Citation Nr: 23022262
Decision Date: 04/13/23	Archive Date: 04/13/23

DOCKET NO. 10-01 319
DATE: April 13, 2023

REMANDED

Entitlement to service connection for a left shoulder disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from June 1986 to June 1990.

This matter comes before the Board of Veterans' Appeals (Board) from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).  The Veteran testified at a hearing with the undersigned in June 2010. 

This issue has been remanded multiple times in 2012, 2015, 2016, 2018, 2019, 2021, and 2022.  Although the Board regrets additional delay, remand is necessary to obtain an adequate opinion.  Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).  A medical opinion based upon an inaccurate factual premise has no probative value.  Reonal v. Brown, 5 Vet. App. 458, 461 (1993).

In March 2022, the Board remanded this issue to obtain an opinion determining if the Veteran's left shoulder disability was caused by or related to his military service, as the Veteran was presumed sound on entrance. 

In May 2022 a VA opinion was obtained. The examiner provided an adequate secondary service connection opinion.  The examiner provided a negative nexus direct service connection, noting that while the Veteran had a reported injury in service, he had no complaints for greater than 13 years after separation when he sought workman's compensation and that condition of suggested longevity would have certainly required medical attention over the 13-year time span. But in May 1995, the Veteran was seen and diagnosed with bilateral shoulder impingement, demonstrating that he sought treatment prior to his workman's compensation claim. Thus, this opinion is based upon an erroneous factual record and is inadequate for adjudication.  

The matters are REMANDED for the following action:

Obtain an addendum opinion regarding the etiology of each left shoulder disorder from a VA clinician.  The entire claims file must be made available to and be reviewed by the examiner.  If an examination is deemed necessary, it shall be provided.  An explanation for all opinions expressed must be provided.  

The clinician must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each diagnosed left shoulder disorder had onset in, or is otherwise related to, active service, including his reported in-service fall from his bunk bed.

The clinician should address the following: (a) the service treatment records noting chronic shoulder dysfunction due to calcium deposits, probably supraspinatus tendonitis, possible bursitis, and normal x-rays; (b) October 1992 and September 1994 examinations in which the Veteran denied arthritis, rheumatism, bursitis, and a painful or "trick" shoulder, and clinical evaluation of the upper extremities and musculoskeletal system was normal; (c) 1995 private records that noted bilateral shoulder impingement; and (d) lay statements in which the Veteran reported he injured his shoulders in service when he fell off a bunk, and that he has shoulder symptoms since that time

For the purposes of this remand only, the examiner should assume that the Veteran's lay assertions concerning his left shoulder pain in service and subsequent issues are true. If there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's recollection is inconsistent with the principles of medical science and/or the evidence in this case.

 

 

K. MILLIKAN

Acting 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.