Citation Nr: 1631978 Decision Date: 08/11/16 Archive Date: 08/23/16 DOCKET NO. 14-24 504 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to a rating in excess of 20 percent for dislocation, with arthritis of the left acromioclavicular joint. ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from February 1953 to December 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision of the VA Regional Office (RO) in Waco, Texas. This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2014). REMAND The regulations with regard to rating service-connected joint disorders require that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59 (2015); Correia v. McDonald, No. 13-3238, 2016 WL 3591858 (Vet. App. July 5, 2016). The Board has reviewed the Veteran's only VA examination findings with range of motion testing during this appeal in April 2012, and concludes that these findings are not adequate. The examination contains active range of motion, but does not include passive motion, in weight-bearing, and nonweight-bearing. Given this, the examination findings are not adequate for rating purposes. Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims, to include treatment for his service-connected left acromioclavicular joint from VA and non-VA providers. Based on his response, and with the appropriate authorizations signed, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources, to include records from Scott & White and all other providers identified by the Veteran. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. Regardless of his response, the RO must obtain treatment records from the Central Texas VA Healthcare system. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. The Veteran must be afforded an appropriate VA examination to determine the severity of his service-connected left acromioclavicular joint. The electronic claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. All symptoms and findings must be reported, and any indicated testing must be conducted. The examiner must conduct full range of motion studies on the service-connected left shoulder, in terms of degrees with a goniometer. If there is clinical evidence of pain on motion, the examiner must indicate the specific degree of motion at which such pain begins on active and passive motion, in weight-bearing and nonweight-bearing, and after at least three repetitions, for both the joint in question and any paired joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, the examiner must clearly explain why that is so. Then, after reviewing the Veteran's complaints and medical history, the examiner must render an opinion as to the extent to which the Veteran experiences functional impairments, such as weakness, excess fatigability, lack of coordination, or pain due to repeated use or flare-ups, etc. Objective evidence of loss of functional use can include the presence or absence of muscle atrophy and/or the presence or absence of changes in the skin indicative of disuse due to the service-connected left shoulder disorder. The examiner must report whether the Veteran has other symptomatology such as impairment of the humerus, clavicle, or scapula. The examiner must also note whether there is ankylosis of the left shoulder. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the evidence of record that shows that notice scheduling the examination was sent to his last known address. Documentation must be also be obtained and associated with the evidence of record demonstrating any notice that was sent was returned as undeliverable. 4. Once the above actions have been completed, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claim on appeal must be adjudicated. If the benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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).