Citation Nr: 1803006 Decision Date: 01/16/18 Archive Date: 01/29/18 DOCKET NO. 14-19 509 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Evaluation of left shoulder lesions and tears with bursitis, currently rated as noncompensable. 2. Evaluation of right shoulder bursitis, currently rated as noncompensable. 3. Evaluation of primary insomnia, currently rated as noncompensable. 4. Evaluation of recurrent bronchitis, currently rated as noncompensable. 5. Evaluation of right knee strain, currently rated as noncompensable. 6. Evaluation of right wrist strain, currently rated as noncompensable. 7. Evaluation of left wrist strain, currently rated as noncompensable. REPRESENTATION The Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and spouse ATTORNEY FOR THE BOARD K. Foster, Associate Counsel INTRODUCTION The Veteran served on active duty from May 2005 to June 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. The Board notes that while the Salt Lake City, Utah RO issued the rating decision on appeal, the Roanoke, Virginia RO has jurisdiction over the claim. The Veteran and his spouse testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ) in August 2017. A transcript of the hearing is of record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran, if further action is required. REMAND The Board finds that addition development is needed prior to adjudication of the issues on appeal. First, the Board finds that additional treatment records must be obtained and associated with the record. At the August 2017 hearing, the Veteran indicated that he has received ongoing private treatment for his service-connected disabilities. The Board will remand to obtain these records. In addition, at the hearing the Veteran testified that all of the disabilities on appeal have worsened since his most recent VA examination. The Veteran is competent to describe his symptoms and their effect on daily activities. Under these circumstances, VA cannot rate the service-connected disability without further medical clarification. Hence, the Veteran is entitled to a new VA examination. See, e.g., Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Accordingly, the appeal is REMANDED for the following action: 1. After securing all necessary consent forms from the Veteran, obtain all medical records, to include any VA and/or private treatment records, pertaining to the Veteran's claimed disabilities. The Board notes that at the August 2017 hearing, the Veteran identified his primary care physician, F.M.F.P., and also stated that he sees a number of specialists. 2. After completion of the above, schedule the Veteran for an appropriate VA examination to assess the severity of his service-connected disabilities: (1) left shoulder lesions and tears with bursitis; (2) right shoulder bursitis; (3) primary insomnia; (4) recurrent bronchitis; (5) right knee strain; (6) right wrist strain; and (7) left wrist strain. The claim folder and all pertinent treatment records should be made available to the examiner for review. Review of the claim folder should be noted in the examiner's report. All necessary diagnostic testing should be performed. In addition, regarding the left shoulder, right shoulder, right knee, right wrist, and left wrist: (a) The examiner is asked to specifically provide range of motion testing (ROM) for each of these service-connected disabilities for active motion, passive motion, weight-bearing, and nonweight-bearing. Full ROM testing also must be conducted on the opposite joint unless the opposite joint is damaged, which includes any disorder that would make the joint in question abnormal. If the opposite joint is determined to be damaged, and no ROM on testing is conducted, this must be explained in the report. (b) In addition, for both the service-connected disability and its opposite joint the examiner must discuss pain for ROM movements on active, passive, and repetitive use testing. The examiner is asked to address the following questions: (1) Are any ROM movements painful on active, passive, and repetitive use testing? If yes, identify whether active, passive, and repetitive use and identify the point in ROM where pain starts. (2) If yes (there are painful movements), does the pain contribute to functional loss or additional limitation of ROM? Please further describe the functional loss or additional limitation of ROM. (3) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. (c) In addition, for both the service-connected disability and its opposite joint the examiner must discuss pain when used in weight-bearing or in nonweight-bearing. The examiner is asked to address the following questions: (1) Is there pain when the joint is used in weight-bearing or nonweight-bearing? If yes, identify whether weight-bearing or nonweight-bearing. (2) If yes (there is pain when used in weight-bearing or nonweight-bearing), does the pain contribute to functional loss or additional limitation of ROM? Please further describe these limitations. (3) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. (d) In addition, the Veteran indicated at the August 2017 hearing that he experiences tingling in his right arm down to his fingertips. The examiner should address this claim and any other neurological symptoms. A detailed rationale is requested for all opinions provided. If upon completion of the above action the issue is denied, the case should be returned to the Board after compliance with appellate procedures. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded expeditious treatment. The law requires that all issues 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. §§ 5109B, 7112 (2012). _________________________________________________ E. I. VELEZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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) (2017).