external rotation, with positive apprehension tests and crepitus in the acromioclavicular joint and a diagnosis of anterior glenoid labrum avulsion; STR dated February 1, 1980 showing treatment for the left shoulder; STR dated February 21, 1980 showing that the Veteran re-injured his left shoulder six days ago during a physical training (PT) test; and STR dated July 14, 1980 (separation examination) wherein the Veteran indicated on his Report of Medical History that he had painful or "trick" shoulder and specifically noted his left shoulder. (Continued on the next page) The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. H. 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.