Citation Nr: 20005641 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 16-33 195 DATE: January 23, 2020 REMANDED Entitlement to an initial rating in excess of 20 percent for degenerative arthritis of right shoulder (claimed as right shoulder condition), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2011 to January 2015. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2016 rating decision that granted service connection for degenerative arthritis of the right shoulder (right shoulder condition) with an initial rating of 10 percent disabling. In October 2019, a hearing was held in this matter via videoconference from Indianapolis, Indiana before the undersigned Veterans’ Law Judge. A transcript of the hearing has been associated with the electronic file. The record was held open for 60 days after this hearing for the submission of additional evidence. As the decision, the claims file does not reflect that additional evidence has been received. As this matter is being remand, the Veteran will have the opportunity to submit any relevant evidence.   Entitlement to an increased rating for degenerative arthritis of right shoulder claimed as right shoulder condition is remanded. The Veteran contends that the initial evaluation of his right shoulder condition was inadequate because his right shoulder condition is much worse than was documented during his February 2016 examination. See NOD received 5/16/2016. Although the Veteran was given a subsequent examination in April 2019, the Regional Office determined that his increased rating of 20 percent should be continued. For the reasons stated below, the Board finds that a remand is warranted. The medical examination provided by the Department of Veterans Affairs to a claimant for VA benefits must be thorough and contemporaneous and must consider prior medical examinations and treatments. El-Amin v. Shinseki, 26 Vet. App. 136 (2013); 38 U.S.C. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4). A medical examination provided by the VA is considered adequate where the examination is based on consideration of the Veteran’s prior medical history and examinations and describes the disability in sufficient detail so that the BVA evaluation on the claimed disability will be a fully informed one. Mathis v. McDonald, 834 F. 3d 1347, 1351 (2016). Here the Board finds that in order to decide on whether an increased rating above 20 percent is warranted a new examination and medical opinion is needed. In his October 2019 testimony, the Veteran stated that he noticed an increase in the severity of pain in his right shoulder. See Hearing Transcript received 10/18/2019 at page 3. He testified that his pain is constant, and he has difficulty lifting more than 10 or 15 pounds. Id. As a computer technician, the Veteran primarily works moving and setting up computers. He testified that because of his impairment he has to ask his co-workers for assistance when he needs to move equipment. Id. at page 4. His functional loss extends to his personal life since he is unable to hold his young daughters, who range from ages one to five. He testified that he cannot hold them with his right arm and instead must use his left. Further, he guards his right shoulder and consciously tries to move it as little as possible. Id. at page 3. He uses a shoulder strap on the right shoulder when doing activities that require long periods of walking, e.g. more than an hour, and wherein it is likely he will put stress on the shoulder. He further elaborated that when his arms swing it puts pressure on his right shoulder and it sometimes pops out of place and pops back in. Id. at page 5. He stated that this happens frequently, “once a week or so”. See Hearing Transcript received 10/18/2019 at page 6. The Veteran was afforded two VA examinations in relation to his right shoulder condition. The April 2019 VA examination updated the February 2016 examination which was incomplete because it did not address the Correia requirements. See Deferred Rating received 2/07/2019; see also Correia v. McDonald, 28 Vet. App. 158 (2016) (holding that to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of 38 C.F. R. §4.59.). Although the April 2019 examination did correct this issue, that examination is incomplete because the examiner did not review the Veteran’s medical records and therefore, neglected to conduct examinations of his rotator cuff and assess whether another MRI is warranted given his subjective symptomatology. In the February 2016 examination, the Veteran was diagnosed with rotator cuff tendonitis in his right shoulder and degenerative arthritis. See C&P Exam received 2/17/2016 at page 1. The examination found that the Veteran tested positive for the Hawkins Impingement Test and the Empty Can Test. Id. at page 7. In the April 2019 examination, the examiner checked the box that stated the Veteran had no rotator cuff issues suspected. See C&P Exam received 4/9/2019 at page 12. Had the examiner done a review of the Veteran’s medical records, the examiner would have recognized that the Veteran had a prior history of issues with his rotator cuff. Relatedly, during his testimony the Veteran testified that he suffers from recurrent dislocations of his right shoulder and that he wears a strap for his right shoulder. See Hearing Transcript received 10/18/2019 at page 5. The April 2019 examiner did not note either of these manifestations on the examination. Rather, the examiner indicated that shoulder dislocation and instability was not suspected, and that the Veteran did not use an assistive device such as a brace. See C&P Exam received 4/9/2019 at page 12-15. Since this information was not of record at the time, the Board finds that a new examination is warranted to assess the severity of the Veteran’s right shoulder condition given the new lay evidence and the insufficiency of the file review. Further, during the hearing the Veteran stated that there was a worsening in his condition. See Hearing Transcript at page 3. Further, the April 2019 examiner also opined that there was a worsening of the Veteran’s symptoms. See C&P Exam at page 17. Since the Veteran last had an MRI in 2015, the Board would direct that the Veteran undergo another MRI or if the examiner believes that one is not necessary state a reason it is unnecessary in the opinion. Additionally, updated VA treatment records should be associated with the record on remand. See Sullivan v. McDonald, 815 F.3d 786, 792 (Fed. Cir. 2016) (finding that because § 3.159(c)(3) expanded the VA’s duty to assist to include obtaining VA medical records without consideration of their relevance.). The May 2019 supplemental statement of the case reflects that VA treatment records up through July 2018 have been obtained and considered. This matter is REMANDED for the following actions: 1. Associate any updated VA treatment records with the claims file. Request that the Veteran provide any relevant private records or authorize VA to obtain any such records. Document the requests and responses in the claims file. 2. After completing #1, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right shoulder disability. The examiner is to provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to right shoulder alone and discuss the effect of the Veteran’s right shoulder disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment 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). The examiner should consider all relevant medical and lay evidence, including the Veteran’s hearing testimony and his prior examinations to include the February 2016 and the April 2019 VA examination. **An MRI study should be performed, if deemed appropriate by the examiner. If not deemed appropriate, the examiner must provide a clear rationale for why an MRI study is not necessary. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Dixon, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.