Citation Nr: 18159935 Decision Date: 12/21/18 Archive Date: 12/20/18 DOCKET NO. 15-29 207 DATE: December 21, 2018 REMANDED Entitlement to increases in the ratings for a right shoulder disability (currently rated 10 percent prior to February 2, 2018, and 20 percent from that date), is remanded. REFERRED The issues of service connection for a right arm and hand disabilities were raised in the Veteran’s September 2014 notice of disagreement and are referred to the Agency of Original Jurisdiction (AOJ) for adjudication. REASONS FOR REMAND The Veteran honorably served on active duty from April 1951 to January 1953. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2013 rating decision (confirmed by an April 2014 rating decision) of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Veteran initially requested a hearing but later withdrew this request. Entitlement to increases in the ratings for a right shoulder disability (currently rated 10 percent prior to February 2, 2018, and 20 percent from that date), is remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an examination that adequately addresses the facts and circumstances presented by the Veteran’s case. VA examinations must include joint testing on both active and passive motion, and in weight-bearing and nonweight-bearing circumstances. Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, estimated ranges of motion should be provided during flare-ups or during functional loss after repetitive use, if feasible, even if the Veteran is not experiencing it during the examination. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this case, the VA shoulder examinations of record do not fully comport with the requirements of Correia. See January 2013, March 2014, and July 2018 VA examinations. Thus, at present, none of the medical evidence of record may fully satisfy the requirements of Correia and 38 C.F.R. § 4.59. Accordingly, a new VA shoulder examination is necessary. The Board also finds a retrospective medical opinion addressing the Veteran’s service-connected right shoulder disability would be helpful in determining the appropriate disability ratings for the periods on appeal. The Board recognizes that it may not be possible for a physician to provide an opinion as to the past state of the Veteran’s right shoulder disability with certainty. However, if the physician concludes that it is not possible to provide a retrospective opinion without resort to speculation, the reason for this conclusion must be thoroughly explained. Additionally, the retrospective medical opinion must be reviewed by the AOJ to ensure that it complies with the below remand directives. The record also suggests that the medical evidence associated with the record is incomplete. In March 2006 correspondence, the Veteran reported being treated at the Detroit VA Medical Center (VAMC). The earliest records of VA treatment contained in the file are from February 2007. Accordingly, because such records are pertinent, and because VA treatment records are constructively of record, they must be obtained, in addition to any updated records of any VA treatment the Veteran received for his right shoulder disability. The matter is REMANDED for the following action: 1. Ask the Veteran to identify the provider(s) of all evaluations and treatment he has received for his right shoulder disability (records of which are not already associated with the claims file or established to be unavailable), and to provide all releases necessary for VA to obtain the complete clinical records of all such treatment or evaluation. With the Veteran’s cooperation (by providing releases), obtain for the record complete clinical records of all such evaluations and treatment. At least two such efforts should be made unless it is clear from the private provider’s response to the first request that a second effort would be futile. If any private records identified are not received pursuant to the AOJ’s request, the Veteran must be so notified and advised that ultimately it is his responsibility to ensure that private records are received; all efforts to obtain such records must be documented and associated with the claims file. 2. Obtain for the record the COMPLETE clinical records of all VA evaluations and treatment the Veteran has received for his right shoulder disability (i.e., update to the present all records of VA evaluations and treatment from all VAMCs). The AOJ should note that the Veteran reported being treated at the Detroit VAMC in March 2006 and the earliest records of VA treatment contained in the file are from February 2007. 3. After the above development is completed, arrange for an orthopedic examination of the Veteran to assess the current severity of his service-connected right shoulder disability, and for a supplemental retrospective medical opinion as to the severity during the entire appeal. The examiner must review the entire record in conjunction with the examination and note such review was conducted. Pathology, symptoms (frequency and severity), and any associated impairment of function should be described in detail. All indicated tests or studies should be completed. Specifically, the VA examiner should address the following: (a) Provide range of motion and repetitive motion findings in degrees for the right shoulder in active AND passive motion and weight-bearing AND non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 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. (b) State whether there is objective evidence of pain on range of motion and after repetitive motion testing, including the degrees at which pain begins and ends. (c) Provide a RETROSPECTIVE opinion regarding the range of motion of the right shoulder in active AND passive motion and weight-bearing AND nonweight-bearing, and an estimated degree of additional range of motion loss due to pain on use or during flare-ups. If the examiner is unable to provide a retrospective opinion, he or she should clearly explain why that is so. (d) Note any further functional limitations due to pain, weakness, fatigue, incoordination, or any other such factors, including retrospectively by providing observed or estimated degree of additional range of motion loss due to pain on use or during flare-ups. Specifically, ask the Veteran to identify the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment resulting from flare-ups and, if possible, offer range of motion estimates based on that information. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups or reduced functioning with repeated use over time 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). A rationale based on the fact that the Veteran is not having a flare-up at the time of the examination will not be deemed adequate. (Continued on the next page)   A detailed explanation (rationale) is requested for all opinions provided. By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested. T. MATTA Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Lambert, Associate Counsel