Citation Nr: 18154701 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 17-27 751 DATE: December 3, 2018 REMANDED The issue of entitlement to a rating in excess of 20 percent for left (minor) shoulder degenerative joint disease is remanded. The issue of entitlement to an initial rating in excess of 20 percent for recurrent left (minor) shoulder dislocation is remanded. REASONS FOR REMAND The Veteran had active service from January 1951 to October 1954. The issues of entitlement to a rating in excess of 20 percent for left (minor) shoulder degenerative joint disease and an initial rating in excess of 20 percent for recurrent left (minor) shoulder dislocation are remanded. In its October 2017 Remand instructions, the Board of Veterans’ Appeals (Board) requested that the Veteran be scheduled for a Department of Veterans Affairs (VA) shoulder examination. The examiner was requested to “provide ranges of motion for passive and active motion of the left shoulder” and to “state whether there is any additional loss of left shoulder function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up.” The requested examination was conducted in December 2017. The VA examination report states that the Veteran complained of recurrent left shoulder pain which limited motion of the joint. The Veteran was found to exhibit a left shoulder range of motion of flexion to 55 degrees, abduction to 50 degrees, no external rotation, and internal rotation to 90 degrees. The ranges of motion were not attributed to either active or passive motion of the shoulder. While indicating that the Veteran exhibited pain with flexion, abduction, and external rotation; “pain noted on exam and causes functional loss;” and no “evidence of pain on passive range of motion testing,” the VA examiner did not state at what degree the noted pain began. The Veteran was diagnosed solely with left shoulder glenohumeral arthritis. The Board observes that although the issue of a higher rating for recurrent left shoulder dislocation is currently on appeal, the VA physician’s assistant indicated that “shoulder instability, dislocation or labral pathology was not suspected.” VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Compliance with the Board’s remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). Because of the cited deficiencies in the December 2017 VA examination report, the Board finds that further action is required to comply with the October 2017 Remand instructions. In a November 2017 written statement, the Veteran indicated that he received all medical treatment for the service connected shoulder disabilities at the Orlando, Florida, VA Medical Center. VA clinical documentation dated after March 2018 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records dated after March 2018, including those pertaining to treatment at the Orlando, Florida, VA Medical Center. 2. Schedule the Veteran for a VA orthopedic examination conducted by a physician to assist in determining the current severity of the service-connected left shoulder disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion, and for weight-bearing and nonweight-bearing, of the left shoulder. The degree at which pain is elicited should be specifically noted. (b) State whether there is any additional loss of left shoulder function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. (c) Provide an opinion as to the impact of the left shoulder disabilities on the Veteran’s vocational pursuits and whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the combined effects of the left shoulder disabilities and the other service connected disabilities. If the Veteran is felt capable of work despite the service connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service connected disabilities. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel