Citation Nr: 18157688 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 14-13 150 DATE: December 13, 2018 REMANDED Entitlement to an increased rating for left shoulder strain, currently evaluated as 20 percent disabling, is remanded. Entitlement to an increased rating for right shoulder labral tear, currently evaluated as 20 percent disabling, is remanded. Entitlement to an increased rating for left wrist carpal tunnel syndrome, currently evaluated as 10 percent disabling, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1989 to January 1992. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2012 rating decision. During the pendency of the appeal, in August 2013 and November 2013 rating decisions, the Agency of Original Jurisdiction (AOJ) proposed and implemented a reduction of the evaluations assigned for the service-connected left and right shoulder disabilities from 20 percent to 10 percent for each shoulder, effective from February 1, 2014. Thereafter, in a May 2016 rating decision, the AOJ increased the evaluations for the left and right shoulder disabilities to 20 percent for each shoulder, effective from January 4, 2016. Subsequently, in a July 2016 rating decision, the AOJ restored the effective date of May 8, 2006, for the 20 percent evaluations for the left and right shoulder disabilities. Therefore, the issues have been recharacterized above. In October 2015, the Board remanded the case for further development. That development has been completed, and the case has since been returned to the Board for appellate review. In the October 2015, the Board, in part, remanded the case to obtain VA examinations to determine the current severity of the Veteran’s left and right shoulder. However, in light of a decision issued by the United States Court of Appeals for Veterans Claims (Court), Correia v. McDonald, 28 Vet. App. 158 (2016), a remand is required for VA examinations to ascertain the current nature and severity of the Veteran’s service-connected left and right shoulder disabilities. In Correia, the Court concluded that 38 C.F.R. § 4.59 requires VA examinations to include joint testing for pain on both active and passive range of motion, as well as with weight-bearing and nonweight-bearing. Because the April 2016 VA examinations do not satisfy the requirements under Correia, additional VA examinations are required in this case. Moreover, the Board notes that an additional VA examination is needed to ascertain the current severity and manifestations of the Veteran’s service-connected left wrist carpal tunnel syndrome. The April 2016 VA examiner indicated that all of the Veteran’s upper extremity nerves were normal, yet noted earlier in the report that there was moderate pain, paresthesias and/or dysethesiasis, and numbness. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his left and right shoulders and left wrist. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service- connected left and right shoulder disabilities. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should report all signs and symptoms necessary for rating the Veteran’s left and right shoulder disabilities under rating criteria. In particular, the examiner should provide the range of motion of the left and right shoulders in degrees. In so doing, the examiner should test the Veteran’s range of motion of both shoulders in active motion, passive motion, weight-bearing, and nonweight-bearing. 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 so in the report. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including additional limitation of motion). The examiner should also state whether there is any form of ankylosis. He or she should further indicate whether there is any impairment of the humerus, such as malunion, fibrous union, nonunion (false flail joint) of the scapulohumeral joint, or loss of the head (flail shoulder). The examiner should also indicate whether there is any impairment of the clavicle or scapula, such as malunion, nonunion with or without loose motion, or dislocation. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After the above development has been completed, the Veteran should be afforded a VA examination to ascertain the severity and manifestation of his service-connected left wrist carpal tunnel syndrome. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s left wrist carpal tunnel syndrome and identify the affected nerves. In particular, he or she should provide an opinion as to whether the paralysis of the left median nerve (or any other affected nerve) is complete or incomplete. If the paralysis of the nerve is incomplete, the examiner should opine as to whether the disorder is mild, moderate, or severe in nature. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Osegueda, Counsel