Citation Nr: 18150381 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-38 043 DATE: November 15, 2018 REMANDED Entitlement to a rating in excess of 20 percent for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran had active service in the United States Navy from February 1977 to July 2002. This matter is before the Board of Veterans’ Appeals (Board) on appeal from the June 2016 decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) reinstating the Veteran’s claim for entitlement to a rating evaluation of 20 percent for his left shoulder disability. Entitlement to a rating in excess of 20 percent for left shoulder disability is remanded. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1 (2017). In a March 2013 VA shoulder and arm condition examination, the Veteran reported flare-ups occurred when doing overhead work and he used ice “when shoulder flares.” The physician noted less movement than normal and painful movement after repetitive use. A radiology report indicated no malalignment or significant degenerative change. In an April 2013 rating decision, the RO granted to continue the 20 percent rating, but informed the Veteran that the evaluation was not permanent. In a May 2015 VA examination request, the RO asked the examiner to (1) Provide an opinion as to whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time and (2) describe any such additional limitation due to pain, weakness, fatigability or incoordination, and if feasible, this opinion should be expressed in terms of the degrees of additional ROM loss due to “pain on use or during flare-ups”; (3) If such opinion is not feasible, please state and provide an explanation as to why the opinion cannot be rendered. In a June 2015 VA examination to evaluate the severity of the Veteran’s shoulder disability, the Veteran reported that he had flare-ups with any activity above the chest and loss of motion. During the initial range of motion testing the physician indicated the Veteran’s initial range of motion was abnormal or outside of normal range of motion with flexion and abduction both 0 to 140 degrees and external and internal rotation 0 to 80 degrees. There was no additional loss of function on repetition; however, the Veteran reported additional loss during flare-ups and the examiner did not attempt to quantify the additional loss based on the Veteran’s reports. The physician indicated that the range of motion itself does not contribute to functional loss and although pain was noted on exam, it “did not result in/cause functional loss.” The physician also indicated that there was no evidence of pain with weight bearing, no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue; no evidence of crepitus; and that Veteran was examined immediately after repetitive use with no reported pain, weakness, fatigability or incoordination significantly limiting functional ability. Subsequent to the examination, the Veteran received VA outpatient occupational therapy (OT) for the left shoulder in September through October 2015. The OT clinicians reported that the Veteran’s active range of motion was “impaired proximally in planes of flexion and abduction, immediate onset of pain described as “burning” from posterior shoulder working into mid-humeral level and distally to the wrist.” A manual muscle test showed “decreased w/ isolated testing of anterior/lateral deltoids/empty can and static ER--vet had onset of spasm & “burning” as described above. Left upper extremity (LUE) bicep flex/tricep extension= 4-/5 w/ onset of spasm to posterolateral shoulder. LUE forearm pro/supination= 3+/5--guarded. LUE wrist flex/ext= 4-/5, thumb extension=within functional limits. Shoulder pain= cramping, “feels out of joint” forearm pain= dull ache to lateral/radial-based musculature hand/web space pain= sharp.” The OT clinicians also conducted two specialty tests: Impingement and Tinsel’s test. With the Impingement test, the clinicians reported “difficult validity due to guarding of LUE during any motions.” With the Tinsel’s test, the clinicians reported “tenderness at level of bilateral carpal tunnels R>L. Attempted manual therapy/STM to quadrilateral space but Vet had increased amounts of pain w/ onset of numbness/tingling to digit #5.” The report was silent as to whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. The report did not discuss whether there were any additional limitations due to pain, weakness, fatigability or incoordination. The report was also silent as to whether there was any additional ROM loss due to “pain on use or during flare-ups.” If a diagnosis is not supported by the findings on the examination report or if the report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2017). Further, as required by 38 C.F.R. § 4.59, joints should be tested for pain on both active and passive motion, in weight bearing and non-weight bearing, and if possible, with the range of opposite undamaged joint. Correia v. MacDonald, 2016 WL 3591858 (July 16, 2016). In Sharp v. Shulkin, 29 Vet. App. 26 (2017) addressed the adequacy of a VA examiner’s opinion concerning additional functional loss during flare-ups of a musculoskeletal disability, pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). Before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare-up, the examiner must “[E]licit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record, including the veteran’s lay information, or explain why [he or] she c[an] not do so.” Sharp, 29 Vet. App. at 35. Since both the June 2015 and September 2015 clinical care observations did not provide the fully descriptive medical opinions with emphasis upon the limitation of activity imposed by the disabling condition, specifically, (1) testing in accordance with the requirements of 38 C.F.R. § 4.59, (2) whether there were any additional limitations due to pain, weakness, fatigability or incoordination, and (3) whether there was any additional ROM loss due to “pain on use or during flare-ups, the Board finds that the evidence of record is not adequate for evaluation purposes. Therefore, the Board is unable to make a fully informed decision. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination of the current severity of his left shoulder disability. 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 left shoulder disability alone and discuss the effect of the Veteran’s left shoulder disability on any occupational functioning and activities of daily living. 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). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. NeSmith, Associate Counsel