BVA9503157 DOCKET NO. 93-07 614 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE 1. Entitlement to service connection for capsulitis with calcific capsulitis of the left shoulder secondary to service-connected residuals of a left shoulder injury. 2. Entitlement to an increased rating for disc disease and arthritis of the cervical spine with left brachial neuritis, currently evaluated as 30 percent disabling. 3. Entitlement to an increased (compensable) rating for arthritis of the left acromioclavicular joint. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Richard F. Williams, Counsel INTRODUCTION The veteran served on active duty from July 1941 to October 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 1990 and June 1992 decisions by the Department of Veterans Affairs (VA), Portland, Oregon, Regional Office (RO). The former decision denied secondary service connection for calcific capsulitis, and the latter decision denied a rating in excess of 30 percent for disc disease and arthritis of the cervical spine with left brachial neuritis and a compensable rating for arthritis of the left acromioclavicular joint. Following a remand by the Board to determine if a hearing was desired, the veteran testified at a hearing conducted at the RO in June 1993. In his substantive appeal, the veteran seems to raise the issue of entitlement to individual unemployability. Further, in written argument received at the RO in September 1990, he referred to an episode of pneumonia during service and a back disability. It is unclear whether he is seeking service connection for a lung disorder and/or a back disability. (He is currently service connected for disability of the cervical spine or neck.) Since these matters have not been adjudicated by the RO or developed for appellate consideration and are not intertwined with the current appeal, I am referring them to the RO for appropriate action. In view of the grant of secondary service connection for calcific capsulitis of the left shoulder joint that follows, and for reasons set forth herein, the other issues will be addressed in the REMAND section of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection is warranted for his calcific capsulitis of the left shoulder joint. He asserts, in essence, that the disability in question is causally linked to the left shoulder injury he sustained while on active duty. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence supports the claim for secondary service connection for calcific capsulitis of the left shoulder joint. FINDING OF FACT The veteran's calcific capsulitis of the left shoulder joint is etiologically related to his service-connected left shoulder injury. CONCLUSION OF LAW Calcific capsulitis of the left shoulder joint is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty from July 1941 to October 1945. His service medical records show that he sustained injuries to his left shoulder and left side of his head in October 1944. He subsequently complained of pain in his neck, left shoulder, and left arm. It was reported in July 1945 that the onset of his symptoms in the left upper extremity could have been from fibrosis secondary to trauma, and it was opined that he had developed brachial neuritis. The veteran underwent a VA orthopedic examination in May 1947. No orthopedic pathology of the left shoulder was demonstrated. An X-ray examination of the left shoulder was normal. Neurological examination revealed brachial neuralgia of the left upper extremity. An RO decision in June 1947 granted service connection and assigned a noncompensable rating for brachial neuralgia of the left upper extremity. VA clinical records show that the veteran was seen on several occasions in June and July 1952 for complaints of left shoulder and neck pains. X-rays of his shoulder and cervical spine were reported as negative. A VA neurological examination of the veteran in April 1953 confirmed a diagnosis of left brachial neuritis. It was noted at that time that there were markedly reduced biceps and triceps reflexes on the left side and a very definite reduction in muscle force of the left upper extremity, which were thought to be due to interstitial changes in the nerve trunks comprising the left brachial plexus. No improvement was expected. An RO decision in June 1953 increased the rating for the veteran's left brachial neuritis from a noncompensable level to 10 percent disabling. A Board decision in September 1954 granted an increased rating to 20 percent for the veteran's left brachial neuritis and an RO rating action implemented the Board's decision shortly thereafter. VA X-ray examinations of the veteran in December 1974 revealed osteoarthritis changes and narrowing of the disc space between C6 and C7 and osteoarthritic changes in both acromioclavicular joints and soft tissue calcification adjacent to the greater tuberosity of the right humerus, representing calcified tendinitis. An RO decision in April 1975 granted service connection for disc disease and arthritis of the cervical spine and arthritis of the left acromioclavicular joint. The RO determined that the veteran's degenerative changes of the cervical spine and left shoulder joint were the result of the original injury during service. Thus, his disability was rated as disc disease and arthritis of the cervical spine and left acromioclavicular joint with brachial neuritis. The disability evaluation was increased from 20 percent to 60 percent. Following VA orthopedic and X-ray examinations in May 1983 (including a radiographic study of the left shoulder which was reported as normal), the disability evaluation for the veteran's cervical spine and left shoulder disabilities was reduced from 60 percent to 30 percent. The veteran underwent a clinical evaluation in August 1983, performed by Joel C. Silverfield, M.D. Clinical findings remained essentially unchanged, and X-rays showed severe degenerative arthritis with associated degenerative disc disease of the cervical spine; it was noted that there had been significant worsening since the 1982 X-rays. Dr. Silverfield's assessment was degenerative arthritis of the cervical spine with associated intermittent cervical radiculopathy. He reiterated that impression in his January 1984 statement. The veteran underwent VA orthopedic and X-ray examinations in June 1984. Clinical findings included limitation of motion of the cervical spine and left shoulder. Radiographic findings included moderately severe degenerative changes of the cervical spine and calcific deposits in the soft tissues of the left shoulder. In an August 1989 statement, Dean L. McGinty, M.D., reported that he had evaluated the veteran earlier that month, the report of which reflects a history, physical examination of the neck and shoulders, and X-rays of same. Dr. McGinty concluded that the veteran suffered from degenerative disease of the cervical spine and adhesive capsulitis of the left shoulder. The doctor opined that these problems abate to an injury sustained while in active service in 1944. It was recommended that the veteran refrain from manual work, including lifting. The veteran underwent a VA orthopedic examination in December 1989. It was noted that he was 71 years old. He said that he essentially had constant, dull pain in the neck and on the left side of the base of the neck toward the left shoulder. He described severe attacks of increased pain radiating from the neck into the left shoulder down the left arm as far as the elbow 2 to 3 times a month. These attacks lasted anywhere from 4 to 5 hours. Jarring of his body increased neck pain, and he was aware of some chronic stiffness in his neck. He also had increased neck pain when he was supine and was only able to be comfortable when he laid on his right side with just the right amount of pillow supporting his head. His neck pain was also helped by heat and analgesic balm. He also took medications. Physical examination revealed slight atrophy of the left shoulder region on the left side compared to the right. He had full, albeit painful motion of the left shoulder with some clicking palpable in the acromioclavicular joint, aside from some limitation of internal rotation. Range of motion of the cervical spine revealed full flexion, extension of approximately 90 percent, bilateral rotation of 70 percent, and side bending of 50 percent. Sensory examination of the upper extremities revealed some hyperalgesia over the left deltoid arm area and middle two fingers of the left hand. Upper extremity reflexes were active and two plus on the right and one plus on the left. X-rays of the left shoulder were reported to show some narrowing of the acromioclavicular joint, some roughness of the joint surfaces, and some calcification in the supraspinous area. The diagnoses were degenerative disc disease and degenerative joint disease of the cervical spine with some secondary neuropathy, calcific capsulitis of the left shoulder, and mild degenerative joint disease in the left acromioclavicular joint. The examiner believed that the veteran's primary symptomatology was secondary to the cervical disease and that he had secondary symptoms from the left acromioclavicular joint and shoulder joint. VA clinical records dated from 1990 to 1992 show that the veteran was evaluated and treated for several different disorders. Left shoulder pain was noted during a hospital stay in April 1990 for pneumonia. He complained of pain in the left upper arm, shoulder, and back in January 1991. He also complained of increased neck pain of six days' duration when seen in June 1991. The veteran underwent a VA compensation examination in April 1992. It was noted that he was a poor and rambling historian and his history was unclear. It was also noted that his medical records were unavailable. He described certain movements of his neck caused pain which radiated down into his left upper extremity. He also said that he had chronic numbness and tingling of his left upper extremity, especially in the area of the forearm and wrist, but also above the elbow. He also complained of weakness of his left hand and upper extremity. Additional complaints included some discomfort in his left shoulder, left upper extremity, and neck when sleeping in certain positions and chronic pain and stiffness in his posterior neck area. It was noted that he was not currently on any medications for this problem. Physical examination showed that he was in no acute distress. Specific muscle testing showed that the left deltoid was 4/5 in strength as compared to 5/5 on the right. The left biceps was a trace weaker on the left. Grip strength was 4/5 on the left compared to 5/5 on the right. There was no clear evidence of decreased sensation of the left upper extremity. Biceps reflexes were 2/4, bilaterally; the left triceps reflex was 1/4 compared to 2/4 on the right. It was noted that a 1991 X-ray report showed evidence of degenerative disc disease at levels C3-4 and C6-7. The clinical diagnosis was cervical disc disease with evidence of cervical radiculopathy involving the left upper extremity. The veteran testified at a hearing conducted at the RO in June 1993 that he essentially had constant neck and left upper extremity pain that had increased in severity and resulted in sleep disturbance. He said that rain and humidity increased his neck pain and medication provided some relief. He described his pain radiating from the neck into the left upper extremity and left upper chest with some tingling sensation, limitation of motion of the cervical spine, and possible muscle spasms in the neck and left shoulder regions. He also testified that he had difficulty raising his left arm to and above the shoulder level and had had episodes of locking of his left first two fingers. It was observed that he was on Carisopol for pain. The veteran's representative requested an orthopedic examination, with an opinion to determine if the veteran's calcium deposits or capsulitis of his left shoulder was causally linked to his service-connected left shoulder disability. II. Analysis The Board initially finds that the veteran's claims are well- grounded, meaning they are not inherently implausible. 38 U.S.C.A. § 5107(a). The relevant evidence has been developed, and there is no further VA duty to assist the veteran with his claims. Id. Secondary Service Connection for Calcific Capsulitis of the Left Shoulder In reviewing the record, I find that the evidence shows that the veteran's calcific capsulitis of the left shoulder was first radiographically demonstrated many years after service. The essence of his claim is that the disability in question is causally linked to his service-connected left shoulder injury. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). At the June 1993 RO hearing, his representative requested an orthopedic examination for the purpose of addressing the contended causal relationship. The examination to determine the answer to this etiological question need not be ordered because the record already contains probative information which answers the question. Notably, a competent medical answer is given by Dr. McGinty, who examined the veteran in August 1989, who concluded that the veteran's adhesive capsulitis of the left shoulder was the result of his in-service trauma to the left shoulder. Thus, the only medical opinion that addresses the question at hand is favorable to the claim. The preponderance of the evidence supports the veteran's claim that his calcific capsulitis of the left shoulder is secondary to his service-connected residuals of a left shoulder injury. Accordingly, secondary service connection for the disability in question is warranted. ORDER Secondary service connection for calcific capsulitis of the left shoulder is granted. REMAND The last VA examination was conducted without benefit of review of the veteran's medical records. That examination was therefore inadequate for rating purposes, and another examination must be ordered, as the United States Court of Veterans Appeals has said that the duty to assist the veteran includes obtaining all relevant treatment records. Murphy v. Derwinski, 1 Vet.App. 78 (1990); Murincsak, 2 Vet.App. 363 (1992). Further, in rating the veteran's orthopedic and neurological disabilities, the RO is advised that "separate and distinct" manifestations from the same injury may be rated separately. Esteban v. Brown, 6 Vet.App. 259 (1994). Hence, this case is REMANDED to the RO for the following actions: 1. The RO should ask the veteran, with the assistance of his representative, to prepare a detailed list of all sources (VA or other) of examination and treatment for his cervical spine, neurological, and shoulder disabilities since April 1992. Names and addresses of the medical providers, and dates of examination and treatment, should be listed. After obtaining any needed release forms from him, the RO should directly contact the medical providers and obtain the records, not already on file. 38 C.F.R. § 3.159. 2. Thereafter, the veteran should undergo VA orthopedic and neurological examinations to determine the current severity of his service-connected upper back and shoulder disabilities. All indicated tests, including range of motion studies and X- ray, must be conducted. The examiners should indicate whether there is evidence of limitation of motion of the cervical spine and if so, whether it is severe; whether favorable or unfavorable ankylosis of the cervical spine is manifested; whether disc disease is moderately severe, or productive of pronounced impairment; whether separate and distinct manifestations due to brachial plexus are present and if so, whether sensory disfunction is of mild, moderate, or severe degree or is complete; whether arthritis of the left shoulder is manifested by painful motion or restriction of motion and if so, whether motion of the left shoulder is limited at the shoulder level, midway between the side and the shoulder level, or to 25 degrees from the side. The claims file must be made available to and reviewed by the examiners prior to the examinations. Thereafter, the claim should be reviewed by the RO. If the veteran is dissatisfied with the decision, he and his representative should be issued a supplemental statement of the case and given an opportunity to respond. The case should then be returned to the Board. M. CHEEK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. } 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, } 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).