Citation Nr: 25004455 Decision Date: 04/01/25 Archive Date: 04/01/25 DOCKET NO. 20-17 875 DATE: April 1, 2025 REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a headache disability is remanded. REASONS FOR REMAND The Veteran served in the Army Reserve with an initial period of active duty for training (ADT) from January 1967 to June 1967 for which he has established "veteran status" based on awards of service connection for bilateral hearing loss and tinnitus related to his initial ADT. See Rating Decision (April 2024). He also has a period of active duty service from March 24, 1970 to March 26, 1970 and with additional Reserve service. This appeal comes before the Board of Veterans' Appeals (Board) from a September 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In an October 2023 decision, the Board denied the claims for service connection for a neck, bilateral shoulder, and headache disabilities. See BVA Decision (October 2023). The Veteran appealed the denial of his claims to the Court of Appeals of Veteran's Claim (Court). In an October 2024 Order, the Court endorsed the parties' findings in a Joint Motion for Partial Remand (JMPR), vacated the October 2023 Board decision that denied the service connection claims and remanded for compliance with the parties' instructions. See CAVC Decision (October 2024). In the JMPR, the parties agreed that the Board shoulder consider the significance, if any, of the Veteran's request for "a call" in relation to arguments he made in his March 2020 substantive appeal form. See CAVC Decision (October 2024); see also VA Form-9 (March 2020). In February 2025, the Board sent him a letter requesting clarification on his hearing request, and he responded in March 2025 asking the Board to withdraw his request for a hearing. See BVA Hearing Clarification (February 2025); Hearing Request (March 2025). As the request for a hearing has been withdrawn, the Board may proceed with this appeal. See 38 C.F.R. § 20.704(e). Lastly, additional VA-generated medical records, including non-VA scanned medical documents from Dr. Jenike from 2011 to 2013 held within VA electronic medical records systems, were recently associated with the claims folder. See VAMC Other Output / Reports (March 2025); see also CAVC Decision at 4 (outstanding records identified by the parties to the JMPR). To the extent the additional VA-generated evidence is applicable to the remanded claims, it will be considered on remand by the AOJ and addressed in a supplemental statement of the case (SSOC) if necessary. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. Issues 1-4: Entitlement to service connection for a neck disability, left shoulder disability, right shoulder disability, and headache disability are remanded. The Veteran contends that he injured his neck and shoulder during his active service while in boot camp in 1967, and he has had chronic problems since then. See Appellate Brief (January 2022). He further asserts that his bilateral shoulder and headaches are secondary to his current cervical spine stenosis. See Hearing Related (Decision Review Office Hearing (DRO)) (January 2020); VA Form 9 (March 2020); Appellant Brief (January 2022). Service treatment records (STRs) of record reflect no complaints or findings pertaining to the neck, shoulder, or headache; and show no abnormal pathology of the neck or shoulder. See STR-Medical (April 2016). Indeed, both a May 1967 Report of Medical Examination (RME) at his release from active duty and a July 1971 Reserve quadrennial RME reflects normal clinical evaluation of the head, neck, spine, upper extremities, and neurologic system, and the summary of defects and diagnoses reveals no annotation of symptoms or signs related cervical spine, shoulder, or headaches. See STR-Medical (April 2016). On the associated May 1967 and July 1971 Reports of Medical History (RMH) the Veteran denied having or ever having, frequent or severe headaches, lameness, arthritis, painful or trick shoulder, or neuritis. See STR-Medical (April 2016). Additionally, regarding question on the RMHs asking "[h]ave you ever had any illness or injury other than those already noted," the Veteran did not report symptoms or signs, treatment, or diagnoses related to neck, shoulders, or headaches. See STR-Medical (April 2016). Post-service treatment records show the Veteran presented with complaints of left shoulder pain in June 2008, but without identifying any known injury, and x-ray film revealed findings of mild degenerative changes in the left shoulder joint. See Medical Treatment Record - Non-Government Facility (April 2016). The first documented complaints of neck pain are shown in March 2010, which was associated with left trapezius tightness with trigger points. See Medical Treatment Record - Non-Government Facility (April 2016). Later, the Veteran was diagnosed as cervical spine stenosis and cervical radiculopathy, and he has complaints of head pain and bilateral shoulder pain that radiates from the neck. See Medical Treatment Record - Non-Government Facility (April 2016); VAMC Other Output / Reports (August 2016). To ensure that VA has met its duty to assist, the Board finds that remand is necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. First, the remand is necessary to obtain complete set of service records from his Reserve service. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(2) (VA's duty to assist includes obtaining records from a Federal department or agency). As noted by the parties to the JMPR, the record reflects the Veteran served in the Army Reserve from January 1967 to October 1972; however, the RO only requested his service records from January 1967 to June 1967, and March 1970. See CAVC Decision at 3. Other than the July 1971 RME and RMH, the record does not contain STRs from Army Reserve service outside his initial ADT period nor does the record indicate that the RO has sought to obtain additional records or determined that such records are unavailable. See STR - Medical (April 2016); VA 21-3101 Request for Information (April 2016). Therefore, a remand is required. Second, a remand is necessary to obtain relevant outstanding non-VA (private) treatment records identified by the record. See 38 C.F.R. § 3.159(e)(2) (if VA becomes aware of the existence of relevant records before deciding a claim, VA records). In April 2016, the Veteran submitted private treatment records from Novant Medical Group - Lakeside (Dr. Jenike) dated from May 2006 to May 2013, Presbyterian Orthopedics in January 2013, Carolina Neurosurgery & Spine in March 2013, and Carolinas Pain Center in May 2013. See Medical Treatment Record - Non-Government Facility (April 2016). However, these records indicate the Veteran received treatment prior to May 2006 from Novant Medical Group - Lakeside and VA treatment records indicate that the Veteran continued to seek non-VA treatment from Dr. Jenike in 2014. See CAPRI (April 2016). Also, the May 2013 treatment record from Carolinas Pain Center indicates additional treatment sessions at that medical facility from Drs. Hartman and Kwan in 2013. See Medical Treatment Record - Non-Government Facility (April 2016). The record does not reveal that VA has attempted to obtain private treatment records from these providers, to include asking the Veteran to submit an authorization for release of the private treatment records. See 38 C.F.R. § 3.159(e)(2). As these private treatment records, if obtained, could bear on the outcome of the Veteran's claims, specific efforts should be made to procure them. It is noted that, although VA has a duty to assist the Veteran in substantiating his claim, the duty is not a one-way street and claimants are expected to cooperate in the development of their claims. Woods v. Gober, 14 Vet. App. 214, 224 (2000); see also Hurd v. West, 13 Vet. App. 449, 452 (2000). The matters are REMANDED for the following action: 1. Obtain the Veteran's Army Reserve service treatment and personnel records from January 1967 to October 1972. Document efforts to obtain additional records, and if no additional records, then provide proper notice to the Veteran and his representative. 2. Update the Veteran's VA treatment records since May 2015 to present. 3. Ask the Veteran to complete a VA Form 21-4142 for treatment for signs and symptoms concerning his neck, shoulder, and headaches, to include from Dr. Jenike and Novant Medical Group - Lakeside prior to May 2006 and since May 2013, and from Carolinas Pain Center in 2013. Make two requests for the authorized records from the identified providers unless it is clear after the first request that a second request would be futile. 4. Conduct any additional development as necessary, and then readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.M., 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.