Citation Nr: 18154298 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 15-32 203 DATE: November 29, 2018 REMANDED Entitlement to a disability rating in excess of 10 percent for right shoulder arthralgia, status post right shoulder surgery, is remanded. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with alcohol abuse in early sustained remission is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from June 1991 to February 1995, October 2004 to January 2006, and September 2010 to September 2011. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, a videoconference hearing was held before the undersigned Veterans Law Judge. As this appeal is being processed under the Board’s “One Touch” program, a transcript of the hearing is not yet in the claims file but will be obtained and added to the claims file at a later time. 1. Entitlement to a disability rating in excess of 10 percent for right shoulder arthralgia, status post right shoulder surgery, is remanded. The most recent VA examination of the Veteran’s right shoulder was conducted in February 2013. The Veteran was diagnosed with adhesive capsulitis of the right shoulder (“frozen shoulder”) by a private orthopedist in May 2017. An October 2018 VA radiology report showed severe focal supraspinatus tendon bursal surface fraying but no supraspinatus tendon tear, and the radiologist’s impression was of rotator cuff tendinosis and SST fraying, no rotator cuff tear, but degenerate SLAP tear. In a November 2018 letter, the Veteran’s wife reported that the Veteran’s shoulder pain has worsened. The Veteran testified at his November 2018 Board hearing that he is no longer able to raise his arm to shoulder level. In light of the foregoing, the Board finds that the Veteran should be afforded a new VA examination to assess the current severity of his right shoulder disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); 38 C.F.R. § 3.327; VAOPGCPREC 11-95 (1995). 2. Entitlement to a disability rating in excess of 50 percent for PTSD is remanded. The most recent VA mental health examination was conducted in February 2013. A June 2018 VA Mental Health General Note found “some regression due to symptom worsening.” In a November 2018 letter, the Veteran’s wife reported that the Veteran had panic attacks at work, had become fearful in public places, had reacted violently to surprises, and that the couple had filed a bankruptcy petition. She said that the Veteran had admitted considering suicide and that he had violent nightmares and sometimes threw punches while she was in the bed with him. In his November 2018 Board testimony, the Veteran reported worsening of his symptoms, including having nightmares nearly every night, relationship problems with his wife and children, and that he had almost struck his wife while having a nightmare. In light of the foregoing, the Board finds that the Veteran should be afforded a new VA examination to assess the current severity of his PTSD. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); 38 C.F.R. § 3.327; VAOPGCPREC 11-95 (1995). The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from June 2015 to the Present. 2. After obtaining any additional records, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right shoulder arthralgia, status post right shoulder surgery. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must 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 right shoulder arthralgia alone and discuss the effect of the Veteran’s right shoulder arthralgia, status post right shoulder surgery, 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). 3. After obtaining any additional records, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD with alcohol abuse in early sustained remission. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Dean, Associate Counsel