Citation Nr: 1300786 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 09-50 100 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an initial disability rating in excess of 10 percent for upper back strain with left scapular winging. ATTORNEY FOR THE BOARD Sara Schinnerer, Associate Counsel INTRODUCTION The Veteran had active service from June 2004 to July 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California, which assigned an initial noncompensable rating for the Veteran's upper back strain, effective from July 31, 2007. In a November 2009 rating decision, the RO increased the rating from noncompensable to 10 percent disabling, effective July 31, 2007. As the rating for the upper back strain disability is less than the maximum available rating, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). REMAND The Board is of the opinion that additional development is required before the Veteran's claim is decided. Specifically, an examination is necessary, for the reasons discussed below. During the most recent August 2009 fee-based examination, the Veteran reported that he has experienced upper back pain that radiates into his left upper extremity. Upon examination, the examiner noted that the Veteran had mild left upper extremity weakness, as well as significant wasting of the left rhomboid. The diagnosis was an upper back strain and left scapular winging. The examiner stated that the Veteran needed further examination by a neurologist in order to determine the etiology of his isolated winging of the left scapula. The report of the August 2009 fee-based examination is thus inadequate to rate the disability, as the Veteran's claimed left upper extremity radiculopathy has not been addressed. In addition, subsequent to the aforementioned examination, the Veteran submitted statements in December 2009 which note his complaints of severe muscle spasms, which he believes are the result of his cervical spine disability. Given the Veteran's credible assertion of increased symptomatology subsequent to the aforementioned examination, and the need for clarification regarding whether the Veteran has a current left upper extremity radiculopathy, and if so, whether it is associated with service-connected disability, an examination is necessary to assess all of the orthopedic and neurological manifestations attributable to the Veteran's service-connected spine disability. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim. 2. Then, arrange for the Veteran to be scheduled for an appropriate VA examination(s) in order to determine the current nature and severity of all manifestations of his service-connected upper back disability with left scapular winging disability, to include any neurological manifestations. The claims file and any pertinent evidence in Virtual VA that is not contained in the claims file must be reviewed by the examiner(s) in conjunction with the examination(s). All indicated evaluations, studies, and tests deemed to be necessary must be accomplished. The RO or the AMC should ensure that all information required for rating purposes is provided by the examiner(s). In particular, the appropriate examiner must identify any neurologic manifestations of the Veteran's service-connected upper back disability with left scapular winging disability, to include specifying any and all neurologic symptoms (e.g., neuritis, neuralgia, sensory loss, body part dysfunction, etc.) with specific reference to the nerve(s) affected. The examiner must provide an opinion as to whether any neurological symptomatology equates to "mild," "moderate," "moderately severe" or "severe," incomplete paralysis or complete paralysis of any nerve. 3. Undertake any other indicated development. 4. Thereafter, readjudicate the Veteran's claim, with application of all appropriate laws and regulations, including consideration of any additional information obtained as a result of this remand. Readjudication must include consideration of whether a separate disability rating for any neurological impairment associated with the service-connected disability is warranted. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he must be furnished a supplemental statement of the case and afforded the requisite period of time to respond. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2012).