Citation Nr: 18160998 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 17-06 727 DATE: December 28, 2018 REMANDED Entitlement to service connection for a left hip disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. Entitlement to an initial rating in excess of 10 percent for a left rotator cuff tear is remanded. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the spine is remanded. REASONS FOR REMAND The Veteran served in the United States Navy from November 1976 to August 1979, and in the United States Army from June 2008 to June 2009, January 2014 to June 2014, and June 2014 to July 2015. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. 1. Entitlement to service connection for a left hip disorder is remanded. 2. Entitlement to service connection for a right hip disorder is remanded. While the Board sincerely regrets further delay, additional development is required before the Veteran's claim for service connection for a right and left hip disorder may be adjudicated on the merits. With respect to the Veteran's claim, the Board notes that the Veteran was provided a VA examination on December 2015, the examination indicated some ambiguity as to the existence of a current diagnosis without providing an explanation or rationale. As the Veteran's lay statements indicate that the Veteran may have a disability that could be related to service, the Board finds that a medical examination with an opinion is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 70 (2006). Specifically, a remand is required to afford the Veteran a VA examination to determine the nature, etiology, and severity for any right or left hip disability the Veteran may have. 3. Entitlement to an initial rating in excess of 10 percent for a left rotator cuff tear is remanded. 4. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the spine is remanded. The Veteran asserts that he is entitled to an initial rating of 30 percent for degenerative arthritis of the spine and an initial rating of 20 percent for a left rotator cuff tear. Since the Veteran’s most recent examination, the U.S. Court of Appeals for Veteran’s Claims (the Court) has issued the decisions in Correia v. McDonald, 28 Vet. App. 158, 166 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) concerning the adequacy of VA orthopedic examinations. The Court in Correia held 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, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In Sharp, the Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record, including the veteran’s lay information, or explain why she could not do so.” Sharp at 35. In light of these decisions, the Board finds that a new VA examination should be provided addressing the Veteran’s back and shoulder disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Obtain all outstanding VA medical records and ask the Veteran to provide authorizations for any private medical records he would like considered in connection with his appeal. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected back and left shoulder disabilities. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. For the Veteran’s orthopedic disabilities, the examiner should conduct all indicated tests and studies, to include range of motion studies. The joints involved should be tested in both active and passive motion, in 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. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. The examiner should also state whether the examination is taking place during a period of flare-up or after repeated use over time. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. A rationale should be provided. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Schedule a VA examination to address the nature, onset and etiology of the Veteran’s left and right hip disorders. The examiner should identify all of the Veteran’s left and right hip disabilities, including any functional impairments. The phrase “functional impairment” is defined as “the inability of the body or a constituent part of it to function under the ordinary conditions of daily life, including employment.” Additionally, the Board notes that pain alone can qualify as a disability “where it diminishes the body’s ability to function, even where it is not diagnosed as connected to a current underlying condition.” For all disabilities and functional impairments identified, the examiner should state whether it is at least as like as not that the disability/functional impairment (1) had its onset in service; (2) is due to an injury or disease incurred in service; (3) is caused by a service-connected disability; or (4) is aggravated by a service-connected disability. (Continued on the next page)   If any opinion requested above cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). TRACIE N. WESNER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. R. Montalvo, Associate Counsel