Citation Nr: 18158322 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-44 075 DATE: December 14, 2018 REMANDED Entitlement to a rating in excess of 20 percent for service-connected residuals of a right shoulder acromioclavicular separation is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1984 to May 1991 and from March 2003 to May 2004. This case is before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision of the Milwaukee, Wisconsin Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, denied a rating in excess of 20 percent for the Veteran’s residuals of a right shoulder acromioclavicular separation. The Veteran’s most recent VA examination in this matter took place in January 2015. The Board finds this VA examination to be inadequate. Specifically, the United States Court of Appeals for Veterans Claims (Court) has found that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, and in weight-bearing and non-weight bearing motion. See Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran was tested for pain on active range of motion, but was not tested for passive range of motion; he was also not tested on non-weight bearing motion. Moreover, the examiner marked that the Veteran exhibited evidence of pain with weight bearing motion, but did not explain how this conclusion was drawn. The Veteran also alleges that the January 2015 VA examiner failed to measure his range of motion using a goniometer, which is classified in 38 C.F.R. § 4.46 as “indispensable” in the measurement of limitation of motion for increased rating claims. As the “accurate measurement of the . . . excursion of joints . . . should be insisted upon,” the Board finds that remand is warranted. Finally, the Veteran underwent an additional VA examination in November 2018. Although this peripheral nerves examination was conducted in conjunction with a separate claim for benefits, it appears to have also addressed right shoulder neurologic symptoms that are pertinent to the Veteran’s instant claim. This evidence has not been addressed in a Supplemental Statement of the Case (SSOC). As the case is being remanded, the medical examiner will have the opportunity to review this evidence in consideration with the current severity of the Veteran’s residuals of a right shoulder acromioclavicular separation. The matter is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to determine the nature and current severity of his service- residuals of a right shoulder acromioclavicular separation. The claims file must be made available to and reviewed by the examiner prior to the examination. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examination must be conducted in accordance with the current disability benefits questionnaire or examination worksheet applicable to the disability. Ranges of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for the right shoulder must be conducted with the use of the goniometer, as appropriate. 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. The examiner should also provide an opinion concerning the functional impairment of the Veteran’s service-connected right shoulder disability. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page)   2. After any additional development deemed warranted, readjudicate the Veteran’s claim. If any benefit sought on appeal remains denied, an SSOC that considers all pertinent evidence, including the report from the November 2018 VA peripheral nerves examination, should be furnished to the Veteran and his representative and they should be afforded the requisite opportunity to respond before the case is returned to the Board. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Griffin, Associate Counsel