Citation Nr: 1531045 Decision Date: 07/21/15 Archive Date: 08/05/15 DOCKET NO. 12-33 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to a compensable rating for left sternoclavicular subluxation. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from August 2004 to February 2005 and January 2011 to January 2012 This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision of the Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that the Veteran was last afforded VA examination to evaluate the nature and severity of his service-connected left sternoclavicular subluxation in June 2012, more than 3 years ago. During the examination, although the examiner did not perform any imaging studies, he noted that there was no apparent deformity of the sternoclavicular joints when comparing right to left on palpation or observed during range of motion testing of the shoulders. However, beginning in his June 2012 notice of disagreement, the Veteran reported that there was a sizable lump on his sternoclavicular joint. Also on his December 2012 substantive appeal, he reported that he told the VA examiner that he had weakness in his left shoulder; however, the examiner reported strength in the left shoulder as normal. In the November 2014 Appellant's Brief, the representative reported that imaging studies, which may have revealed arthritis or other damage, were not performed during the June 2012 VA examination. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). A new VA examination is indicated to assess the severity of the Veteran's left shoulder disability. Additionally, in a June 2014 Statement of Accredited Representative in Appealed Case, the representative indicated that the Veteran sought medical treatment for his left shoulder; however, treatment records have not been associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify any medical treatment records for a left shoulder disability and furnish appropriate authorization for the release of private medical records that have not been previously associated with the claims file. If the Veteran fails to furnish any necessary releases for private treatment records, he should be advised to obtain the records and submit them to VA. 38 C.F.R. § 3.159 (2014). Any negative search response must be noted in the record and communicated to the Veteran. 2. Take the necessary steps to obtain any identified records of VA treatment for a left shoulder disability. Efforts to obtain VA records must continue until they are obtained, or it is reasonably certain that they do not exist or that further efforts would be futile. 3. After the completion of steps 1 and 2 above, schedule the Veteran for a VA examination to evaluate the current severity of his service-connected left sternoclavicular subluxation. All indicated tests and studies shall be conducted. a) All appropriate ranges of left shoulder motion shall be reported in degrees. The examiner shall also specify whether and to what extent there is any additional loss of left shoulder motion (stated in degrees) due to any weakened movement, excess fatigability, incoordination, flare ups, and/or pain. b) The examiner shall also report the nature and severity of any ankylosis of the scapulohumeral articulation and any impairment of the humerus, clavicle, and scapula. c) The examiner should also address the Veteran's complaints of weakness in his left shoulder and a sizable lump in his sternoclavicular joint, as well as his concerns regarding arthritis or other damage in the left shoulder area. d) The examiner is also asked to provide an assessment of the functional impairment associated with the Veteran's left shoulder disability, as it relates to the his ability to perform activities required in various occupational situations. The examiner must provide reasons for any opinion given. 3. If the benefit sought on appeal remains denied, the AOJ shall issue a supplemental statement of the case. After the Veteran is given an opportunity to respond, the case shall be returned to the Board. 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). 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 2014). _________________________________________________ T. Mainelli Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2014).