Citation Nr: 18140164 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 14-02 826 DATE: October 2, 2018 ORDER A higher initial disability rating of 50 percent for posttraumatic stress disorder (PTSD) from October 1, 2011 to August 1, 2013 is granted. An initial disability rating for maxillary sinusitis of 10 percent, but no higher, from October 1, 2011 to August 29, 2013 is granted; a rating in excess of 50 percent from August 29, 2013 is denied. A higher initial disability rating of 20 percent for a right foot disability from October 1, 2011 is granted. A higher initial disability rating of 20 percent for a left foot disability from October 1, 2011 is granted. REMANDED A higher initial disability rating in excess of 10 percent for left shoulder strain (non-dominant) is remanded. FINDINGS OF FACT 1. For the rating period on appeal from October 1, 2011 to August 1, 2013, PTSD has been manifested by occupational and social impairment with reduced reliability and productivity. 2. For the rating period on appeal from October 1, 2011 to August 29, 2013, sinusitis has been manifested by three to six non-incapacitating episodes per year, and has not been manifested by three or more incapacitating episodes per year or more than six non-incapacitating episodes per year. 3. For the rating period on appeal from August 29, 2013, the Veteran is in receipt of the maximum schedular rating of 50 percent for service-connected sinusitis. 4. For the rating period on appeal from October 1, 2011, the right and left foot disabilities have been manifested by moderately severe foot injury residuals. 5. For the rating period on appeal from October 1, 2011, the right and left foot disabilities have not more closely approximated severe foot injury residuals. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for a higher disability rating of 50 percent for PTSD have been met for the rating period on appeal from October 1, 2011 to August 1, 2013. 38 C.F.R. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. Resolving reasonable doubt in favor of the Veteran, the criteria for a higher disability rating of 10 percent for sinusitis have been met for the rating period from October 1, 2011 to August 29, 2013. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6513. 3. The criteria for an initial disability rating in excess of 50 percent for sinusitis are not met or more nearly approximated for the period from August 29, 2013. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.97, Diagnostic Code 6513. 4. Resolving reasonable doubt in favor of the Veteran, the criteria for a 20 percent rating for a right foot disability have been met for the rating period on appeal from October 1, 2011. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284. 5. Resolving reasonable doubt in favor of the Veteran, the criteria for a 20 percent rating for a left foot disability have been met for the rating period on appeal from October 1, 2011. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, had active service from September 1991 to September 2011. This appeal derived from a downstream element of a claim for service connection for PTSD, plantar fasciitis, a sinus disorder, and a left shoulder disorder that was received in April 2011 (prior to the Veteran’s separation from active service in September 2011). This appeal comes to the Board of Veterans’ Appeals (Board) from April 2012 and January 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The April 2012 rating decision, in pertinent part, granted service connection for PTSD, left foot plantar fasciitis, right foot plantar fasciitis, and left shoulder strain, and assigned initial 10 percent disability ratings, and granted service connection for maxillary sinusitis and assigned an initial noncompensable (0 percent) disability rating. The disability ratings were made effective October 1, 2011 (the day after the Veteran’s separation from active service). The Veteran entered a notice of disagreement with the initial disability ratings assigned. The January 2014 rating decision assigned 50 percent disability ratings for the PTSD and maxillary sinus, effective August 1, 2013 and August 29, 2013, respectively, creating “staged” initial disability ratings. In February 2015, the Veteran testified at a Board videoconference hearing at the local RO in Lincoln, Nebraska, before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This case was previously before the Board in February 2016, where the Board remanded the issues on appeal for additional development, including obtaining a private medical opinion from Dr. A.T., as well as providing a VA shoulder examination. A January 2015 private medical opinion from Dr. A.T. and an April 2016 VA examination report have been associated with the record. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Review of the record reflects that the Veteran received adequate notice concerning the issues on appeal. As to the duty to assist, the record reflects that VA obtained VA and private treatment (medical) records. The Veteran has received multiple VA examinations throughout the course of this appeal. The examination reports are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. The examination reports reflect that, taken together, the VA examiners reviewed the record, conducted in person examinations with appropriate testing, and adequately answered all relevant questions. There remains no question as to the substantial completeness of the record as to the issues on appeal. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Any duties imposed on VA, including the duties to assist and to provide notification, have been met. 1. Higher Initial Rating for PTSD Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Pertinent in this case, the General Rating Formula provides that a 10 percent rating is assigned for occupational and social impairment due to mild and transient symptoms that decrease work efficiency and ability to perform occupational tasks only during significant stress or with symptoms controlled by continuous medication. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R § 4.130. A 70 percent rating will be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent schedular rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. The use of the term “such as” in the General Rating Formula for Mental Disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disability, and the effect of those symptoms on his/her social and work situation. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that VA “intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms.” The Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” In Golden v. Shulkin, No. 16-1208 (U.S. Vet. App., Feb. 23, 2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating when the appeal was certified after August 4, 2014. As the instant appeal was certified after August 4, 2014, the Board will not rely on GAF scores for rating purposes. The Veteran contends generally that the service-connected PTSD has been manifested by more severe symptoms and impairment than contemplated by the 10 percent disability rating assigned for the initial rating period from October 1, 2011 to August 1, 2013. Specifically, at the February 2015 Board hearing, the Veteran testified that PTSD symptoms have remained the same since 2011 and should be rated as 50 percent disabling (the rating assigned from August 1, 2013). See February 2015 Board hearing transcript. After a review of the lay and medical evidence, the Board finds that, for the initial rating period on appeal from October 1, 2011 to August 1, 2013, the weight of the competent and probative lay and medical evidence demonstrates the service-connected PTSD more nearly approximates occupational and social impairment with reduced reliability and productivity, to meet the criteria for a higher 50 percent rating under Diagnostic Code 9411. An August 2013 private examination report reflects the private examiner assessed flattened affect, depressed mood, suspiciousness, anxiety, and difficulties establishing and maintaining effective relationships. The August 2013 private examiner opined also that PTSD manifested as occupational and social impairment with reduced reliability and productivity. Significantly, a January 2015 private medical opinion reflects that Dr. A.T. indicated that symptoms and impairment of the service-connected PTSD manifested as occupational and social impairment with reduced reliability and productivity from October 2011. The private examiner reasoned that the symptoms and impairment that the Veteran was currently experiencing were similar to the symptoms and impairment experienced in October 2011. The February 2015 Board hearing transcript also reflects the Veteran indicated that symptoms of PTSD have been the same since 2011. For these reasons, and after resolving all reasonable doubt in favor of the Veteran, the Board finds that, for the rating period from October 1, 2011 to August 1, 2013, a 50 percent disability rating is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The appeal for a higher initial disability rating for PTSD is fully granted in this Board decision, which includes any question of extraschedular rating referral. At the February 2015 Board hearing, the Veteran indicated that a 50 percent disability from October 1, 2011 to August 1, 2013 would fully satisfy the appeal as to this issue. Such a full grant of benefits sought, coupled with express indication that the rating percentage sought fully satisfies the appeal, is distinguished from a case where a veteran does not express satisfaction with a partial increased rating during an appeal that is less than the maximum schedular rating. See A.B. v. Brown, 6 Vet. App. 35, 39 (1993) (recognizing that a claimant may limit the claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum allowed by law for a particular service-connected disability). The Board finds the Veteran’s waiver of the remaining aspects of the appeal for an initial rating was knowing and intelligent, was made with representation and in the presence of the representative, and was supported by the Veteran’s testimony and the other evidence of record. A 50 percent disability rating for PTSD is granted for the period from October 1, 2011 to August 1, 2013, and the Veteran had limited this appeal in both extent and time by withdrawing the aspects of the appeal that encompassed an initial rating in excess of 50 percent for any period. See 38 C.F.R. § 20.204 (providing that an appellant may withdraw an issue at any time before the Board issues a final decision). For these reasons, any questions of a disability rating in excess of 50 percent for the initial rating period from October 1, 2011, and any questions of special monthly compensation or extraschedular rating, are rendered moot, with no remaining questions of law or fact to decide. See 38 U.S.C. § 7104; see also Sabonis v. Brown, 6 Vet. App. 426, 429-30 (1994) (where the law is dispositive, the claim must be denied due to a lack of legal merit). In summary, the Board finds that the service-connected PTSD more closely approximates the criteria for a 50 percent rating under Diagnostic Code 9411 for the appeal period from October 1, 2011 to August 1, 2013; therefore, the appeal is fully granted. 38 C.F.R. §§ 4.3, 4.7. 2. Higher Initial Rating for Sinusitis Diagnostic Code 6513 pertains to chronic maxillary sinusitis, which is rated to the General Rating Formula for Sinusitis (General Rating Formula). Under the General Rating Formula noncompensable (0 percent) rating is warranted for sinusitis detected by X-ray only. A 10 percent rating is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. A 30 percent rating is warranted for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Finally, a 50 percent rating is warranted for chronic sinusitis following radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain, and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97. Throughout the course of the appeal, the Veteran has contended generally that sinusitis has been manifested by more severe than those contemplated by the 0 percent disability rating assigned for the period from October 1, 2011 to August 29, 2013, and the 50 percent disability rating assigned for the period from August 29, 2013. See February 2015 Board hearing transcript. From October 1, 2011 to August 29, 2013 After a review of all the evidence, lay and medical, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the rating period from October 1, 2011 to August 29, 2013, sinusitis has been manifested by three to six non-incapacitating episodes per year, and, therefore, more nearly approximates the criteria for a 10 percent disability rating under Diagnostic Code 6510. 38 C.F.R. §§ 4.3, 4.7, 4.97. Specifically, a March 2012 VA examination report reflects the Veteran reported sinus infections four times per year, lasting approximately two weeks. The Veteran also reported treating the sinus infections with antibiotics. The February 2015 Board hearing transcript reflects the Veteran reported experiencing a sinus infection three to four times per year, which was treated with antibiotics. For these reasons, the Board finds that the criteria for a 10 percent disability rating under Diagnostic Code 6513 have been more nearly approximated for the rating period on appeal from October 1, 2011 to August 29, 2013. 38 C.F.R. §§ 4.3, 4.7, 4.97. The Board also finds that, for the entire rating period on appeal, the criteria for a disability rating in excess of 10 percent for service-connected sinusitis have not been more nearly approximated. The March 2012 VA examination report reflects the VA examiner specifically assessed one non-incapacitating episode per year, zero incapacitating episodes per year, and that the Veteran had not had sinus surgery. The February 2015 Board hearing transcript also reflects the Veteran testified to experiencing a sinus infection three to four times per year from 2011 to 2013, which was treated with antibiotics, and sinus surgery in 2014. The numerous VA and private treatment records do not demonstrate that sinusitis has been manifested by three or more incapacitating episodes per year or more than six non-incapacitating episodes per year. The Board has also considered evidence demonstrating complaints of sinusitis characterized by headaches, sinus pain, and purulent discharge; however, the weight of the evidence of record does not demonstrate three or more incapacitating episodes per year requiring four to six weeks of antibiotic treatment, or more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting, which is required for a 30 percent disability rating. 38 U.S.C. § 4.97, Diagnostic Code 6513. From August 29, 2013 The January 2014 rating decision favorably assigned a 50 percent rating under Diagnostic Code 6513 for sinusitis, which is the maximum schedular rating available under Diagnostic Code 6513. 38 C.F.R. § 4.97. In addition, the maximum rating under Diagnostic Code 6522 is 30 percent; therefore, a higher rating than 50 percent is not available under either Diagnostic Code 6513 or Diagnostic Code 6522. 3. Higher Initial Rating for Right Foot Disability 4. Higher Initial Rating for Left Foot Disability The Veteran is in receipt of a 10 percent disability rating for both the right and left foot disability under Diagnostic Code 5284 from October 1, 2011. Under Diagnostic Code 5284, a 10 percent rating is assigned for a moderate foot injury. A 20 percent rating is assigned for a moderately severe foot injury, and a 30 percent rating is assigned for a severe foot injury. Words such as “severe,” “moderate,” and “mild” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Throughout the course of the appeal, the Veteran has contended generally that the right and left foot disabilities have been manifested by more severe symptoms than those contemplated by the 10 percent disability ratings assigned for the period from October 1, 2011. At the February 2015 Board hearing, the Veteran testified to moderately severe foot pain, tingling, numbness, soaking the feet three times per week, and the inability to use an elliptical machine due to the service-connected bilateral foot disability. After a review of the lay and medical evidence, the Board finds that, for the rating period on appeal from October 1, 2011, the Veteran’s symptoms and functional impairment have more closely approximated the criteria for a 20 percent rating for each foot for moderately severe residuals of a foot injury under Diagnostic Code 5284 as the right and left foot disabilities have been manifested by moderately severe overall impairment, to include pain, flare ups, tenderness, and use of inserts. The evidence demonstrates pain on manipulation and use of the feet and extreme tenderness of plantar surface as reflected in the March 2013 VA examination report. The March 2013 VA examination report also reflects the use of inserts. The Veteran has credibly reported as to having moderately severe bilateral foot pain, tingling, and numbness since service separation in 2011. The February 2015 Board hearing transcript reflects the Veteran testified to soaking the feet three times per week and the inability to use an elliptical machine due to the right and left foot disabilities. For these reasons, the Board finds that the criteria for a 20 percent disability rating under Diagnostic Code 5284 have been more nearly approximated for each foot for the rating period on appeal from October 1, 2011. 38 C.F.R. §§ 4.3, 4.7, 4.97. The Board finds that 30 percent rating criteria under Diagnostic Code 5284 have not been met or more nearly approximated for the period on appeal from October 1, 2011. Even with consideration of pain on use, the right and left foot disabilities have not more nearly approximated severe residuals of a foot injury. At the September 2013 VA examination, the Veteran reported foot pain in the mornings and after walking for long periods of time. The September 2013 VA examiner assessed that right and left foot symptoms were relieved by arch supports and did not discern swelling. The September 2013 VA examiner also did not discern marked deformity or marked pronation of either foot. Further, at the February 2015 Board hearing, the Veteran specifically testified to moderately severe symptoms, and not severe symptoms. The Veteran also indicated that the right and left foot disabilities did not impact the ability to operate a car, and denied that the bilateral foot disability caused falls. See February 2015 Board hearing transcript. The Board has considered whether any other diagnostic code would allow for a higher or separate rating for pertaining to the right and left foot. In this case, the Board finds that the criteria for a 30 percent rating under Diagnostic Code 5276 for flatfoot have not been met or more nearly approximated for any part of the rating period from October 1, 2013. Under Diagnostic Code 5276, a 30 percent rating for unilateral disability and a 50 percent rating for bilateral disability is warranted for pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, that is not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a. As discussed above, while the March 2013 VA examiner assessed extreme tenderness of plantar surfaces, the VA examiner also specifically assessed that tenderness was improved by orthotic shoes or appliances. Further, the March 2013 VA examiner did not discern marked pronation, marked inward displacement, or severe spasm of the tendo achillis, and the Veteran has not alleged otherwise. As such, even with consideration of tenderness, the weight of the evidence does not demonstrate severe flatfoot. Extraschedular Referral Consideration The Board has considered whether the Veteran or the record has raised the question of referral for an extraschedular rating adjudication under 38 C.F.R. § 3.321(b) for any period for the sinusitis and bilateral foot rating issues on appeal. See Thun v. Peake, 22 Vet. App. 111 (2008). After review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been made by the Veteran or raised by the record as to the rating issues on appeal for any period on appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record); Yancy v. McDonald, 27 Vet. App. 484, 494 (2016), citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff’d, 226 Fed. Appx. 1004 (Fed. Cir. 2007) (holding that when 38 C.F.R. § 3.321(b)(1) is not “specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted”). REASONS FOR REMAND 5. Higher Initial Rating for Left Shoulder Strain Disability At the February 2015 Board hearing, the Veteran contended that the March 2012 and August 2013 VA examination reports did not adequately reflect the current severity of the left shoulder disability because the VA examiner did not discuss any functional limitation with regard to the shoulder. See February 2015 Board hearing transcript. An April 2016 VA examination report reflects that the VA examiner assessed flare-ups of left shoulder pain, which decreased range of motion. The VA examiner also assessed functional loss due to pain as to flexion and abduction. The April 2016 VA examiner also noted that the examination was not being conducted during a flare-up and that additional limitation of function due to flare-ups could not be determined without resorting to mere speculation as the examination was not being performed after repeated use over time or during a flare-up. The April 2016 VA examiner also did not assess where left shoulder pain began during range of motion testing. In Sharp v. Shulkin, 29 Vet. App. 26 (2017) Court held that examiners have to offer opinions with respect to the additional limitation of motion during flare-ups based on estimates derived from information procured from relevant sources, including a veteran’s lay statements. The Court explained that an examiner must do all that reasonably could be done in order to become informed before concluding that a requested opinion cannot be provided without resorting to speculation. The Court held in Sharp that the VA examination was inadequate because the examiner, although acknowledging that the veteran in that case was not suffering from a flare-up at the time of the examination, failed to ascertain adequate information such as frequency, duration, characteristics, severity, or functional loss regarding flare-ups in order to provide the requested opinion. In this case, and in accordance with Sharp, the mere fact that the Veteran was not experiencing a flare-up of left shoulder pain at the time of the April 2016 VA examination is insufficient rationale as to whether additional limitation of function due to flare-ups could be determined. A medical opinion regarding whether there would be additional limits on functional ability on repeated use or during flare-ups, and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups would also be helpful. Correia v. McDonald, 28 Vet. App. 158 (2016). The matter is REMANDED for the following action: 1. Associate with the record all VA treatment records pertaining to the treatment of the issue on appeal, not already of record. 2. Schedule the appropriate VA examination in order to assist in determining the current level of severity of the service-connected left shoulder disability. The VA examiner should report the extent of left shoulder disability symptoms in accordance with VA rating criteria. Range of motion testing, in degrees, should be performed. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain and the specific excursion(s) of motion, if any, accompanied by pain. The examiner should test range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. The extent of any incoordination, weakened movement, and excess fatigability on use should also be described by the examiner. If feasible, the VA examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. The VA examiner should put forth best efforts in estimating the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss based on all information procured from relevant sources, including the Veteran’s lay statements. 3. Thereafter, the Agency of Original Jurisdiction should readjudicate the issue on appeal. If the benefits sought on appeal are not granted, the Veteran and representative should be provided with a supplemental statement of the case. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Tenney, Associate Counsel