Beyrle v. Brown

9 Vet. App. 377, 1996 U.S. Vet. App. LEXIS 709, 1996 WL 502117
United States Court of Appeals for Veterans Claims·Decided September 6, 1996·No. No. 94-688·Published·Cited by 14 cases

Opinion

STEINBERG, Judge:

The pro se appellant, World War II veteran Joseph R. Beyrle, Sr., appeals an April 29, 1994, Board of Veterans’ Appeals (BVA or Board) decision denying an increased (com-pensable) rating for residuals of a gunshot wound of the right upper extremity [hereinafter residuals] and finding no clear and unmistakable error (CUE) in a May 26, 1947, Department of Veterans Affairs (VA) regional office (RO) final decision. Record (R.) at 4-12. For the reasons that follow, the Court will vacate the Board decision, reverse as to one finding, and remand the case to the Board for readjudication of both claims.

[379] I. Background

The veteran served on active duty in the United States Army from September 1942 to November 1945 (R. at 18), and was held as a prisoner of war (POW) by the German government from June 1944 until January 1945 (R. at 41, 47, 49, 123, 241). Service medical records do not contain any notations with respect to the veteran’s having received a gunshot wound to his upper right shoulder. See R. at 22-47. An undated “Personal History” related by the veteran indicated that he had suffered an injury to his upper right arm while a POW. R. at 32.

An April 1947 VA physical examination report noted that, although the veteran’s complaints at that time did not include right-shoulder residuals (R. at 50), the report noted “two elliptical shaped, slightly elevated, well healed cicatrices” of the “right deltoid area” which were “not bound down” and had “no disturbance of underlying muscular function” and were “the residual of superficial through and through bullet wound” which had been received while he was in the German prison camp. R. at 54. The diagnosis included “[cicatrices, healed, right deltoid area, residual through and through bullet wound”. R. at 56. In a May 1947 decision, a VA regional office (RO) granted service connection for “sears, right deltoid area” and assigned a 0% rating. R. at 59.

At a May 1949 VA examination, the veteran’s complaints did not include residuals in the deltoid area, and the diagnosis did not include a reference to the scar in the deltoid area or any residuals of the deltoid area. R. at 68, 73. A neuropsychiatric examination report of the same date noted that the veteran had been “shot in the upper arm in the P.O.W. camp”. R. at 74. Written notes accompanying the May 1949 examination reported “normal range of motion” as to the veteran’s right shoulder. R. at 77. A June 1949 RO decision noted that the current VA examination did not show any change of conditions affecting, inter alia, the previously awarded 0% rating for “wound[], slight, r[ight] deltoid”. R. at 82-83.

In April 1952, the veteran sought an increased rating (R. at 87) and provided a March 1952 medical report from Dr. Teifer (R. at 89). The report stated: “Examination of the right shoulder shows a penetrating type of scar which is approximately one inch in diameter, indicating that the foreign body penetrated the [djeltoid [mjuscle of the right shoulder. [The veteran] has pain on motion of the affected shoulder.” R. at 89. On a June 1952 VA medical examination report, the veteran stated that his present complaints included soreness to his right shoulder and arm. R. at 91. The physician noted the existence of two “10cm flat scars over [the] r[igh]t deltoid lateral to r[igh]t shoulder” and reported: “[The veteran h]as no muscle atrophy in [his] shoulder but alleges pain on extremes of motion. [He h]as full motion [of his] r[igh]t shoulder [with] no crepitation.” R. at 93. A September 1952 RO decision again denied an increase in the assigned 0% disability rating. R. at 104.

A VA medical examination report in February 1982 recorded the veteran’s complaints of, inter alia, “pain in arms [and] hands”. R. at 108. An examination of the musculoskele-tal system included a reference to two “faint[,] [1-inch,] pliable[,] non-adherent scars of [his] upper r[igh]t arm over deltoid musclef, three inches] below [the] acromion.” R. at 110. (Acromion is “the lateral extension of the spine of the scapula, projecting over the shoulder joint and forming the highest point of the shoulder”, Dorland’s Illustrated Medical DICTIONARY 20 (28th ed. 1994) [hereinafter Dorland’s].) The report noted a normal range of motion of the shoulders and elbows with “no loss of muscle tone or strength”. R. at 110. An October 1982 RO decision denied, inter alia, an increased rating for residuals of right deltoid-area scars. R. at 118-19.

A March 1983 VA physical examination report noted a 2%-uich diagonal scar on the veteran’s right arm “over [the] deltoid [with a % inch] bridge of unscarred skin (thru [and] thru wound)”. R. at 153. A VA x-ray report of the veteran’s right shoulder in September 1983 revealed “proliferative changes at the acromio-clavicular [ (AC) ] joint”. R. at 136-37. A VA ex-POW protocol consultation report of the same month included a diagnosis of “[s]car[,] SFW [shell fragment wound of the] r[igh]t arm over r[igh]t deltoid”. R. at [380]*380143. A December 1983 RO decision, inter alia, denied an increased rating for residuals of the deltoid-area scar. R. at 159-64.

In May 1991, the veteran’s representative submitted a letter to the RO claiming CUE in the May 1947 RO decision and subsequent decisions as to the veteran’s right deltoid. R. at 191-93. In its May 1992 decision, the RO, noting that the provisions of 38 C.F.R. §§ 4.56(b) and 4.72 had been considered in its 1947 RO decision, denied the veteran’s CUE claim. R. at 199-201. At a November 1992 hearing on appeal to the Board, the veteran’s representative argued that the evidence showed that the veteran had a through-and-through gunshot wound and that the RO had failed to properly apply the regulations which “required a rating for moderate injury for muscle group of the deltoid and [that its] failure to do so was prejudicial to the veteran”. R. at 235. A February 1993 Board decision, inter alia, remanded the CUE claim to the RO for it to provide the veteran with “a VA special orthopedic examination to determine the nature and extent of the veteran’s service-connected residuals of a gunshot wound of the right deltoid.” R. at 260. The Board further directed:

The report of examination should contain a complete account of all manifestations of residuals of a gunshot wound to the right deltoid found to be present. It is requested that the examiner review the various examination reports on file pertaining to the right deltoid wound and attempt to reconcile the findings so as to determine whether the wound resulted in muscle damage or was superficial and without muscle damage_ The report of examination should contain a complete rationale for all conclusions and opinions expressed.

R. at 260.

The veteran submitted a May 1993 private orthopedic examination report prepared by Dr. Mead; the report related that the veteran had been shot in the right shoulder while he was a German POW, that the bullet “went in the front [of his shoulder] and came out the back”, and that the veteran had stated that “he has had trouble with both shoulders ever since that episode”. R. at 263. Examination reportedly revealed “quite a bit of shoulder girdle atrophy” and two “scar[s, each 3-inch long] in the area of the lateral aspect of the [right] shoulder”. Ibid. The report stated:

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Beyrle v. Brown, 9 Vet. App. 377, 1996 U.S. Vet. App. LEXIS 709, 1996 WL 502117 (Cal. 1996).

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