Citation Nr: 18160600
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 09-28 247
DATE:	December 27, 2018
REMANDED
Service connection for a right shoulder disability is remanded. 
 
REASONS FOR REMAND
The Veteran served on active duty from March 1986 to March 1990.
The case is on appeal from a June 2008 rating decision.
In June 2014, the Veteran testified at a Board hearing.
Service connection for a right shoulder disability. 
As noted in the Board’s August 2014 and April 2017 remands, the Veteran contends that he currently has a right shoulder disability resulting from an in-service fall down a stairwell.  He testified to having either arthritis or strain of the right shoulder.  See Board hearing transcript at 8.  As such the Board found that the Veteran should be afforded a VA examination for the right shoulder in order to clarify whether the Veteran has a current right shoulder disability and whether any such disability is related to service.  
Accordingly, the Veteran was afforded a VA examination for the right shoulder in November 2015.  However, on an April 2016 claim form, the Veteran contends that he has a right shoulder disability that is secondary to his service-connected thoracolumbar spine arthritis, and this new theory of service connection has yet been addressed as he is now service connected for a low back disability.  As a result, the Veteran was scheduled for another examination in September 2017 pursuant to the Board’s April 2017 remand.  The Veteran did not appear for the examination.  However, it appears that the Veteran was unable to attend the examination due to work obligations.  See October 2017 Statement in Support of Claim.  He appears to have attended other scheduled VA examinations.  Therefore, the Board finds that the Veteran should be rescheduled and for a new VA examination and opinion in order to address the theory of secondary service connection and any relevant records obtained as a result of this remand.   
Regarding records, the Board noted in the August 2014 and the April 2017 remands that the Veteran testified that he sought treatment for his right shoulder at St. Anthony’s, to include treatment as recent as to one to three months prior to the June 2014 Board hearing, but it does not appear that such records are currently associated with the claims file.  The Veteran was sent a September 2014 and an April 2014 letter asking him to fill out an authorization for a records request.  He should be asked to do this again on remand.  
In light of the remand, updated VA treatment records should be obtained.
The matter is REMANDED for the following action:
1. Obtain VA treatment records dated since September 2018. 
2. Ask the Veteran to provide the names, addresses, and approximate dates of treatment of all health care providers who have treated his right shoulder.  After securing any necessary releases, request records identified which are not duplicates of those contained in the claims file.  Specifically, obtain the Veteran’s treatment records from St. Anthony’s, to include any relevant x-rays.  If any requested records are unavailable, then the file should be annotated as such, and the Veteran should be so notified.  
3. After associating any pertinent, outstanding records with the claims folder, schedule the Veteran for a VA examination for the right shoulder.  The claims folder should be made available to and reviewed by the examiner, and all necessary tests should be conducted.  
The examiner should first identify whether the Veteran has a current right shoulder disability.  
Then, the examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that any identified right shoulder disability is related to or had its onset in service, to consider the Veteran’s contention regarding a fall down a stairwell.  
The examiner should also opine on whether it is at least a likely as not (50 percent probability) that any right shoulder disability is caused, or aggravated, by the Veteran’s service-connected thoracolumbar spine arthritis.  
The examination report should include a complete rationale for all opinions expressed. 

 
RYAN T. KESSEL
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	E. Gray

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

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