Citation Nr: 1319555 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-48 133 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 20 percent for impingement of the left shoulder, status post arthroscopy. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The Veteran had active service from May 1986 to August 1986 and from October 2002 to March 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a December 2009 substantive appeal, the Veteran requested a Travel Board hearing before a Veterans Law Judge. However, in a December 2010 statement, the Veteran withdrew her hearing request. Thus, the Board may proceed to adjudicate the appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran has asserted that she is entitled to a higher rating for her service-connected impingement of the left shoulder. The most recent VA examination was in July 2008, nearly five years ago. The evidence in the claims file also indicates that the Veteran's left shoulder disability may have worsened since the previous examination. A September 2009 VA treatment record reflects that the Veteran reported having pain in her shoulder that radiated down the arm, which is not noted in the July 2008 VA examination report. Additionally, as noted by the Veteran's representative in a May 2013 Informal Hearing Presentation, the July 2008 VA examination noted that there was pain on active motion, but did not note the specific degree at which pain began. The Veteran's representative also requested that a VA examination address the Veteran's claimed muscle loss and damage due to the shoulder disability. As the evidence indicates the disability may have worsened and the most recent VA examination was nearly five years ago, the Board finds that the July 2008 VA examination is not sufficiently contemporaneous for purposes of evaluating the nature and severity of the Veteran's impingement of the left shoulder. The Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, the Board finds that a VA examination is necessary prior to appellate adjudication of the claim. Additionally, the Veteran's complete VA treatment records have not been associated with the claims file. The VA treatment records in the file only date to September 2009. It also does not appear that the Veteran's complete VA treatment records from one year prior to her December 2007 claim are in the claims file. As the VA treatment records are relevant to the claim, the Board requests the Veteran's complete VA treatment records from December 2006 to present. Accordingly, the case is REMANDED for the following action: 1. Obtain names and addresses of all medical care providers who treated the Veteran for left shoulder complaints since December 2006 to present. After securing the necessary release, obtain the records. 2. After completion of the above and after any records received have been associated with the claims file, schedule the Veteran for an appropriate VA examination to determine the current severity the Veteran's impingement of the left shoulder. The examiner should conduct range of motion testing of the left shoulder. The examiner should also report whether there is any pain, weakened movement, excess fatigability or incoordination on movement should be noted, and whether there is likely to be additional range of motion loss due to any of the following should be addressed: pain on use, including during flare-ups; weakened movement; excess fatigability; or incoordination. The examiner is asked to describe whether pain significantly limits functional ability during flare-ups or when the left shoulder is used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report. The VA examiner should note whether the Veteran has limitation of motion of the arm to shoulder level, midway between side and shoulder level, or to 25 degrees from side. The VA clinician is requested to provide a thorough rationale for any opinion provided. The clinician should review the claims folder and this fact should be noted in the accompanying medical report. 3. Thereafter, readjudicate the issue on appeal of entitlement to a rating in excess of 20 percent for impingement of the left shoulder. If the benefit sought is not granted, issue a supplemental statement of the case and afford the Veteran an appropriate opportunity to respond. The case should then be returned to the Board, as warranted. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The appellant should be advised that failure to appear for an examination as requested, and without good cause, could adversely affect his claims, to include denial. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims 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). _________________________________________________ M. E. LARKIN 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).