BVA9505330 DOCKET NO. 92-07 789 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Fargo, North Dakota THE ISSUE Entitlement to service connection for a right shoulder disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. J. McCafferty, Counsel INTRODUCTION The veteran had active service from November 1950 to August 1952. The Board of Veterans' Appeals (Board) entered a decision in this case on December 1, 1992. In February 1993, a motion for reconsideration of the December 1992 decision was filed with the Board. Reconsideration has been ordered by the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991). The case is now before an expanded reconsideration panel of the Board. This decision by the reconsideration panel replaces the decision of December 1, 1992, and is the final decision of the Board. CONTENTIONS OF APPELLANT ON APPEAL The veteran argues that the Regional Office (RO) erred in failing to grant service connection for a right shoulder disorder as secondary to his service-connected left shoulder disorder. The veteran contends that his service-connected disability of the left shoulder necessitated placing additional stress and strain on his right shoulder with the subsequent development of a right shoulder disability. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all evidence and material of record in the veteran's claims file and for the following reasons and bases, it is the decision of the Board that, with resolution of reasonable doubt in the veteran's favor, the record supports a grant of service connection for a right shoulder disability. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the instant appeal has been obtained. 2. The evidence is in relative equipoise as to whether there is a direct causal relationship between the veteran's service- connected left shoulder disability and his right shoulder disability. CONCLUSION OF LAW With resolution of reasonable doubt in the veteran's favor, a right shoulder disorder is proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.310 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board finds initially that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a); that is, it is not inherently implausible. We also find that the facts relevant to the issue on appeal have been properly developed and that the statutory obligation of the Department of Veterans Affairs (VA) to assist the veteran in the development of his claim has been satisfied. 38 U.S.C.A. § 5107(a). Factual Background Initially, we note that service medical records contain no indication of the presence of a right shoulder disability and it has not been so contended. Rather, the veteran has contended that his right shoulder disability arose as a result of his left shoulder disability. Service medical records do show that the veteran sustained shell fragment wound injuries. The veteran was granted service connection for his left shoulder disability, which was evaluated as 10 percent disabling, from the day following his discharge from service. The veteran's rating was increased to 20 percent effective in January 1990. VA outpatient records for January to October 1990 show that the veteran was treated for a rotator cuff tear and degenerative changes of the left shoulder. A VA hospital summary dated in October 1990 shows that the veteran underwent a left shoulder subacromial decompression and left rotator cuff repair. The veteran received private treatment for his left shoulder from February to October 1991. An entry of May 1991 shows that the veteran complained of right shoulder pain similar to that in the left shoulder, said to be of six months' duration. An entry dated in July 1991 referred to increasing pain, stiffness, and difficulty in overhead motion with respect to the right shoulder. The examiner suspected a right rotator cuff tear. In a September 1991 letter, from T. H. Christianson, M.D., a private orthopedist, stated that the veteran began experiencing right shoulder pain in January 1991 and that in August 1991 a right rotator cuff tear had been confirmed by arthrogram. In an October 1991 letter, D. Eggert, M.D., stated that the veteran had a new rotator cuff tear on the right side and that he had reinjured it "yesterday" while lifting. He supported the theory that the prior left shoulder injury and residual impairment caused and/or contributed to early degeneration and a tear of the right rotator cuff because of the excessive demands placed on the right shoulder secondary to the decreased function of the left shoulder. VA outpatient clinic records dated in January 1992 reflect that the veteran had tried to pull himself up on a truck during the previous fall harvest and had significant discomfort in his right shoulder. A right rotator cuff tear was diagnosed. The examining orthopedist stated that, since the veteran's left rotator cuff repair in 1990, he had been relying more on his right shoulder and upper extremity and, because he was not able to pull with both arms, jeopardized his right shoulder. At a hearing on appeal held at the RO in March 1992, the veteran testified with regard to working during the harvest. He indicated that, since he was unable to use his left arm due to his service-connected disability, he overused his right arm and this resulted in a rotator cuff tear. The veteran reported that he had been climbing into a truck over a three-day period and that he had to rely on his right arm, which resulted in the rotator cuff tear. The veteran's right arm was immobilized at the time of the hearing, and the veteran indicated that he would soon be undergoing physical therapy. The veteran also stated that he never had any problems with his right shoulder before the fall harvest incident. In an informal hearing presentation in August 1992, the veteran's representative asked that a medical opinion be obtained with regard to the relationship claimed between the veteran's service- connected left shoulder disability and his right rotator cuff tear. Thereafter, the case was submitted to a Board consulting orthopedic physician for an opinion. In his written opinion, dated in October 1992, the consulting orthopedist noted that the veteran's service medical records established that he is right- handed. He further stated that: The orthopedic literature regarding the etiology of rotator cuff tears is generally in agreement. The rotator cuff deteriorates with age and deterioration is present in almost all rotator cuffs after age sixty. (Orthopaedics, Principles and Their Application, Turek, 1984, p. 924) In that age group, relatively minor trauma such as pulling, pushing or lifting is likely to cause a tear in the tendinous part of the cuff. There is no consensus in the orthopedic literature that an impairment of function of one shoulder joint causes or predisposes the other shoulder joint to become impaired. It would be more unlikely that an impairment of a nondominant shoulder joint would cause impairment in the dominant shoulder. The consulting orthopedist then stated that, in his opinion, the right rotator cuff disorder, which first became symptomatic in January 1991, was definitely diagnosed in August 1991, and became precipitously more symptomatic in October 1991, was due to wear associated with use over many years rather than as a result of limitation of function of the left shoulder. In a September 1993 letter, Dr. Eggert restated his opinion that the veteran's right shoulder injury is related to the service- related left shoulder injury and that because of these injuries the veteran had compounded his disability and impairment. In view of the conflicting medical opinions with respect to the etiology of the veteran's right rotator cuff tear, an opinion of an independent medical expert was requested. The question posed the expert was, "Did impairment resulting from the shell fragment wound of the left shoulder that the veteran sustained during his Korean Conflict service cause the veteran's right rotator cuff tear, first diagnosed in 1991?" The independent medical expert's response, dated in September 1994, noted that she had reviewed the veteran's medical records, which she summarized. She then continued: The pathogenesis of rotator cuff tears appears to be multifactorial. Extrinsic compression of the rotator cuff may result in wear and tear with subsequent rupture of the rotator cuff. More recently attention has been directed to intrinsic failure of the cuff with gradual loss of blood supply, partial thicknesss [sic] tear and cuff dysfunction leading to superior migration of the humeral head and complete cuff failure. These degenerative changes appear to be age related (Acta Orthop Belg 1991, 57:124-129, Clin Orthop 1990, 254:39-48). Abnormal acromial morphology (status in this patient not documented) can also result in impingement and mechanical wear on the rotator cuff. Lower extremity functional loss as seen in paraplegics or amputees can result in a "weight-bearing" upper extremity as an individual places increased reliance on the upper extremities to support the body weight leading to functional overload of the rotator cuff. Although there is no documentation in the orthopaedic literature to my knowledge to support the contention that impairment of the function of one upper extremity predisposes the other upper extremity to rotator cuff injury, a relationship between the injury to the left shoulder and subsequent degenerative injury to the right shoulder must be seriously considered. If indeed the patient had been unable to use his left upper extremity to perform the heavy manual labor involved in an active farming operation, it is possible that subsequent overload to the right shoulder occurred. Mitigating factors such as the patients [sic] age and acromial morphology may have also played a significant role in the development of rotator cuff disease in the right shoulder but these factors cannot be clearly separated from the "overload" issue. It is therefore my medical opinion that data is [sic] present in the medical record to support the contention that the shell fragment wound to the left shoulder and subsequent left rotator cuff injury may be related to the patients [sic] right shoulder injury. The history as obtained from the medical record documents a significant disability of the left shoulder followed temporally by the development of right rotator cuff pathology. Although a direct link between these injuries cannot be proven, it cannot be ruled out to a degree of medical certainty. Analysis 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 (1994). To establish secondary service connection for a claimed disability, the medical evidence of record must establish a direct, causal relationship between a service-connected disease or injury and the disability for which secondary service connection is sought. The mere coexistence of separate disorders in the same individual does not establish that these disorders are causally related. In reviewing the totality of the evidence, to include the medical opinions set out above, we are drawn to the conclusion that, with resolution of reasonable doubt in the veteran's favor, service connection for a right rotator cuff tear is warranted. While it is clear that the veteran's right rotator cuff tear is not of service origin, the record is equivocal as to whether this disability arose as a result of the veteran's service-connected left upper extremity disability. Under 38 C.F.R. 3.102, when a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. A reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 U.S.C.A. § 5107(b). In the instant case, the appellant's contention that his service- connected left shoulder disorder caused overuse, stress, and strain resulting in degeneration of the right shoulder joint is supported by the opinion of Dr. Eggert and opposed by the opinion of the Board's consulting orthopedic physician. However, the independent medical expert's opinion lends support, in effect, to both of the foregoing opinions. In such cases, where the evidentiary record is evenly balanced, then the benefit of the doubt must go to the veteran. Thus, with resolution of reasonable doubt in the veteran's favor, service connection for a right rotator cuff tear is warranted. ORDER Service connection for a right rotator cuff tear is granted. GARY L. GICK CHARLES E. HOGEBOOM VICKY L. JORDAN JACQUELINE E. MONROE RENÉE M. PELLETIER WARREN W. RICE, JR. 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.