Citation Nr: A25030516 Decision Date: 04/02/25 Archive Date: 04/02/25 DOCKET NO. 240712-455894 DATE: April 2, 2025 REMANDED Entitlement to service connection for trapezius muscle spasms of the left side is remanded. Entitlement to service connection for trapezius muscle spasms of the right side is remanded. REASONS FOR REMAND The Veteran had active service from August 1971 to August 1973. In July of 2024, the Veteran filed a notice of disagreement (NOD) in which he requested the direct review lane under the Appeals Modernization Act (AMA) review system in response to an April 2024 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Under direct review, no development may be undertaken; the Board of Veterans' Appeals considers the same record as the RO in rendering a decision. The only exception is if, as here, the Board finds that there was pre-decisional error by the RO. 1. Entitlement to service connection for trapezius muscle spasms, left side, is remanded. 2. Entitlement to service connection for trapezius muscle spasms, right side, is remanded. Turning next to the reasons for this remand, it is observed that the VA clinician who authored the October 2022 negative nexus opinion concluded that, "Veteran has claimed trapezius muscle spasms as being directly related to military service. The veteran's records are silent on left shoulder/trapezius spasm/issue during service. Shoulder and arm examination is normal. The issue would be better evaluated on a C spine evaluation which was not part of this examination. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of normal left shoulder and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. In addition, there is no convincing evidence in the record during service or since separation to connect 5 mile runs in basic training with full packs to his current condition over 40 years after separation from service. There is no evidence in the research to connect 5 mile running type events with packs to his current complaint of left trapezius muscle spasm which he describes as 'swelling' and tension. No mention of muscle spasm on examination is noted in the record until neurology workup for headaches in 2021. No convincing connection can be made to the veteran's current neck/trapezius complaint and service. The Veteran does not have a diagnosis of (a) trapezius muscle spasms that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) There is no doubt in my mind that this shoulder damage was caused by 5 mile runs in basic training with full back pack loads during service. A nexus has not been established." In particular relevance, this VA clinician indicated that, "Shoulder and arm examination is normal. The issue would be better evaluated on a C spine evaluation which was not part of this examination." Thus, this VA clinician's findings clearly indicated that an additional VA examination was warranted. Notably, the Board observes that the RO attempted to fulfill the duty to assist by administering contemporaneous VA examinations in regard to the respective conditions relevant to this appeal in the form of examinations for "neck and shoulder pain and tingling, nerve or muscle attached to the base of my neck on the left side, painful knot in my upper left shoulder" and "left side neck ligament problems". See May 2023 Exam Requests. Each of these examinations was cancelled due to, "Veteran unavailable". However, no correspondence to the Veteran containing notice of the examination time, date and location is of record. Therefore, the Board finds that the Veteran should be provided an additional opportunity to attend a scheduled VA examination before the claims are decided on the merits in order to ensure that this pre-decisional error is corrected. In addition, while the Board need not detail the internal inconsistencies in the prior opinion at this time for the sake of brevity, it should be ensured that any new opinion authored contains a rationale that is consistent with the conclusions reached. The matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination(s) with an appropriately situated VA clinician assess the nature and etiology of the claimed left and right trapezius muscle spasm conditions. The Veteran should be informed in advance of all scheduled VA examination(s) with all such efforts documented in the claims file. Further, the Veteran should be informed concurrent with the examination scheduling that a failure to report for any additional scheduled examinations without good cause could result in the denial of either or both of his claims. The clinician should provide a full description of the disability being evaluated and report all signs and symptoms necessary for evaluating the Veteran's claimed conditions. In addition, after administering all relevant tests and recording results, and following a confirmed review of the evidence of record, to include the lay statements of record, it should be clarified in regard to both claimed conditions: (a.) Whether the Veteran has or has had at any point during the relevant period, a confirmed diagnosis relevant to a claim on appeal. (b.) Whether the claimed condition is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to an in-service injury, event, or illness, to include as the result of any environmental exposure to in-service toxins. It is emphasized that a full rationale must be provided for all conclusions reached which should wholly address and reconcile to the extent possible the lay contentions and prior medical results recorded in the record, to include any neck-related complaints in the Veteran's post-service treatment records (such as Kaiser records from the 1980s) and any attestations regarding continuity since service. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a fully reasoned explanation, and the clinician is additionally asked to reconcile to the extent possible any conflicting evidence or opinions of record, and ensure that the opinion authored is internally consistent. A clear basis for all opinions should be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the clinician is unable to provide any of the requested information without resorting to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 2. Thereafter, adjudicate the Veteran's claims after consideration of the pertinent evidence. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Smith, 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.