Citation Nr: 1629738 Decision Date: 07/26/16 Archive Date: 08/04/16 DOCKET NO. 13-28 315A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to an initial compensable rating for service-connected right shoulder strain with degenerative arthritis. REPRESENTATION Veteran represented by: AMVETS ATTORNEY FOR THE BOARD I. Cannaday, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from June 1991 to June 2011. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. This appeal was processed using Virtual VA and the Veterans Benefits Management System (VBMS). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND A remand is required to afford the Veteran a new VA examination. The Veteran was most recently afforded a VA examination for his service-connected right shoulder strain in February 2012. Since that examination, the Board finds that, liberally construed, the Veteran's October 2013 Substantive Appeal indicates a possible worsening of his condition since the February 2012 VA examination. Specifically, the Veteran stated that he constantly feels the side effects from his right rotator cuff; has a limited range of motion; and that his issue only worsened with time. In that regard, VA's General Counsel has indicated that, when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Additionally, the Board notes that during the February 2012 VA examination the examiner did not indicate if the Veteran had pain during his range of motion testing. Specifically, while performing range of motion testing, the examiner did not indicate that the Veteran had no objective evidence of painful motion nor did he indicate at which degree painful motion began. Thus, the Board cannot determine if the Veteran had pain during range of motion testing. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his right shoulder disability. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA treatment records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the severity and manifestations of his right shoulder disability. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, to include the Veteran's service treatment records, post-service medical records, and lay assertions. It should also be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran's right shoulder disability pursuant to the schedule for rating disabilities. In particular, the examiner should provide the range of motion of the right shoulder in degrees and indicate whether there is any ankylosis. He or she should also address whether there is any malunion, recurrent dislocation, fibrous union, nonunion (false flail joint), or loss of head (flail shoulder) of the humerus. The examiner should further state whether there is any impairment of the clavicle or scapula. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including any additional loss of motion). Specifically, the examiner should note at what degree any painful motion begins. The examiner should also address whether there is any additional functional impairment during flare-ups. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. As it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or, in the alternative, the entire claims file, must be made available for review. 3. In the event that the Veteran does not report for the scheduled examination, documentation should be obtained which shows that notice scheduling the examination was sent to his last known address. It should also be indicated whether any notice sent was returned as undeliverable. 4. The AOJ should review the claims file and ensure that the foregoing development actions have been conducted and completed. 5. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. 6. When the development has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran 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). _________________________________________________ ANTHONY C. SCIRÉ, JR. 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) (2015).