Citation Nr: 18147742 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-35 705A DATE: November 6, 2018 REMANDED Entitlement to an initial evaluation in excess of 20 percent for a left, non-dominate, disability of the flexor muscles of the elbow (Group V) is remanded. REASONS FOR REMAND The Veteran had active service from July 1998 to July 2001 and from June 2002 to June 2006. Entitlement to an Initial Evaluation in Excess of 20 Percent for a Muscle Disability of the Left Upper Extremity Is Remanded The Veteran’s appeal originates from a June 2013 rating decision of a Department of Veterans Affairs (VA) regional office (RO) in Waco, Texas. In that rating decision, the RO granted service connection for disability of the flexor muscles of the elbow (Group V) and assigned a 20 percent evaluation under 38 C.F.R. § 4.73, Diagnostic Code 5305. The RO based it’s rating decision on a May 2013 VA examination. The findings from that examination noted constant complaints of cardinal signs and symptoms of muscle disability of muscle Group V. It did not, however, identify disabilities of the intrinsic or extrinsic muscles of the shoulder girdle (Groups I, II, III, and IV), which are evaluated pursuant to diagnostic codes 5301 to 5304. The Veteran perfected his appeal in a July 2016 VA Form 9, Substantive Appeal. He noted that he did not injure shoulder ligaments while on active duty, but instead ruptured his left biceps tendon and underwent surgery to repair it. The Veteran, who is right handed, noted constant pain in his left arm, limited range of motion, and decreased function in his left hand. The Veteran reported that he could not make a fist or open his left hand, and he had decreased sensation in his left arm and hand. The Board notes October 2016 VA treatment records that similarly report weakness, radiating pain, and numbness in the Veteran’s left arm and hand. The Veteran received a new VA examination in January 2017. This examination evaluated the intrinsic and extrinsic muscles of the shoulder girdle and the flexor and extensor muscles of the elbow. The examiner noted consistent cardinal signs and symptoms of muscle disability for muscle groups I, II, III, and IV but not groups V or VI. Relying on the January 2017 VA examination, the RO increased the Veteran’s evaluation to 30 percent disabling. In doing so, the RO changed the diagnostic code from 5305 to 5301, determining that the Veteran’s in-service biceps tendon rupture resulted in severe disability of the extrinsic muscles of shoulder girdle that control upward rotation of the scapula and elevation of the arm above shoulder level. The medical evidence indicates that the Veteran is experiencing symptomatology that adversely impacts the use of his left, non-dominate, arm and hand. It is unclear, however, how the Veteran’s in-service biceps tendon rupture, post-surgical repair, is related to the Veteran’s reported symptoms. The 30 percent evaluation under Diagnostic Code 5301 does not address the previously evaluated flexor muscles of the left elbow even though the January 2017 VA examination noted strength of 1/5 on elbow flexion. The Board also notes that the January 2017 VA examination did not note cardinal signs and symptoms of muscle disability for Group V that were previously documented in the May 2013 examination even though the Veteran has not reported improved function on flexion of his left elbow. The 30 percent evaluation under Diagnostic Code 5301 does not contemplate the loss of sensation and function in the Veteran’s left forearm and hand as reported in his VA Form 9, October 2016 VA treatment records, and the January 2017 VA examination. Consequently, it is unclear to what extent the Veteran’s ruptured biceps tendon, post-surgical repair, impacts the function of muscles groups I through VI. A new examination is therefore necessary to assess the scope and severity of the Veteran’s service connected disability. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2017 to the present. 2. Schedule the Veteran for an examination to assess the current severity of his service-connected muscle disability of the left upper extremity. (a.) The examiner should identify and assess the impact, if any, of the Veteran’s ruptured biceps tendon, post-surgical repair, on the function of the following muscle groups: (i) intrinsic and extrinsic muscles of the shoulder girdle (groups I, II, III, and IV), (ii) flexor muscles of the elbow (Group V), and (iii) extensor muscles of the elbow (Group VI). (b.) The examiner should determine whether the Veteran’s ruptured biceps tendon, post-surgical repair, is etiologically related to the Veteran’s reported numbness, loss of sensation, and loss of function in his left forearm and hand. (c.) The examiner must specifically address whether the Veteran’s service-connected disability impairs functionality of the left arm such that no effective function remains other than that which would be equally well serviced by an amputation with prosthesis. (d.) The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to a muscle disability of the left upper extremity alone and discuss the effect of the Veteran’s service-connected disability on any occupational functioning and activities of daily living. (e.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Douglas M. Humphrey, Associate Counsel