Citation Nr: 22039769 Decision Date: 07/12/22 Archive Date: 07/12/22 DOCKET NO. 18-29 679 DATE: July 12, 2022 REMANDED Entitlement to service connection for a right shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1999 to September 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2022. A transcript of that proceeding is associated with the record. Upon review, the Board finds that additional development is needed prior to adjudication of the issue on appeal. The service treatment records document complaints of right shoulder pain and popping in May 2002. The Veteran reported that he injured the shoulder moving rounds of ammunition, and he complained of right shoulder pain when lifting or playing sports. A physical examination was normal, and he was diagnosed with right shoulder pain. The Veteran was prescribed Motrin and ice as needed, and he was placed on a temporary profile. A June 2002 separation examination noted the reported history of right shoulder pain, but found that the Veteran's shoulder was normal. On the June 2002 report of medical history, the Veteran indicated that he had past or present swollen or painful joints. He described the right shoulder pain and popping, which was made worse by carrying heavy objects such as ammunition and playing sports. He stated that it also pops when he raises his right arm to pull himself up. The Veteran was afforded a VA examination in November 2016. The examiner noted the reported history of injuring his right shoulder during service loading ammunition. He reported having a sensation of popping of the right shoulder when he lifts something heavy since that time. He did not report any flare-ups or functional impairment. A physical examination was normal, and the Veteran had full range of motion with no pain noted on examination. X-rays of the right shoulder also showed no significant abnormality. The examiner found that there were no objective findings to render a diagnosis of a current right shoulder disorder. Nevertheless, since the November 2016 VA examination, private treatment records were received in June 2018. Those records include a September 2016 MRI report for the right shoulder revealing a small focus of tendinopathy of the infraspinatus tendon at its insertion. Other findings included a small subchondral cyst in the posterior humeral head and a downsloping type II acromion process. A physical examination at that time had also revealed crepitus with range of motion. The November 2016 VA examiner did not have the opportunity to review those records. Moreover, during the March 2022 hearing, the Veteran testified that he still experiences symptoms such as pain, but that he self-medicates rather than seeking medical treatment. The Board notes that pain alone, without a specific diagnosis or identifiable disease, may cause a functional impairment and therefore qualify as a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356, 1362 (Fed. Cir. 2018) (holding that a "disability" under 38 U.S.C. § 1110 refers to functional impairment of earning capacity; pain need not be diagnosed as connected to a current underlying condition to function as an impairment). Therefore, the Board finds that another VA examination and medical opinion are needed to determine the nature and etiology of any right shoulder disorder that may be present. The matter is REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his right shoulder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any right shoulder disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, hearing testimony, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current right shoulder disorders. If the Veteran does not have a current diagnosis associated with his reported symptoms, the examiner should state this with a fully reasoned explanation. The examiner should also state whether there is any functional impairment caused by the Veteran's reported pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. For each right shoulder diagnosis identified or any functional impairment caused by pain, the examiner should opine as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran's military service, to include any symptomatology or injury therein. The examiner should specifically address the May 2002 service treatment records documenting complaints of right shoulder pain and popping and the Veteran's reports that he first injured the shoulder in service while carrying heavy loads of ammunition, as well as the June 2002 separation examination report. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Chilcote 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.