Citation Nr: 18147147 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 14-31 259A DATE: November 5, 2018 REMANDED Entitlement to a rating in excess of 10 percent for the service-connected post-operative right rotator cuff repair is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1993 to June 1997. Entitlement to a rating in excess of 10 percent for the service-connected post-operative right rotator cuff repair is remanded. The Veteran’s service-connected post-operative right rotator cuff repair was most recently assessed at a July 2017 VA examination. Significantly, however, the record shows that the Veteran subsequently underwent right shoulder surgery in August 2018. Indeed, by an October 2018 rating decision, the RO awarded a temporary total rating, based on the need for surgical or other treatment necessitating convalescence from August 3, 2018 to September 30, 2018. In that recent rating action, the RO noted that a decision on the matter of the evaluation for this service-connected disability was deferred pending a new VA examination. Accordingly, the Board finds that a remand is necessary either to obtain a copy of this examination or, if one has not been conducted yet, to schedule a relevant evaluation of the Veteran’s service-connected right shoulder disability. The matter is REMANDED for the following action: 1. Make reasonable efforts to obtain any outstanding and relevant VA or private treatment records. The Board is particularly interested in a copy of a VA examination conducted on the Veteran’s right shoulder, as referenced in the October 2018 rating decision. With the Veteran’s assistance, if necessary, obtain copies of any pertinent records and add them to the claims file. If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 2. Then, and only if a current VA examination of the Veteran’s right shoulder has not already been conducted as referenced in the October 2018 rating decision, a VA examination should be conducted on the Veteran’s right shoulder to determine the current severity of his service-connected post-operative right rotator cuff repair. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner as part of the examination. All indicated tests should be accomplished and all clinical findings reported in detail. The examiner is asked to describe fully the current severity of the Veteran’s right shoulder disability including all objective manifestations. In addition, the examiner should: a) address range of motion loss specifically due to pain and any functional loss during flare-ups. The examiner is to express an opinion on whether pain could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited range of motion caused by functional loss during a flare-up as well as after repeated use over time. If rendering this opinion is not possible, the clinician must provide an adequate explanation as to why. b) test the range of motion must include testing in active motion and passive motion. The examiner should also discuss weight-bearing and nonweight-bearing ranges, if possible, obtain ranged of motion of the opposite undamaged joint. If such are not applicable, the examiner should state such along with an explanation. c) comment on the functional impairment caused by the Veteran’s service connected right shoulder disorder. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need (CONTINUED ON NEXT PAGE) for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. E. Metzner, Associate Counsel