Citation Nr: 23047697 Decision Date: 08/30/23 Archive Date: 08/30/23 DOCKET NO. 19-36 218A DATE: August 30, 2023 REMANDED Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for dizziness is remanded. REASONS FOR REMAND The Veteran had active-duty service in the United States Air Force (USAF) from December 2003 to December 2009. This appeal comes to the Board of Veterans' Appeals (Board) from a Department of Veterans Affairs (VA) July 2018 rating decision of the Agency of Original Jurisdiction (AOJ). 1. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected disabilities is remanded. The Veteran asserts that his left shoulder disability, claimed as arthritis, manifested by stiffness, pain, and limited mobility, as a result of his service-connected right shoulder disability. See April 2017 VA 27-0820 Report of General Information; February 2018 Claim; December 2019 VA Form 9; December 2020 Appellate Brief. The Veteran was given a VA examination in March 2017. The examiner did not diagnose any left shoulder conditions. The Veteran reported no flare-ups of the left shoulder and the examiner found there was no pain with range of motion testing, either active or passive, and no objective evidence of pain on non-weight bearing of the left shoulder. A March 2017 cervical spine examination found no sensory issues related to the cervical spine. The Veteran was also given a VA examination in July 2018. The examiner did not diagnose any left shoulder conditions. The Veteran reported that his left shoulder started hurting in the past year. A physical examination showed normal range of motion in the left shoulder with no painful motion, either active or passive, and there was no objective evidence of pain in non-weight bearing. The Veteran again did not report any flare-ups. Despite finding that the Veteran did not have a disability or pain resulting in functional impairment, the July 2018 examiner opined that there is "[n]o medical reason that [the] left shoulder would be strained related to [the] right shoulder." The rationale was that the left shoulder was normal on examination and there was no objective evidence on examination to warrant a diagnosis of a left shoulder condition. These examinations, however, did not address evidence that the Veteran has reported left shoulder pain that may be related to his cervical spine disability. September 2008 STRs show that an MRI of the neck was ordered based on complaints of numbness, weakness, and radicular pain in bilateral upper extremities with neck pain. March 2009 STRs show loss of normal cervical lordosis with a gradual kyphosis of the upper-to-mid cervical spine. The impression was reversal of cervical lordosis. The Veteran also complained of a sensation of needles going down the left upper extremity for about a week after his back and neck started hurting. June 2009 STRs from the 2nd Medical Group, Chiropractic Clinic, show the Veteran complained of pain in the neck and upper back as well as a shock-like sensation from the neck to the left hand. The Veteran was assessed with nonallopathic lesions, cervical, cervical radiculopathy, and myalgia and myositis. He was prescribed chiropractic treatment, electrical stimulation, and hot and cold application. July and August 2009 STRs show the Veteran complained of frequent, sharp, stabbing, shooting, dull ache in the neck, shoulder and back as well as numbness and tingling in the arms for several months. He was assessed with nonallopathic lesions, cervical, and cervical radiculopathy as well as paresthesias. May 2011 VA treatment records show the Veteran complained of neck, shoulder, and back pain for 3-4 years and he was assessed with cervical, thoracic, and lumbar myofascial pain syndrome and prescribed physical therapy. June 2011 VA physical therapy treatment records noted the Veteran presented with very rounded shoulders and slumped posture. November 2011 VA treatment records note the Veteran had complained of left-hand numbness sporadically. March 2016 VA treatment records show the Veteran reported chronic neck, back, and shoulders issues since 2006. January 2019 VA treatment records show the Veteran complained of dull pain in the right shoulder and numbness and pain in both arms. In May 2019 VA treatment records, the Veteran reported aching shoulder pain and tingling in his hands. While the Veteran claimed left shoulder arthritis, he is not competent to provide a specific diagnosis in this case. A remand is needed to clarify whether the Veteran has a left shoulder disability that is related to his cervical spine disability and to get an opinion that addresses the Veteran's history of complaints of left shoulder pain. 2. Entitlement to service connection for dizziness is remanded. The Veteran alleges that his dizziness is caused by, due to, or otherwise related to his military service. See Appellate Brief, December 2020. The Veteran was given several examinations that address his complaint of dizziness. In a January 2010 VA examination, the Veteran reported experiencing dizziness after changes in his physical position, such as going from sitting to standing. The examiner noted that while the Veteran did not have a traumatic brain injury (TBI) resulting from his in-service head injury, the Veteran's symptoms "are related to non-traumatic brain injury etiology." See C&P Exam, January 2010. The June 2017 VA vestibular examiner diagnosed dizziness due to head trauma and found the Veteran had positional dizziness and attributed it to Meniere's syndrome. However, the examiner then opined that it was not related to service because there was no objective evidence on examination to warrant a diagnosis for claimed dizziness. The examiner's opinion is inadequate because it did not address the Veteran's history of reports of dizziness or the January 2010 VA examiner's findings. Further, it was internally inconsistent regarding the nature of the Veteran's dizziness. The July 2018 VA vestibular examiner found the Veteran did not have a diagnosis of Meniere's syndrome or any other condition. The Veteran reported a couple of spells of dizziness in service and then experiencing more dizziness within the past year. He reported that when he gets up, he feels dizzy. The examiner concluded that while the Veteran reported some dizziness with change in position there was nothing positive on examination and no diagnosis. The examiner's opinion is inadequate because it does not actually address the Veteran's reported dizziness and explain why there is no underlying diagnosis or condition. A remand is needed to resolve this conflicting evidence regarding whether the Veteran has a condition manifested by dizziness and, if so, to obtain an adequate opinion regarding whether it is related to service, to include the Veteran's in-service head injury in approximately July 2005 and his complaints of dizziness in July 2009. See STR, March 2018. In July 2009, the Veteran complained of dizziness and vertigo-swaying back and forth when walking. A CT image of the brain was normal and he was assessed with light-headedness, possibly benign positional vertigo. He was referred to ear, nose, and throat for evaluation. See STR, March 2018; see also STR, March 2018. As noted above, he reported movement dizziness again during his January 2010 VA examination, in June 2015 VA treatment records, and during his June 2017 and July 2018 VA examinations. As such, a remand is necessary to obtain an adequate examination and an adequate medical opinion regarding the nature and etiology of the Veteran's dizziness. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination of the Veteran's complaints of left shoulder pain, to include as due to arthritis or a cervical spine disability. The examiner should review the claims file, including a copy of this remand, and answer the following: (a) Clarify the nature of the Veteran's left shoulder disability. If the examiner finds no formal diagnosis, the examiner should consider pain that results in functional impairment a disability for VA purposes. (b) For each disability, opine whether it at least as likely as not (likelihood in approximate balance, or greater) began during service or is otherwise related to service. (c) For each disability, opine whether it is at least as likely as not (likelihood in approximate balance, or greater) that the disability would not have developed, or would not have worsened or been prevented from improving, but for service-connected disability, to include cervical spine disability and right shoulder disability? The Veteran specifically contends that his left shoulder pain is due to his right shoulder disability. The examiner should review evidence that the Veteran's complaints of pain have been associated with his cervical spine disability: (d) September 2008 STRs show that an MRI of the neck was ordered based on complaints of numbness, weakness, and radicular pain in bilateral upper extremities with neck pain. (e) March 2009 STRs show loss of normal cervical lordosis with a gradual kyphosis of the upper-to-mid cervical spine. The impression was reversal of cervical lordosis. The Veteran also complained of a sensation of needles going down the left upper extremity for about a week after his back and neck started hurting. (f) June 2009 STRs from the 2nd Medical Group, Chiropractic Clinic, show the Veteran complained of pain in the neck and upper back as well as a shock-like sensation from the neck to the left hand. The Veteran was assessed with nonallopathic lesions, cervical, cervical radiculopathy, and myalgia and myositis. He was prescribed chiropractic treatment, electrical stimulation, and hot and cold application. (g) July and August 2009 STRs show the Veteran complained of frequent, sharp, stabbing, shooting, dull ache in the neck, shoulder and back as well as numbness and tingling in the arms for several months. He was assessed with nonallopathic lesions, cervical, and cervical radiculopathy as well as paresthesias. (h) May 2011 VA treatment records show the Veteran complained of neck, shoulder, and back pain for 3-4 years and he was assessed with cervical, thoracic, and lumbar myofascial pain syndrome and prescribed physical therapy. (i) June 2011 VA physical therapy treatment records noted the Veteran presented with very rounded shoulders and slumped posture. (j) November 2011 VA treatment records note the Veteran had complained of left-hand numbness sporadically. (k) March 2016 VA treatment records show the Veteran reported chronic neck, back, and shoulders issues since 2006. (l) January 2019 VA treatment records show the Veteran complained of dull pain in the right shoulder and numbness and pain in both arms. (m) In May 2019 VA treatment records, the Veteran reported aching shoulder pain and tingling in his hands. The examiner must provide a complete rationale and medical explanation for all opinions provided. If the examiner cannot provide the required opinions without resorting to mere speculation, they must explain why. 2. Schedule the Veteran for an examination of the Veteran's complaints of dizziness, to include as due to a head injury or a vestibular condition. The examiner should review the claims file, including a copy of this remand, and answer the following: (a) Clarify the nature of the Veteran's dizziness complaint. The examiner should review the January 2010, June 2017, and July 2018 VA examinations and resolve the conflicting findings regarding whether the Veteran's dizziness is a symptom of a head injury, Meniere's disease, or related to a change in position. (b) For each disability, opine whether it at least as likely as not (likelihood in approximate balance, or greater) began during service or is otherwise related to service, to include the Veteran's head injury in 2005, and to include the Veteran's complaints of dizziness in July 2009. (c) For each disability, opine whether it is at least as likely as not (likelihood in approximate balance, or greater) that the disability would not have developed, or would not have worsened or been prevented from improving, but for service-connected disability? The examiner should review evidence that the Veteran has complained of dizziness intermittently since service: (a) STRs showing an in-service head injury in approximately July 2005. (b) July 2009 STRs showing complaints of dizziness and vertigo-swaying back and forth when walking and an assessment of light-headedness, possibly benign positional vertigo. (c) The Veteran's reports during the January 2010 VA examination of dizziness after changes in physical position, such as going from sitting to standing. The examiner noted that while the Veteran did not have a traumatic brain injury (TBI) resulting from his in-service head injury, the Veteran's symptoms "are related to non-traumatic brain injury etiology." (d) June 2015 VA treatment records showing the Veteran reported movement dizziness. (e) The June 2017 VA vestibular examiner's diagnosis of dizziness due to head trauma and found positional dizziness attributed to Meniere's syndrome. (f) The Veteran's report during the July 2018 VA vestibular examination of a couple of spells of dizziness in service, and then more dizziness within the past year when he gets up. (Continued on the next page) ? The examiner must provide a complete rationale and medical explanation for all opinions provided. If the examiner cannot provide the required opinions without resorting to mere speculation, they must explain why. MARISSA CAYLOR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Neville, Mikael 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.