SHOULDER IMPAIRMENT OF

EMILY TAMLYN · 2026 · Case ID: A26018177

GRANTED

Summary

The Veteran, an Army veteran who served from February 1975 to December 1993, appeals the denial of service connection for a left shoulder disability and cardiovascular symptoms. The left shoulder disability was claimed as secondary to service-connected right shoulder bursitis, and the cardiovascular symptoms (coronary artery disease, hypertension, bradycardia) were claimed as secondary to service-connected obstructive sleep apnea (OSA). The Board found favorable findings that the Veteran has a current left shoulder disability and service-connected right shoulder bursitis, and also has current diagnoses of bradycardia, arteriosclerotic heart disease, and coronary artery bypass graft. The primary issue for the left shoulder was whether the service-connected right shoulder bursitis caused or aggravated the left shoulder condition. The VA examiner provided a negative nexus opinion, stating no evidence linked injury in one shoulder to the contralateral shoulder. However, a private clinician provided a detailed, probative opinion, explaining how compensatory overuse of the left shoulder due to right shoulder pain could lead to degenerative changes, citing medical literature and applying it to the Veteran's history. The Board found the VA opinion inadequate and the private opinion highly probative. Given the approximate balance of evidence, the Board resolved doubt in the Veteran's favor, granting service connection for the left shoulder disability secondary to right shoulder bursitis. For the cardiovascular symptoms, the Veteran's service treatment records were negative for these conditions, but OSA was service-connected. The VA examiner's opinions addressed direct causation but not secondary aggravation by OSA. The private clinician, however, provided a detailed opinion linking OSA to cardiovascular disease through physiological mechanisms like hypoxia and sympathetic nervous system activation, concluding the symptoms were secondary to OSA. The Board found the VA opinions did not fully address the secondary theory, while the private opinion was persuasive and probative. With the evidence in approximate balance, the Board resolved doubt in the Veteran's favor, granting service connection for cardiovascular symptoms secondary to OSA.

Rationale

VA opinion inadequate; did not address aggravation or Veteran's compensatory overuse.; Private opinion highly probative; detailed rationale on compensatory overuse and degenerative change.; Evidence in approximate balance; benefit of doubt applied.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251121-597480

Full Decision Text

Citation Nr: A26018177
Decision Date: 02/27/26 Archive Date: 02/27/26

DOCKET NO. 251121-597480
DATE: February 27, 2026

ORDER

Entitlement to service connection for left shoulder disability, secondary to service-connected right shoulder bursitis, is granted.

Entitlement to service connection for cardiovascular symptoms, secondary to service-connected obstructive sleep apnea, is granted.

FINDINGS OF FACT

1. The evidence is in approximate balance as to whether the Veteran's left shoulder disability was due to or aggravated by his service-connected right shoulder bursitis.

2. The evidence is in approximate balance as to whether the Veteran's coronary artery disease, status post CABG, hypertension, and bradycardia were due to or aggravated by his service-connected obstructive sleep apnea.

CONCLUSIONS OF LAW

1. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to service connection for left shoulder disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to service connection for cardiovascular symptoms have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from February 1975 to December 1993.

This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2024 rating decision, issued by the Department of Veterans Affairs Regional Office (RO), which is also the Agency of Original Jurisdiction (AOJ).

By way of procedural history, the Veteran initially filed a claim seeking service connection for left shoulder arthritis in April 2013. See April 2013 VA Form 21-526EZ. The AOJ obtained a VA examination in May 2014 and subsequently denied the claim in a September June 2014 rating decision. See June 2014 Rating Decision. In May 2023, the Veteran filed a claim seeking service connection for cardiovascular symptoms in May 2023. See May 2023 VA Form 21-526EZ. He also filed a Supplemental Claim appealing the June 2014 denial of his left shoulder arthritis the same day. See May 2023 VA Form 20-0995 Supplemental Claim.

Following VA examinations for both conditions in October and November 2023, the AOJ denied the appeal for service connection of left shoulder arthritis in November 2023. See November 2023 Rating Decision. A second VA examination and opinion for the Veteran's cardiovascular symptoms was sought in December 2023, prior to the AOJ denying the Veteran's claim of service connection for cardiovascular symptoms in December 2023. See December 2023 Rating Decision. In August 2024, the Veteran submitted a VA Form 20-0996, Request for Higher Level Review of the November and December 2023 Rating Decisions denying service connection for left shoulder arthritis and cardiovascular symptoms.

In November 2024, the AOJ issued a rating decision continuing the prior denial for service connection for left shoulder arthritis and cardiovascular symptoms. In November 2025, the Veteran filed a timely appeal to the Board under the Veterans Appeals Improvement and Modernization Act of 2017 (AMA) with the submission of a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), electing review under the Evidence Submission docket, whereby the Board will only consider evidence of record at the time of the November 2024 rating decision, as well as any evidence submitted with the VA Form 10182 or within 90 days follow its receipt. 38 C.F.R. § 20.303.

If evidence was associated with the claims file during the periods when the record closed, the Board has not considered it in its decision. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file which the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.
Board has not considered it in its decision. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file which the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a)-(b). Secondary aggravation exists when the non-service-connected disability not caused by a service-connected disability would be less severe were it not for a service-connected disability. Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023). For example, secondary aggravation may be established where the natural progression of the non-service-connected disability could have been arrested or improved but for the service-connected disability. Id.

Aggravation, for secondary service connection purposes, refers to any incremental increase in disability of a nonservice-connected condition that is due to or the result of a service-connected disability and not due to the natural progression of the disease. 38 C.F.R. § 3.310(b); Spicer, 34 Vet. App. at 316-18. In Spicer, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that under the causation standard of section 1110 of Title 38 of the United States Code, secondary service connection is warranted where a nonservice-connected disability would have been less severe "but-for" a service connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability. Id. at 1365.

The Federal Circuit concluded the causation standard "proximately due to" under section 3.310(b) of the regulations is inconsistent with section 1110 of the statute and, therefore "unlawful." Consequently, for "aggravation of non-service-connected disabilities" it is enough to show that "but-for" the service-connected disability the incremental increase in severity of a nonservice-connected disease or injury would not have occurred. Id. at 1364-66.

When there is an approximate balance of positive and negative evidence regarding any material issue, VA shall resolve reasonable doubt in favor of the Veteran. 38 C.F.R. § 3.102.

1. Entitlement to service connection for left shoulder disability.

The Veteran contends that his left shoulder disability was caused by his service-connected right shoulder bursitis due to overcompensation. Specifically, the Veteran contends that heavy lifting, carrying and moving military equipment, and routine physical readiness training and exercise during service caused his right shoulder injury. However, he reports that "he would avoid using his right shoulder due to pain and began compensating by using his left shoulder for any heavy lifting or carrying." See November 2025 Medical Treatment Record-Non Government Facility.

In the November 2024 rating decision, the AOJ made the Favorable Findings that the Veteran has been diagnosed with a left shoulder disability, and the claimed primary disability of right shoulder bursitis is service connected. See November 2024 Rating Decision. The Board is bound by these favorable findings. Therefore, the remaining question is whether the Veteran's left shoulder disability was caused or aggravated by his service-connected right shoulder disability.

At the October 2023 VA examination, the Veteran reported pain in both upper extremities with lifting heavy objects and any lifting over shoulder height. See October 2023 VA Disability Benefits Questionnaire. The examiner provided a negative nexus opinion with the rationale that "there is no evidence found contained within the current medical literature that an injury to one upper extremity/shoulder can caused by an injury in the contralateral upper extremity/shoulder." See October 2023 VA Medical Opinion. The examiner did not address aggravation in rendering their negative nexus opinion.

Conversely, in a private medical opinion dated November 2025, a private clinician noted review of the medical evidence and found the Veteran's left shoulder disability was due to his service-connected right shoulder disability. See November 2025 Private Medical Opinion. In so doing, the private clinician provided a detailed explanation of how chronic compensatory overuse of one shoulder can lead to repetitive microtrauma, altered joint mechanics, progressive degenerative change, and ultimately osteoarthritis in the contralateral joint. Id. The private clinician further cited medical literature concerning occupational exposures, overuse injuries, and joint degeneration and explained that individuals with long-standing injury to one shoulder frequently develop degenerative disease in the opposite shoulder due to years of altered biomechanics and compensatory loading. Id. The private clinician concluded that the Veteran's left shoulder problems are secondary to the right shoulder disability.

In considering whether service connection is warranted, the Board initially notes that the VA examiner's rationale relied on a generalized statement regarding medical literature and did not meaningfully address the Veteran's competent reports of long-standing compensation and overuse of the left shoulder due to right shoulder pain. An opinion that fails to adequately consider lay evidence regarding mechanism of injury is of diminished probative value. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (probative value of a medical opinion is derived from it being factually accurate, fully articulated, and soundly reasoned); see also Stefl v. Nicholson, 21 Vet. App. 120, 124.

Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical evidence. See Bloom v. West, 12 Vet. App. 185, 187 (1999).

Therefore, the Board finds the VA medical opinion to be inadequate and of limited probative value. Nevertheless, VA is not permitted to completely ignore even an 'inadequate' opinion or examination, whether it is in favor or against a veteran's claim. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). However, in contrast, the private clinician provided a detailed rationale to support her opinion that coincides with the Veteran's statements. The Board finds her opinion to be highly probative. It reflects review of the medical record, addresses the Veteran's history of compensation, provides a clear medical explanation, and applies accepted musculoskeletal principles to the Veteran's circumstances.

VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 21 F.4th 776, 781 (2021); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001).

As the evidence is in at least approximate balance as to whether the Veteran's left shoulder disability is due to his service-connected right shoulder bursitis, the Board finds the
claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 21 F.4th 776, 781 (2021); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001).

As the evidence is in at least approximate balance as to whether the Veteran's left shoulder disability is due to his service-connected right shoulder bursitis, the Board finds the Veteran's service-connected right shoulder bursitis caused the Veteran's left shoulder disability. Resolving any reasonable doubt in favor of the Veteran, the Board finds that service connection for a right shoulder disability is warranted.

2. Entitlement to service connection for cardiovascular symptoms.

The Veteran seeks service connection for coronary artery disease (CAD), status post CABG, hypertension, and bradycardia, asserting that these conditions are secondary to his service-connected obstructive sleep apnea.

As stated above, service connection may also be established on a secondary basis for a disability that is due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a), (b). Additionally, in Spicer, 61 F.4th at 1365, as also explained above, the Federal Circuit held that under the causation standard of section 1110 of Title 38 of the United States Code, secondary service connection is warranted where a nonservice-connected disability would have been less severe "but-for" a service connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability.

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that evidence is in at least approximate balance as to whether the Veteran is entitled to service connection for cardiovascular symptoms secondary to his service-connected obstructive sleep apnea. Therefore, service connection is warranted.

The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of cardiovascular symptoms. However, the Veteran is currently service connected for obstructive sleep apnea. See November 2023 Rating Decision. Additionally, in a December 2023 rating decision, the AOJ made the Favorable Finding that the Veteran was diagnosed with bradycardia, arteriosclerotic heart disease, and coronary artery bypass graft. As already mentioned, the Board is bound by these favorable findings. Therefore, the remaining question is whether the Veteran's cardiovascular symptoms were caused or aggravated by his service-connected OSA.

VA medical opinions from November 2023 addressed direct causation and toxic exposure theories and concluded that the Veteran's coronary artery disease was multifactorial in etiology, citing traditional risk factors including age, male sex, obesity, hyperlipidemia, tobacco use, and family history. The examiner provided a negative opinion with the rationale that an exposure event was negative as to nexus. However, those opinions did not address whether the Veteran's cardiovascular symptoms were caused or aggravated by his service-connected OSA. As such, they do not directly rebut the secondary theory that the Veteran, through his representative, submitted before the Board in November 2025.

Conversely, in a private medical opinion dated November 2025, a private clinician noted review of the medical evidence and found the Veteran's cardiovascular symptoms to be due to his service-connected OSA. In doing so, the private clinician reviewed the Veteran's medical history and provided a detailed explanation of the physiological mechanisms linking untreated obstructive sleep apnea to cardiovascular disease, hypertension, and bradycardia. See November 2025 Private Medical Opinion. She discussed intermittent hypoxia, sustained sympathetic nervous system activation, endothelial dysfunction, vascular inflammation, and oxidative stress as mechanisms by which OSA contributes to or aggravates atherosclerotic progression and arrhythmogenic changes. Id. Her opinion cited peer-reviewed medical literature and applied those principles to the Veteran's clinical history, including the severity of his sleep apnea and subsequent cardiovascular diagnoses. Id. The private clinician concluded that the Veteran's cardiovascular symptoms are secondary to his OSA.

In considering whether service connection is warranted, the Board initially notes that the November 2023 opinions do not fully address or consider the theory of secondary service connection. Although the VA opinions identify traditional cardiovascular risk factors, they did not analyze whether OSA contributes to the development of or progression of coronary artery disease, hypertension, or bradycardia, whereas the private opinion fully addresses that question with a detailed rationale based in medical literature and
erotic progression and arrhythmogenic changes. Id. Her opinion cited peer-reviewed medical literature and applied those principles to the Veteran's clinical history, including the severity of his sleep apnea and subsequent cardiovascular diagnoses. Id. The private clinician concluded that the Veteran's cardiovascular symptoms are secondary to his OSA.

In considering whether service connection is warranted, the Board initially notes that the November 2023 opinions do not fully address or consider the theory of secondary service connection. Although the VA opinions identify traditional cardiovascular risk factors, they did not analyze whether OSA contributes to the development of or progression of coronary artery disease, hypertension, or bradycardia, whereas the private opinion fully addresses that question with a detailed rationale based in medical literature and applied to the Veteran's medical history. Therefore, the Board finds the opinions to be of diminished probative value as applied to the theory at issue here, secondary service connection. The opinion has some value. See Monzingo, 26 Vet. App. at 106. However, the private clinician provided a detailed rationale to support his opinion that coincides with the Veteran's statements.

Additionally, the Board acknowledges the contentions purported by the Veteran through his representative, in November 2025. See November 2025 Appellate Brief. The Board finds the argument to be persuasive in that it gives detailed lay testimony as to the Veteran's argument supporting secondary service connection, as well as reiterates the private medical opinion submitted concurrently. As a lay person is competent to report on the onset and reoccurrence of current symptomatology, (see Layno v. Brown, 6 Vet. App. 465, 470 (1994) which stated that a veteran is competent to report on that of which he or she has personal knowledge), the Board finds the appellate brief probative in that it clearly articulates the Veteran's theory to entitlement and supporting lay testimony.

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The Board finds the probative evidence to be at least in approximate balance as to whether the Veteran's coronary artery disease, hypertension, and bradycardia were caused by the Veteran's service-connected obstructive sleep apnea. VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 21 F.4th 776, 781 (2021); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). Resolving any reasonable doubt in favor of the Veteran, the Board finds that service connection for cardiovascular symptoms is warranted.

EMILY TAMLYN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Pieper, C.

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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