BVA9501137 DOCKET NO. 93-07 744 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Francisco, California THE ISSUE Entitlement to service connection for a right shoulder disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his mother ATTORNEY FOR THE BOARD P. M. Lynch, Associate Counsel INTRODUCTION The veteran's active military service extended from April 1987 to March 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1991 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Francisco, California. That rating decision denied entitlement to service connection for a right shoulder disability. REMAND Following service, the veteran was treated for a right shoulder disability in April 1990 at the VA Medical Center in La Jolla, California. At that time, he reported that he originally injured his shoulder in 1987, and that it had dislocated several times since his original injury. He was subsequently treated at the VA Medical Center in Palo Alto, California and diagnosed as having recurrent right shoulder dislocation. In December 1990, he underwent a right bristow shoulder reconstruction. In February 1991, the RO denied the veteran's claim of service connection for a right shoulder disability on the grounds that no such disability was shown in the service medical records. The veteran contends that the RO committed error in its decision in that an x-ray report dated in August 1987 from the Balboa Naval Hospital in San Diego, California verifies that he had a right shoulder disability during service. He submitted a copy of this report along with his Notice of Disagreement received by the RO in April 1991. The x-ray revealed some asymmetry in the space between the glenoid fossa and the head of the humerus on the right with the right being somewhat greater than the left. The examiner stated that this may be related to the patient positioning. However, he stated that other etiologies could not be entirely excluded, including joint effusion or possible posterior dislocation. He recommended a clinical correlation and a full right shoulder series, including a transaxillary view for further delineation. Review of the service medical records indicates that neither the x-ray report submitted by the veteran nor any documentation of the follow-up testing recommended by the examiner are present. Significantly, only copies of the service medical records, and not originals, are included in the claims folder. Therefore, it appears that the veteran's service medical records are not complete. The RO should make arrangements to obtain his complete service medical records and associate them with the claims folder. At his personal hearing at the RO in May 1992, the veteran's representative stated that it was possible that the examiner who interpreted the August 1987 x- ray would remember the veteran. He further indicated that he was making efforts to locate him. There is no subsequent documentation with respect to this activity in the claims folder. The RO should make an attempt to locate the examiner and to obtain all pertinent evidence in his possession, including a statement in the event that he has a recollection of his contact with the veteran. A review of the record also indicates that the veteran has made arrangements to have certain x-rays associated with his claims folder. As of December 1994, these records had not yet been received. The RO should make arrangements to obtain the x-rays referred to by the veteran. To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should contact the National Personnel Records Center in St. Louis, Missouri and request the veteran's complete service medical records. 2. The RO should make arrangements to obtain the veteran's complete medical records from the Balboa Naval Hospital in San Diego, California. The Board is particularly interested in the examination conducted in August 1987. If these records are unavailable, that fact should be annotated in the claims folder. 3. The RO should make arrangements to locate the examiner who interpreted the August 1987 x- ray and obtain all pertinent evidence in his possession, including a statement in the event that he has a recollection of his contact with the veteran. 4. The RO should contact the veteran and request that he provide the names and addresses of all health care providers who have treated him for a right shoulder disorder since his discharge from service. The Board is particularly interested in treatment from March 1988 to April 1990 and in the recent x-rays referred to by the veteran in December 1994. After obtaining the necessary releases, the RO should make arrangements to obtain all treatment records not already on file. If these records are unavailable, that fact should be annotated in the claims folder. 5. Following the above, the veteran should be afforded an examination by a VA orthopedist. The report of examination should include a detailed account of all manifestations of right shoulder pathology found to be present. All necessary tests and X-rays should be conducted and the examiner should review the results of any testing prior to completion of the report. A copy of this remand and the claims folder must be made available to and reviewed by the examiner prior to the examination. The report should be comprehensive and the orthopedist should provide a complete rationale for all conclusions reached. In particular, the examiner should review any records obtained in connection with this REMAND reflecting treatment for a right shoulder disorder while the veteran was in service, and furnish opinions as to the following: a. Whether there is a reasonable medical probability that any current right shoulder disorder is the same condition reportedly treated during the veteran's active service. b. Whether the x-ray taken in August 1987 revealed manifestations consistent with any current right shoulder disorder. 6. The RO should review the examination report and determine if it is adequate for rating purposes and in full compliance with this remand. If not, the report should be returned to the examiner for corrective action. Following completion of these actions and, if the decision remains unfavorable, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable period of time in which to respond. Thereafter, in accordance with the current appellate procedures, the case should be returned to the Board for completion of appellate review. No action is required of the veteran until further notice is issued. JOAQUIN AGUAYO-PERELES 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. 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).