SHOULDER IMPAIRMENT OF

MARISSA CAYLOR · 2026 · Case ID: A26035908

MIXED

Summary

The veteran, who served from October 2009 to November 2024 with multiple periods of active duty and reserve service, appeals the denial of service connection for several conditions and seeks higher ratings for others. The Board granted service connection for right shoulder degenerative arthritis, finding it was presumptively incurred in service due to a diagnosed bilateral triceps tendon rupture and subsequent degenerative changes noted in service treatment records, corroborated by the veteran's credible testimony of ongoing pain. The Board remanded claims for higher ratings for bilateral pes cavus with hallux valgus, plantar fasciitis, hammertoes, left ankle impingement, and left shoulder disability. These remands were primarily due to duty-to-assist errors, including VA's failure to obtain complete treatment records from MedStar Georgetown University Hospital and to obtain a VA opinion on the nexus between the veteran's service-connected left ankle and the claimed left knee disability. Additionally, the Board remanded claims for left and right arm disabilities and left shoulder disability, citing the need for VA examinations to assess the nexus between current conditions and in-service injuries like bilateral triceps tendon ruptures and shoulder pain. The Board also remanded a claim for low back disability secondary to service-connected ankle and foot conditions, finding it within the scope of the remanded claims for higher ratings of those conditions.

Rationale

Service treatment records show bilateral triceps tendon rupture and subsequent degenerative changes in right shoulder.; Veteran credibly testified to ongoing right shoulder pain since service.; Service connection granted on a presumptive basis.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210420-154644

Full Decision Text

Citation Nr: A26035908
Decision Date: 04/16/26 Archive Date: 04/16/26

DOCKET NO. 210420-154644
DATE: April 16, 2026

ORDER

Service connection for right shoulder degenerative arthritis is granted.

REMANDED

Entitlement to a rating higher than 30 percent for bilateral pes cavus with hallux valgus, plantar fasciitis, and hammertoes is remanded.

Entitlement to a compensable rating for left ankle impingement is remanded.

Entitlement to service connection for a low back disability secondary to the Veteran's service-connected left ankle and bilateral foot disabilities is remanded.

Entitlement to service connection for a left knee disability secondary to the Veteran's service-connected left ankle disability is remanded.

Entitlement to service connection for a left arm disability is remanded.

Entitlement to service connection for a right arm disability is remanded.

Entitlement to service connection for a left shoulder disability is remanded.

FINDING OF FACT

The Veteran was diagnosed with degenerative arthritis of the right shoulder during a period of active duty that was longer than 90 days, and he has credibly testified to ongoing right shoulder pain ever since.

CONCLUSION OF LAW

The criteria for service connection for right shoulder degenerative arthritis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from October 2009 to March 2010, from March 2010 to June 2014, from April 2017 to September 2017, from December 2017 to February 2019, from January 2021 to January 2022, and from January 2023 to November 2024, with additional Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2020 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), also known as the Agency of Original Jurisdiction (AOJ).

In an April 20, 2021, VA Form 10182, Decision Review Request: Board Appeal, the Veteran appealed the November 2020 rating decision to the Board and selected the hearing docket, allowing him 90 days from the date of his hearing to submit additional evidence in support of his claims. On September 18, 2024, the Veteran testified at a hearing before a Veterans Law Judge, and a transcript of that hearing is of record. Accordingly, the Board may only consider the evidence of record at the time of the November 2020 rating decision and evidence submitted within 90 days of the September 2024 Board hearing. See 38 C.F.R. § 20.302. If evidence was submitted either: (1) during the period after the November 2020 rating decision and prior to the September 2024 hearing, or (2) more than 90 days after the September 2024 hearing, the Board did not consider it in its decision. 38 C.F.R. § 20.302. However, with respect to the claims the Board is remanding, any evidence the Board could not consider will be considered by the AOJ in the re-adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and certain chronic disabilities, including arthritis, become manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 110
Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

1. Entitlement to service connection for a right shoulder disability

On the Veteran's October 2020 application for service connection, he asserted that a current right shoulder disability was incurred during service when he sustained a triceps tendon tear. During the September 2024 Board hearing, the Veteran testified that his shoulder pain was initially caused by an altered gait resulting from a left ankle injury, which caused him to change the way he held his pack. He also testified that his right shoulder was further aggravated by physical training and bilateral triceps tendon ruptures that occurred during service. The Veteran indicated that he has had ongoing right shoulder pain ever since.

Upon review of the record, the Board finds that service connection for degenerative arthritis of the right shoulder is warranted.

Service treatment records from the Veteran's period of active duty from December 2017 to February 2019 show that the Veteran sought emergency treatment in October 2018 after hearing a popping sound in both biceps while lifting weights, followed by bilateral arm swelling. The diagnosis was bilateral triceps tendon rupture. In January 2019, the Veteran sought treatment for worsening right shoulder pain since the October 2018 triceps injury. An MRI of the right shoulder revealed degenerative changes of the right acromioclavicular (AC) joint. In March and April 2019, he reported ongoing bilateral shoulder pain, which was worse on the right.

In sum, service treatment records show that the Veteran was diagnosed with arthritis of the right shoulder during a period of active duty that was longer than 90 days, and he has credibly testified to ongoing right shoulder pain ever since. As there is no evidence to the contrary, the Board finds that service connection for degenerative arthritis of the right shoulder is warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

REASONS FOR REMAND

1. Entitlement to a rating higher than 30 percent for bilateral pes cavus with hallux valgus, plantar fasciitis, and hammertoes

2. Entitlement to a compensable rating for left ankle impingement

If, after making reasonable efforts to obtain relevant private records, VA is unable to obtain all of the relevant records sought, VA shall notify the claimant that it was unable to obtain records with respect to the claim. 38 U.S.C. § 5103A(b); 38 C.F.R. § 3.159(e). The notice must contain: (1) the identity of the records VA was unable to obtain, (2) an explanation of the efforts VA made to obtain the records, (3) a description of any further action VA will take regarding the claim, including notice that VA will decide the claim based on the evidence of record unless the claimant submits the records VA was unable to obtain, and (4) a notice that the claimant is ultimately responsible for providing the evidence. 38 C.F.R. § 3.159(e)(1).

With the Veteran's October 4, 2020, claim, he submitted a signed authorization to obtain private treatment records from MedStar Washington Health, where he reportedly received treatment from March 2020 to January 2021. In October 2020 letters, VA notified the Veteran that it requested treatment records from Medstar Washington, but advised the Veteran that it was ultimately his responsibility to see that VA receives it. In November 2020, MedStar Washington informed VA that it had no records of treatment for the dates requested. Therefore, VA closed the request. The following day, VA issued the November 2020 rating decision on appeal without notifying the Veteran that records were not received from MedStar Washington. See 38 C.F.R. § 3.159(e). Accordingly, the claims are remanded to correct this duty-to-assist error. See
MedStar Washington Health, where he reportedly received treatment from March 2020 to January 2021. In October 2020 letters, VA notified the Veteran that it requested treatment records from Medstar Washington, but advised the Veteran that it was ultimately his responsibility to see that VA receives it. In November 2020, MedStar Washington informed VA that it had no records of treatment for the dates requested. Therefore, VA closed the request. The following day, VA issued the November 2020 rating decision on appeal without notifying the Veteran that records were not received from MedStar Washington. See 38 C.F.R. § 3.159(e). Accordingly, the claims are remanded to correct this duty-to-assist error. See 38 U.S.C. § 5103A; 38 C.F.R. § 20.802.

Additionally, on October 4, 2020, the Veteran submitted a few pages of treatment records from MedStar Georgetown University Hospital dated July 2020 and October 2020. As the record shows that the Veteran was treated at MedStar Georgetown University Hospital during the dates he wrote on his authorization for MedStar Washington Health, and MedStar Washington Health had no records of treatment from those dates, the Board finds that VA should have asked the Veteran to submit a signed authorization to obtain treatment records from MedStar Georgetown University Hospital. See 38 C.F.R. § 3.159(c); see also https://www.medstarhealth.org/services/medical-records (providing different addresses to request records from MedStar Washington Hospital and MedStar Georgetown University Hospital). Accordingly, the claims are also remanded to correct this duty-to-assist error. See 38 U.S.C. § 5103A; 38 C.F.R. § 20.802.

3. Entitlement to service connection for a low back disability secondary to the Veteran's service-connected left ankle and bilateral foot disabilities

On the Veteran's April 2021 VA Form 10182, he indicated that he was seeking to appeal a claim for service connection for low back pain caused by his service-connected left ankle and bilateral foot disabilities. A claim for service connection for a low back disability was most recently denied in a May 2015 rating decision. Therefore, the April 2021 VA Form 10182 is not timely with respect to that decision, nor is the appeal filed on the proper form. See 8?U.S.C. §?7105(b)(1)(A); 38?C.F.R. §§?3.2500(a)(1), 20.202, 20.203. Nevertheless, a claim for secondary service connection for a back disability is within the scope of the claims for higher ratings for the Veteran's left ankle and bilateral foot disabilities. See Bailey v. Wilkie, 33 Vet. App. 188, 191 (2021) (when entitlement to compensation for complications of a service-connected disability is reasonably raised during the course of a claim for an increased rating for that disability, the claimant need not file a separate claim). As the Board is remanding the claims for higher ratings for left ankle and bilateral foot disabilities, the claim for service connection for a low back disability secondary to the left ankle and bilateral foot disabilities is also remanded for contemporaneous adjudication. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991).

4. Entitlement to service connection for a left knee disability secondary to the Veteran's service-connected left ankle disability

On the Veteran's October 2020 claim for a higher rating for his left ankle disability, he indicated that he was seeking service connection for a left knee disability in connection with the left ankle disability. He also submitted a July 2020 private treatment record showing treatment for left ankle instability and left knee pain. The AOJ did not adjudicate the claim for service connection for a left knee disability because the claim had previously been denied and was not submitted on a supplemental claim form, which was consistent with VA practice at that time. See Chisholm v. Collins 38 Vet. App. 140, 150 (2025) (holding that a supplemental claim can be filed on any form prescribed by the Secretary, and it does not need to be filed on a supplemental claim form). However, the Veteran's claim for secondary service connection for a left knee disability is within the scope of the claim for a higher rating for the left ankle disability. See Bailey, 33 Vet. App. at 191. Moreover, the Veteran's October 2020 claim raised a new theory of entitlement from his previously denied claim for service connection for a left knee disability, and he submitted new and relevant evidence in support of the claim. See 38 C.F.R. § 3.2501(a). Therefore, at the time of the November
140, 150 (2025) (holding that a supplemental claim can be filed on any form prescribed by the Secretary, and it does not need to be filed on a supplemental claim form). However, the Veteran's claim for secondary service connection for a left knee disability is within the scope of the claim for a higher rating for the left ankle disability. See Bailey, 33 Vet. App. at 191. Moreover, the Veteran's October 2020 claim raised a new theory of entitlement from his previously denied claim for service connection for a left knee disability, and he submitted new and relevant evidence in support of the claim. See 38 C.F.R. § 3.2501(a). Therefore, at the time of the November 2020 rating decision, VA had a duty to develop and adjudicate the claim for service connection for a left knee disability secondary to the left ankle disability as part of the claim for a higher rating for the left ankle disability. See 38 C.F.R. §§ 3.159(c), 3.2504(c),

In this case, the Veteran underwent a VA ankle examination in October 2020. However, he did not receive a VA knee examination, nor did the October 2020 VA examiner provide an opinion as to whether a current left knee disability was caused or aggravated by his service-connected left ankle disability. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c); see also McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006); see also 38 C.F.R. § 3.310. Accordingly, the claim is remanded to correct this duty-to-assist error. See 38 U.S.C. § 5103A; 38 C.F.R. § 20.802.

5. Entitlement to service connection for a left arm disability

6. Entitlement to service connection for a right arm disability

7. Entitlement to service connection for a left shoulder disability

On the Veteran's October 2020 claim, he asserted that current bilateral arm and shoulder disabilities were caused by bilateral triceps tendon tears he sustained during service.

Service treatment records from the Veteran's period of active duty from December 2017 to February 2019 show that the Veteran was treated for bilateral triceps tendon rupture in October 2018. Later that month, he was diagnosed with bilateral strains of the muscle, fascia, and tendons of the triceps. In March and April 2019, he reported ongoing bilateral shoulder pain. After the Veteran's discharge from active duty, he sought follow-up treatment in September 2019, during which he was diagnosed with bilateral biceps tendinitis. Based on the foregoing, the Board finds that VA should have provided the Veteran with VA examinations and obtained medical opinions as to whether current bilateral arm and/or left shoulder disabilities were incurred in or caused by service. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); McLendon, 20 Vet. App. at 84. Accordingly, the claims are remanded to correct this duty-to-assist error. See 38 U.S.C. § 5103A; 38 C.F.R. § 20.802.

The matters are REMANDED for the following action:

1. Provide the Veteran with notice that records could not be obtained from MedStar Washington Hospital and that VA will decide his claims based on the evidence of record unless he submits the records VA was unable to obtain.

2. Ask the Veteran to submit a signed authorization to obtain complete treatment records from MedStar Georgetown University Hospital. If any requested records are unavailable, the Veteran should be notified of such.

3. After completing #1 and #2, schedule the Veteran for a VA examination regarding a left knee disability secondary to his service-connected left ankle disability. The examiner should review the claims file, including a copy of this remand, conduct any necessary testing, and answer the following:

(a.) Is it at least as likely as not (likelihood is in approximate balance, if not higher) that any current left knee disability would not have developed but for, or was worsened or prevented from improving by, his service-connected left ankle impingement, to include as due to an altered gait?

The examiner should provide a detailed rationale and complete medical explanation for all opinions. If the examiner is unable to provide an opinion without resorting to speculation, the examiner should explain why.

4. After completing #1 and #2, schedule the Veteran for a VA examination pursuant to his claims for service connection for left and right arm disabilities. The examiner should review the claims file, including a copy of this remand, conduct any necessary testing, and answer the following:

(a.) Is it at least as
in approximate balance, if not higher) that any current left knee disability would not have developed but for, or was worsened or prevented from improving by, his service-connected left ankle impingement, to include as due to an altered gait?

(a.) Is it at least as likely as not (likelihood is in approximate balance, if not higher) that a current left arm disability was incurred in or caused by service, to include the October 2018 bilateral triceps tendon rupture; October 2018 diagnosis of bilateral strains of the muscle, fascia, and tendons of the triceps; and March and April 2019 reports of bilateral shoulder pain?

(b.) Is it a least as likely as not (likelihood is in approximate balance, if not higher) that a current right arm disability (other than right shoulder degenerative arthritis) was incurred in or caused by service, to include the October 2018 bilateral triceps tendon rupture; October 2018 diagnosis of bilateral strains of the muscle, fascia, and tendons of the triceps; and March and April 2019 reports of bilateral shoulder pain?

5. After completing #1 and #2, schedule the Veteran for a VA examination pursuant to his claim for service connection for a left shoulder disability. The examiner should review the claims file, including a copy of this remand, conduct any necessary testing, and answer the following:

(a.) Is it at least as likely as not (likelihood is in approximate balance, if not higher) that any current left shoulder disability was incurred in or caused by service, to include the October 2018 bilateral triceps tendon rupture; October 2018 diagnosis of bilateral strains of the muscle, fascia, and tendons of the triceps; and March and April 2019 reports of bilateral shoulder pain?

Marissa Caylor

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board C. Banister

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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