Citation Nr: 1648527	
Decision Date: 12/30/16    Archive Date: 01/06/17

DOCKET NO.  11-28 649	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Montgomery, Alabama


THE ISSUES

1.  Entitlement to service connection for bilateral tinnitus.

2.  Entitlement to service connection for left carpal tunnel syndrome.

3.  Entitlement to service connection for a right shoulder disability.

4.  Entitlement to service connection for a left shoulder disability.

5.  Entitlement to an initial evaluation greater than 10 percent for the service-connected right carpal tunnel syndrome.


REPRESENTATION

Appellant represented by:	Alabama Department of Veterans Affairs



WITNESS AT HEARING ON APPEAL

Veteran


ATTORNEY FOR THE BOARD

L.J. Bakke, Counsel


INTRODUCTION

The Veteran served on active duty from December 1971 to October 1991.  

This appeal to the Board of Veterans Appeals (Board) arose from a July 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama.

The Veteran testified before the undersigned Veteran's Law Judge during a September 2016 video teleconference hearing.  A transcript of that testimony is associated with the claims file.

The issues of service connection for right and left shoulder disabilities, and to entitlement to an evaluation greater than 10 percent for right carpel tunnel syndrome is addressed in the REMAND portion of the decision below and REMANDED to the Agency of Original Jurisdiction (AOJ).



FINDINGS OF FACT

1.  The Veteran's currently diagnosed bilateral tinnitus is related to active duty service.

2.  The Veteran's currently diagnosed left carpal tunnel syndrome is related to active duty service.


CONCLUSIONS OF LAW

1.  The criteria for entitlement to service connection for bilateral tinnitus have been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2014); 38 C.F.R. § 3.102, 3.303, 3.304, 3.307, 3.309 (2016).

2.  The criteria for entitlement to service connection for left bilateral carpal tunnel syndrome have been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2014); 38 C.F.R. § 3.102, 3.303, 3.304, 3.307, 3.309 (2016).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I. Duties to Notify and Assist

The Board is cognizant of VA's notification and assistance requirements under 38 U.S.C.A. § 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. § 3.159 (2016).  However, given the favorable actions taken below as to the issue on appeal, no further notification or assistance in developing the facts pertinent to that limited matter is required at this time.


II. Analysis

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service.  38 U.S.C.A. § 1110, ; 38 C.F.R. § 3.303(a).  Establishing service connection generally requires competent evidence of three things:  (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability.  Holton v. Shinseki, 557 F.3d 1362, (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).  

If certain diseases, including organic diseases of the nervous system, become manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of such disease during service.  This presumption is rebuttable by affirmative evidence to the contrary.  38 U.S.C.A. § 1101, 1112, 1113; 38 C.F.R. § 3.307, 3.309.  

An alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" under 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology.  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Barr v. Nicholson, 21. Vet. App. 303, 307 (2007).  A claimant can establish continuity of symptomatology with competent evidence showing:  (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology.  38 C.F.R. § 3.303(b).  Organic disease of the nervous system, as recognized as a chronic disease under 38 C.F.R. § 3.309, is one of the conditions in which the theory of continuity of symptomatology can be applied.  See Walker, supra.  

However, evidence relating the currently diagnosed condition to service must be medical unless it relates to a disorder that may be competently demonstrated by lay observation.  Walker, supra and Savage, 10 Vet. App., 488 at 495-97 (1997).  For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic."  38 C.F.R. § 3.303(b).  

Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b).

Tinnitus

Service connection for tinnitus was originally denied as a condition which neither occurred in nor was caused by service (see July 2009 rating decision, p.4; see also August 2011 SOC, p. 14).  While a May 2009 VA examination for audiology reflects that the Veteran reported tinnitus, the examiner noted that the Veteran reported onset of the condition ten years prior, which would have been in 1999, or eight years following discharge (see May 2009 VA audiological examination, p. 2).  Acknowledging the Veteran's complaints of current ringing in his ears and his report of inservice noise exposure, the examiner nonetheless explained that the onset of the condition was, by the Veteran's own report, eight years after discharge from active service (Id., p. 2-3).  It is noted that the VA examiner made reference to audiological findings in the service treatment records-specifically the Veteran's report of medical examination at entrance to and discharge from active service, dated in December 1972 and June 1991, respectively (Id., p1).  Based in part on findings of hearing loss revealed on the Veteran's June 1991 report of examination at separation, service connection for left ear hearing loss was service connected (Id., p. 1; see also July 2009 rating decision, p. 3).

The Veteran averred that his claimed tinnitus had its onset during active service.  In September 2016, he testified before the undersigned Veterans Law Judge that he was employed as a mechanic for 18 years in the military and was exposed constantly to loud noises, including jet engines, his entire time.  He described his first four years, in which he worked as a catapult mechanic the USS ENTERPRISE (CVN-65) and the USS CONSTELLATION (CV-64)-both aircraft carriers-as involving 12+ hour shifts working around jet engines (see Board Transcripts, p. 3).  Even with hearing protection, he acknowledged, he experienced ringing in his ears during service, which continued from then to the present (Id., pp. 4, 5).  He further testified that he was not exposed to such noise post-service (Id., pp. 4).  

In September 2016, the Veteran submitted additional evidence with waiver of AOJ review.  Included is an October 2011 VA treatment entry that show a diagnosis of tinnitus and a notation that the condition had its onset during active service (see Pvt & VA rec post hrng w/waiv p. 3, rec'd September 8, 2016).  

Service medical records reflect observations of and treatment for hearing loss during active service.  Of note are entries dated in August 1991 associated with his retirement physical.  These records show a past history of extensive noise exposure around jet aircraft.  The Chief of Audiology, who signed the report, noted that the asymmetric decreased hearing acuity was probably associated with noise exposure (see STRs: retirement audio w/+opinion noise exp ('91)( p4-5), audio/ENT, dental, p. 5, rec'd May 9, 2016).

Furthermore, the Veteran is competent to observe and attest to having ringing in his ears, and to have those symptoms from service or shortly thereafter to the present.  See Layno v. Brown, 6 Vet. App. 465, 469 (1994).  Despite some discrepancies between his reported history and his testimony before the Board-for example, that he reported in the May 2009 VA examination for audiology his tinnitus began approximately ten years prior-the Board finds that the Veteran's reports, statements, and testimony are generally consistent, i.e., that he experienced the onset of ringing in his ears during service and that he experienced ringing in his ears from service to the present.

The Board turns to the question of whether service-connection may now be granted for tinnitus.  For reasons explained below, the Board finds in the positive.

In May 2009, the VA examiner for audiology opined tinnitus was less likely as not related to or caused by the Veteran's military noise exposure based on the Veteran's self-report that his tinnitus had its onset ten years prior, or about eight years following his discharge.  However, the Veteran testified before the undersigned Veterans' Law Judge that the onset of ringing in his ears began while he was on active service immediately following exposure to acoustic trauma from jet engine noise, especially during his work as a catapult mechanic on board aircraft carriers.  

The Board finds the Veteran to be a credible witness.  The Board further observes that the Veteran's statements are consistent with his military occupational specialty (MOS) as an AMH, or Aviation Structural Mechanic (hydraulic mechanic).  In addition, and as noted above, service treatment entries show an increase in hearing impairment during active service.  In particular, entries associated with his retirement physical reflect observations of extensive noise exposure around jet aircraft and audiometric findings consistent with noise induced hearing loss.  Given the foregoing, the Board accepted the veracity of the Veteran's statements concerning the manifestation of ringing in his ears occurring during active service in conjunction with his exposure to acoustic trauma.  The Board concludes that the examiner's dating the onset of tinnitus to eight years after the Veteran's active service is based on an erroneous understanding-either of the Veteran in his response to the examiner, or in the examiner's interpretation of the Veteran's response.  

Because the May 2009 VA examiner's opinion is found to be based on erroneous information, it cannot therefore be probative.  See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); see also Dalton v. Peake, 21 Vet. App. 23 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) and Sklar v. Brown, 5 Bet. App. 140 (1993).  

Given the lack of probative value in the May 2009 negative audiological opinion and the Veteran's competent and credible testimony that he first noticed the onset of ringing in his ears during active service and that ringing in his ears has been consistently present from then to the service-which is consistent with service treatment entries concerning the impact of acoustic trauma on his hearing acuity and with his MOS-the evidence is, at the least, in equipoise.  As such, the benefit of the doubt weighs in favor of the Veteran as to whether his tinnitus is related to service.  

Entitlement to service connection for bilateral tinnitus is appropriate.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102(a); see also Layno, supra.

Left Carpel Tunnel Syndrome

In this case, left carpal tunnel syndrome was originally denied as a condition not found on examination or in clinical findings, and as a condition that neither occurred in nor was caused by service.  (see July 2009 rating decision, pp. 3,6).  While service treatment records were found to show complaints of intermittent pain and paresthesia with a note of carpal tunnel syndrome in the left, as well as right, arm in July 1991, clinical studies revealed no evidence of carpal tunnel syndrome in the left upper extremity in March 2009 (see August 2011 Statement of the Case (SOC), p. 14; see also Pvt rec (Dr. DM, R Hosp) 1988, 1996-2009 (not sure '88 same hosp), tx CTS, incl Dr. RA EMG/NCV p5, pp. 5-7, rec'd June 24, 2009).

The Veteran has attributed his left carpal tunnel syndrome to the physical work he performed as a mechanic, specifically to the wear and tear over the years.  In August 2016, he testified before the undersigned that he was not able to put down his toolbox in the 18 years he was in the military (see Board Transcripts, p. 7).  Pain and symptoms of right and left carpal tunnel persist from service to the present day, equally in both the right and left wrists, hands, and forearms (Id., pp. 10-14).  During active service, he was treated with splints for the condition.  Post-service, in 1995, he had surgery on both hands for carpal tunnel syndrome (Id., p. 7-8).  He testified he was also treated with Lyrica and Lortab, which he found did not work well (Id., p. 10).  

It is noted that Dr. RA interpreted the March 2009 EMG/NCV test results as abnormal (see Pvt rec (Dr. DM, R Hosp) 1988, 1996-2009 (not sure '88 same hosp), tx CTS, incl Dr. RA EMG/NCV p5, p.7, rec'd June 24, 2009).

A May 2016 VA examination for peripheral nerves reflects that the Veteran was diagnosed with right carpal tunnel syndrome in 2016, and that the date of onset was in the 1980s.  The onset of the condition appears to have been by the Veteran's report to the examiner.  The examiner diagnosed left, as well as right, carpal tunnel syndrome, but offered no opinion as to the etiology of the left carpal tunnel syndrome (see VA examination for peripheral nerves, pp., 1, 11, rec'd May 16, 2016).

The Veteran's claim was again denied on the basis that, although the record now showed findings of mild partial paralysis of the left upper extremity median nerve,  the evidence did not show that the condition was related to military service, aggravated by military service, or secondary to a service-connected disability (see May 2016 Supplemental SOC (SSOC) p. 2).

After the August 2016 hearing, the Veteran submitted additional evidence with waiver of AOJ review.  Included was an August 2016  statement proffered by a private treating physician, KH, MD.  The statement reflects that the Veteran is the physician's patient and has been diagnosed with bilateral carpal tunnel syndrome.  The physician described the condition as impeding the Veteran's ability to work, and as productive of losing grip strength bilaterally.  As to the presence of an etiological link between the Veteran's active duty and his currently diagnosed left carpal tunnel syndrome, the physician reported that the Veteran had provided copies of his military record confirming that he acquired bilateral carpel tunnel syndrome while serving in the military.  The physician stated the Veteran reported sustaining a cervical fracture of C5 with residual neuropathy involving both shoulders and hands and underwent evaluation of these complaints in July 1991 at a military facility.  The symptoms related to the C5 cervical fracture included bilateral carpal tunnel syndrome, the physician opined, and these symptoms had continued to the present.  (see Pvt & VA rec post hrng w/ waiv: +opin CTS Dr KH p7 & insvc onset tinn p3, p. 7, rec'd September 8, 2016). 

A review of service treatment records contain a Report of Medical Board dated in December 1988 which shows that the Veteran was involved in a motor vehicle accident (MVA) in 1988, in which he sustained a C5 fracture (see STRs (orig) Med Bd p4, sep phys dx C5 fx w result sx of pain & paresthesias, HL p11, p. 4, rec'd May 9, 2016).  In September 1990, he was found to have negative Tinel's sign and positive Phalen's in both hands (see Id, p. 13).  In July 1991, prior to discharge, he was seen for complaints of intermittent episodes of bilateral arm pain and paresthesias.  He was diagnosed with bilateral carpal tunnel syndrome (see STRs: NavHops Jax rec (MVA '88), HL p3, MVA resid sx cont '91 p5, p. 5, rec'd May 9, 2016).  

Moreover, the Veteran is competent to observe and attest to have pain in his forearms and wrists during active service, and to have those symptoms in addition to the beginning of weakness, burning sensation, and inability to grip and use his arms and hands effectively from service or shortly thereafter to the present.  See Layno, supra.  The Board finds that the Veteran's reports, statements, and testimony are generally consistent, i.e., that he experienced the onset of pain in his forearms, and wrists during service; that he experienced the beginning symptoms of weakness, burning sensation, and inability to grip and use his arms and hands effectively from service or shortly thereafter to the present; and that he sought treatment for his arm and wrist conditions, to include surgery on both wrists and prescribed medication from approximately 1995 to the present (see, generally, Board Transcripts).  The Board finds the Veteran to be a credible witness.  Moreover, as will be demonstrated, his reports to medical professionals, statements, and testimony are consistent with and corroborated by the record, to include the records and statements of his private treating physicians as well as service treatment records.  

Other private medical treatment records already of record reflect that the Veteran was treated for carpel tunnel syndrome, including with carpel tunnel release for left, as well as right, carpal tunnel syndrome (see Pvt rec (Dr. DM, R Hosp) 1988, 1996-2009 (not sure '88 same hosp), tx CTS, incl Dr. RA EMG/NCV p5, pp. 10-11, 19, rec'd on June 24, 2009; see also Pvt tx rec R Hosp & Dr DM: CTS OPREPs bilat hands, p. 1-2, rec'd Jun 5, 2009).  Despite normal EMG findings on the left, Dr. DM believed the Veteran had carpal tunnel on the left as well as the right (see Pvt rec (Dr. DM, R Hosp) 1988, 1996-2009 (not sure '88 same hosp), tx CTS, incl Dr. RA EMG/NCV p5, pp. 14, 10 (stating that positive bilateral Tinel's sign, Phalen's maneuver, and the Veteran's symptoms are highly suggestive of carpal tunnel syndrome despite the normality of the EMG study; stating that the EMG study is not entirely sensitive for carpal tunnel syndrome; and stating that carpal tunnel syndrome is possible despite negative electrical studies).  

The Board now turns to the question of whether service-connection may be granted for left carpal tunnel syndrome.  For reasons below the Board finds in the positive.

As above noted, neither the 2009 nor the 2016 had VA examiner provided an opinion as to the etiology of the Veteran's claimed left carpal tunnel syndrome.  These examinations cannot therefore provide probative value concerning the etiology of the left carpal tunnel syndrome.  It therefore weighs neither for nor against the claim.  See Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Sklar v. Brown, 5 Vet. App. 140 (1993); Perman v. Brown, 5 Vet. App. 237, 241 (1993).  

The record contains no other negative medical opinion concerning the etiological relationship between left carpel tunnel syndrome and active service.

The August 2016 statement of Dr. KH documents current diagnoses of left, as well as right, carpel tunnel syndrome with onset during active service (see Pvt & VA rec post hrng w/ waiv: +opin CTS Dr KH p7 & insvc onset tinn p3, p. 7, rec'd September 8, 2016.

The record reflects that service connection for the right carpal tunnel syndrome was granted, presumably based on the report onset of symptoms and continuity of those symptoms from active service to the present as well as clinical findings of the condition in the March 2009 EMG/NCV test results.  These test results did not reveal clinical findings of left carpal tunnel syndrome, but the Board notes that Dr. RA stated the test results were abnormal.  In addition, the Board is also mindful of Dr. DM's statements in 1996 that negative EMG findings do not necessarily foreclose a diagnosis of carpal tunnel syndrome.  Furthermore, close examination of the 2016 VA examination reveals nearly identical neurological findings in the right and left upper extremities despite the fact that the Veteran's complaints differed widely right from left.  In pertinent part, median nerve testing revealed positive Phalen's sign and Tinel's sign, bilaterally, and the examiner assessed the median nerve to be mildly incompletely paralyzed, bilaterally.  (see May 2016 VA examination for peripheral nerves).

Based on the totality of the record, the Board finds that service treatment records establish the onset of left, as well as right, carpal tunnel syndrome during active service and the Veteran's testimony with records from Dr. DM, Dr. RA, and the statement of Dr. KH together establish continuity of symptomatology from service to the present-additionally lending greater probative weight to Dr. KH's opinion that left, as well as right, carpal tunnel syndrome is the result of active service.  

Entitlement to service connection for left carpal tunnel syndrome is warranted.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102(a).


ORDER

Service connection for tinnitus is granted.

Service connection for left carpal tunnel syndrome is granted.


REMAND

The Veteran also seeks service connection for right and left shoulder disabilities and a higher initial evaluation for right carpal tunnel syndrome.  For reasons explained below, the Board finds that the record is not adequate for judicial review and this time.

Service connection for right and left shoulder disabilities has been denied on the basis that the evidence does not establish an etiological connection, or nexus, between the right shoulder injury in 1975 and bilateral shoulder impingement shown diagnosed in July 1991-both occurring during active service-and the biceps tendonitis with chronic strain in the right and left shoulder diagnosed in the June 2009 VA examination (see July 2009 rating decision, pp. 5-6; see also June 2009 VA examination pp. 4-5).  

In August 2016, the Veteran testified before the undersigned Veterans Law Judge and attributed his bilateral shoulder disabilities-as well as his bilateral carpal tunnel syndrome-to the physical work he performed as a mechanic, specifically to the wear and tear over the years.  He stated he was not able to put down his toolbox in the 18 years he was in the military (see Board Transcripts, p. 7).  His shoulders have been in constant pain, he testified, from service to the present, requiring right rotator cuff surgery in about 2010 (Id., p. 15-6).  Service treatment records do show that he sustained injury to his neck in a 1988 MVA.  He was assessed with left shoulder impingement syndrome in September 1990 and with bilateral shoulder impingement syndrome in July 1991 (see STRs (orig) Med Bd p4, sep phys dx C5 fx w result sx of pain & paresthesias, HL p11, p. 13, rec'd May 9, 2016; see also see STRs: NavHops Jax rec (MVA '88), HL p3, MVA resid sx cont '91 p5, p. 5, rec'd May 9, 2016).

His report of medical examination at discharge reflects intermittent bilateral arm pain and paresthesias.  He was diagnosed with residuals of C5 fracture with resultant symptoms of pain and paresthesias (see STRs (orig) Med Bd p4, sep phys dx C5 fx w result sx of pain & paresthesias, HL p11, p. 11, rec'd in May 9, 2016).  Private medical records from Dr. LF, MD, reflect that the Veteran was diagnosed in January 2010 bilateral acromioclavicular joint arthritis, torn right rotator cuff and partially torn left rotator cuff.  The physician stated the Veteran had a long history of shoulder problems.  In March 2010, he underwent right rotator cuff repair.  The operative report reflects pre- and post-operative diagnoses of chronic impingement syndrome, right shoulder (see Pvt tx rec shoulder (Dr. LF) see notes, pp. 4, 5, rec'd June 11, 2010).

In June 2009, the Veteran underwent VA examination which, as noted above, revealed diagnoses of biceps tendonitis with chronic strain in the right and left shoulder (see June 2009 VA examination for spine, p. 4).  March 2009 private EMG/NCV results showed no definite evidence of cervical radiculopathy in the muscled of both upper extremities.  However, the physician, Dr. RA, noted that a negative study will not rule out cervical radiculopathy and clinical correlation was suggested (see Pvt rec (Dr. DM, R Hosp) 1988, 1996-2009 (not sure '88 same hosp), tx CTS, incl Dr. RA EMG/NCV p5, pp. 5-7, rec'd June 24, 2009).  The VA June 2009 VA examiner in did not have these clinical findings for review, and did not request new studies, and stated he was unable to determine if C5 radiculopathy was present (see June 2009 VA examination for spine, p 4-5).  The May 2016 VA examination for peripheral nerves did not test the upper radicular nerve group (5th and 6th cervicals) (see VA examination for peripheral nerves, p. 6).

In an August 2016, another of the Veteran's private treating physicians, Dr. KH, proffered a statement in which she opined that the Veteran continues to exhibit symptoms related to his inservice cervical fracture with residual neuropathy involving both shoulders and hands, including impingement syndrome.  (see Pvt & VA rec post hrng w/ waiv: +opin CTS Dr KH p7 & insvc onset tinn p3, p 7, rec'd September 8, 2016).  However, the statement does not discuss the intervening right rotator cuff tear and operation, and left partial rotator cuff tear.

In October 2016, the Veteran submitted the statement of GC, MD, in which the physician opined that bilateral shoulder impingement is mostly likely caused by or as the result of transport between hospital during active service (see Pvt med op (posit) w/waiver (Dr. GC, undated), p. 2, rec'd October 28, 2016).  However, this statement, also, does not discuss the intervening right rotator cuff tear and operation, and left partial rotator cuff tear.

Accordingly, the record as a whole, and the VA examinations from June 2009 and May 2016 in particular, provide an inadequate basis upon which to adjudicate the claim for service connection for bilateral shoulder disabilities.  Further examination with appropriate clinical tests and review of the entire record is required.

In addition, additional VA examination should be conducted to provide a clear picture of the Veteran's symptoms of his right carpal tunnel syndrome and their disabling effects.

Accordingly, the case is REMANDED for the following action:

1.  Obtain all available VA treatment records that are not already present in the claims file.  

2.  Ask the Veteran to provide the names of any additional private health care providers who have treated him for his bilateral shoulder disabilities that are not already of record.  Make all appropriate attempts to obtain these records.

3.  If any VA or identified records cannot be obtained, a notation to that effect should be inserted in the file.  Notify the Veteran of the unsuccessful efforts in this regard, and provide him the opportunity to obtain and submit those records for VA review.

4.  Thereafter afford the Veteran VA examination to determine the nature, extent and etiology of the claimed bilateral shoulder disabilities.  

Based on review of the evidence and examination of the Veteran, the examiners should specifically provide an opinion as to whether:  
(a) it is as likely as not (50 percent or greater probability) that any diagnosed bilateral shoulder disability is 
i. related to active service to include the 1975 fall and/or 1988 MVA or
ii. had their onset during active service.

The examiner must provide adequate reasons and bases for any opinions rendered.  All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail.  The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination including, in pertinent part, the Veteran's testimony before the undersigned Veterans' Law Judge in August 2016. 

5.  Thereafter afford the Veteran VA examination to determine the nature and extent and etiology of right carpal tunnel syndrome.  All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail.  The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination.

6.  After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations.  If the benefits sought remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded the opportunity to respond.  Thereafter, the case should be returned to the Board for appellate review, if in order.

The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).




______________________________________________
MICHAEL LANE
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs

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