Citation Nr: 18151870
Decision Date: 11/20/18	Archive Date: 11/20/18

DOCKET NO. 16-46 830
DATE:	November 20, 2018
REMANDED
Entitlement to a compensable rating for right acromioclavicular joint strain is remanded.
Entitlement to service connection for a left shoulder disability, to include as due to service connected disease or injury is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the U.S. Marine Corps from November 2006 to September 2007.
1. Entitlement to a Compensable Rating for Right Acromioclavicular Joint Strain is Remanded.
2. Entitlement to Service Connection for a Left Shoulder Disability, to include as due to Service Connected Disease or Injury is Remanded.
The RO assigned a noncompensable rating for the Veteran’s service-connected right shoulder disability. The Veteran contends that this rating does not adequately assess the severity of his disability.  
The Veteran also believes that he is entitled to service-connection for a left shoulder disability, secondary to his right shoulder disability.
The Veteran underwent a VA examination for his shoulders in December 2015.  The examination report reflects no painful motion, no limitation of motion, and no excess fatigability for either shoulder.  
The December 2015 examiner also concluded that the Veteran’s left shoulder was normal, and therefore an opinion regarding an etiology for a left shoulder disability was not provided. 
April 2016 correspondence reflects that the Veteran reported right shoulder painful motion, limitation of motion, and excess fatigability, as well as left shoulder weakened movement, excess fatigability, and painful motion. 
Additional VA and private outpatient treatment records were obtained and added to the file following the most recent supplemental statement of the case issued in November 2016. 
March 2017 private treatment records reflect that the Veteran had diagnostic testing performed on his shoulders, which revealed a right superior labral SLAP tear, and left shoulder minimal acromioclavicular osteoarthritis.  
The private treatment records also mention additional diagnostic testing performed in January 2017, therefore indicating that there are outstanding treatment records regarding that Veteran’s shoulders.  
Accordingly, a remand is required to assess the current severity of the Veteran’s right shoulder, as well as to obtain an opinion on the etiology of any left shoulder disability, and acquire relevant private treatment records. 
The matter is REMANDED for the following action:
1. Contact the Veteran requesting any additional private treatment records, or alternatively, authorization to obtain any such records.
2. Obtain any outstanding VA treatment records and associate with the claims file.
3. Afford the Veteran an appropriate VA examination to determine the current severity of his right shoulder disorder.
With respect to range of motion testing, this must be conducted on active and passive motion and in weight-bearing and nonweight-bearing conditions (pursuant to 38 C.F.R. § 4.59 and Correia v. McDonald, 28 Vet. App. 158 (2016)) and assessment of flare-up episodes (pursuant to Sharp).  
If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so.
All opinions must be accompanied by a complete rationale.  
4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left shoulder disability.  
The examiner must opine:
(a.) Whether a left shoulder disability is at least as likely as not caused by an in-service injury or disease.  
(b.) Whether a left shoulder disability is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability.
All opinions must be accompanied by a complete rationale.  
The examiner is also asked to address the March 2017 private treatment records. 


  


 
J.W. FRANCIS
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	T. Fitzgerald, Associate Counsel