Citation Nr: 25005368
Decision Date: 04/21/25	Archive Date: 04/21/25

DOCKET NO. 19-24 526
DATE: April 21, 2025

REMANDED

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

REASONS FOR REMAND

The Veteran served in the Army National Guard from September 1985 to September 1995 with active duty service from January to June 1986, and November 1990 to April 1991. 

This matter comes to the Board of Veterans' Appeals (Board) from an August 2018 rating decision issued by the agency of original jurisdiction (AOJ). In October 2024, the Board remanded the appeal for a medical nexus opinion, which was obtained in February 2025.

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

The Veteran relates that he injured his left shoulder when he jumped off of a tank while carrying a heavy toolbox with his left hand. See February 2025 Shoulder and Arm Conditions Disability Benefits Questionnaire (DBQ) at 3 (reporting the injury occurred around 1991). The current VA examination noted a diagnosis of left shoulder strain disability. Id. 

Although the Board regrets the delay, the Veteran's claim must again be remanded for a medical nexus opinion. Barr v. Nicholson, 21 Vet. App. 303,311-12 (2007). In the October 2024 Board remand, it directed a VA examiner to address whether the Veteran's left shoulder injury resulted in his current left shoulder sprain disability. The Board cannot accept the February 2025 VA examiner because she did not address the questions in a way that are adequate to decide the claim. The examiner opined that the left shoulder disability is not related to service because there is an absence of in-service medical evidence documenting left shoulder problems. See February 2025 Medical Opinion ("There is/are no service period medical record(s)/supporting documentation involving a left shoulder related injury.") The Board cannot rely on this opinion because the absence of medical documentation of the injury cannot be the sole basis for an unfavorable nexus opinion. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (holding that in general, absence of evidence should not be considered as negative evidence). The claim must be remanded for an addendum medical opinion that helps the adjudicator make an informed decision on the Veteran's left shoulder disability claim.

The matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left shoulder disability is related to service. The Veteran may be recalled for examination, if necessary. 

The examiner is asked to respond to the following:

a.	Is the Veteran's left shoulder strain disability at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to active service, including jumping off of a tank while carrying toolboxes in each hand (sometime around 1991)? For purposes of the examination, the clinician should know the only active duty service periods are from January to June 1986, and November 1990 to April 1991.

The examiner must provide a complete rationale for his or her opinion(s) in the examination report. The examiner is advised that a negative opinion may not be based solely on the absence of treatment during or after service and that the examiner must provide a proper foundation explaining why the absence of evidence is relevant in determining whether the disability is related to service. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion.

 

DAVID L. WIGHT

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Dean, Michael S.

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.