Citation Nr: 18156512
Decision Date: 12/11/18	Archive Date: 12/10/18

DOCKET NO. 16-59 203
DATE:	December 11, 2018
REMANDED
Entitlement to a temporary total rating for convalescence following left shoulder surgery on November 20, 2015, under 38 C.F.R. § 4.30, is remanded.
REASONS FOR REMAND
The appellant is a Veteran who served on active duty in the Army from July 2009 to July 2012; his service included a one-year tour of duty in Iraq and his decorations include a Combat Infantryman Badge.  This case is before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 Department of Veterans Affairs (VA) rating decision.  
Entitlement to a temporary total rating under 38 C.F.R. § 4.30 for convalescence following left shoulder surgery on November 20, 2015 is remanded.
On November 20, 2015 the Veteran underwent arthroscopic surgery by VA on his service-connected left shoulder.  Complete records pertaining to the surgery are not in his claims file.  (An orthopedic surgery note in April 2016 indicates that he underwent a biceps tenodesis, rotator cuff debridement, subacromial bursectomy, and an open left carpal tunnel release.)  Moreover, it does not appear that complete postoperative orthopedic records have been associated with the claims file.  For instance, a December 4, 2015 occupational therapy evaluation note cited to a portion of an orthopedic note, dated December 1, 2015, but the full orthopedic note is not in the file.  Furthermore, a shoulder immobilizer was requested from the prosthetics department on November 20, 2015, and postoperative instructions state that the Veteran was to wear the immobilizer continuously and to follow-up in 10-14 days.  However, as the complete December 1, 2015 orthopedic note is not in the file, it is unknown whether he was then advised to continue wearing the immobilizer, and if so, for how long.  
In a March 2016 statement, the Veteran provided some clarifications.  He stated that the postoperative instructions, which indicate he was to remain off work until December 2, 2015, was not in reference to his left shoulder recuperation but was instead about his recuperation from the left wrist carpal tunnel syndrome surgery.  He also indicated, regarding his left shoulder surgery, that he consulted with the VA orthopedics department that day and was informed by medical staff that his doctor had not yet released him to return to work.  He maintains that his “return to work” date was April 26, 2016, which is the date of an orthopedic note indicating he may return to full activity with a permanent 50-pound weight restriction for lifting with the left upper extremity.   
Because the record is incomplete, further development is needed the Veteran’s claim can be decided.  
The matter is REMANDED for the following:
1.  Secure for the record all VA records (which are not already in the claims file) pertaining to the Veteran’s November 20, 2015 left shoulder VA surgery and follow-up visits, to include those in the orthopedic clinic such as on December 1, 2015.  
2.  Then, review the record and determine if a medical examination and/or opinion is necessary to decide whether the Veteran’s November 20, 2015 left shoulder surgery (a) necessitated one or more months of convalescence for the left shoulder (and if so, how many months), or (b) resulted in severe postoperative residuals or therapeutic immobilization of one major joint (and if so, for how long).  If so, arrange for the medical examination and/or opinion.      
 
 George R. Senyk
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Debbie Breitbeil, Counsel