Citation Nr: 20006984 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 10-26 973 DATE: January 28, 2020 REMANDED Entitlement to a rating in excess of 30 percent for a degenerative disc disease of the right shoulder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1981 to December 1992. This matter was denied by the Board in a December 2018 decision. The Veteran appealed the Board’s denial to the Court of Appeals for Veterans Claims; and, in a September 2019 Joint Motion for Remand, the issue was returned to the Board. 1. Entitlement to a rating in excess of 30 percent for a degenerative joint disease of the right shoulder with numbness is remanded. The September 2019 JMR indicated that additional clarification was required on the question of whether the Veteran has muscle atrophy due to his right shoulder disability. Reference was made to action taken in September 2017 wherein the Board remanded the matter to reconcile the findings of an April 2017 VA examination that showed no muscle atrophy and earlier VA records that noted the presence of atrophy. The parties agreed that the report of an October 2017 VA examination failed to sufficiently address this question. The October 2017 examiner provided measurements indicating no difference in size between the right and left upper extremities, i.e. no suggestion of atrophy, and was unable to explain the previous notations of muscle atrophy, noting the lack of measurements in the previous medical records. On remand, the examiner should attempt to more clearly explain why the previous reports of atrophy cannot be reconciled with the current measurements which do not show any muscle atrophy. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right shoulder degenerative joint disease with numbness of the right shoulder. 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. (a.) The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. (b.) The examiner is asked to describe whether pain significantly limits functional ability during flares, and if so, the examiner must estimate range of motion during flares. If the examination does not take place during a period of flare-up, the examiner should glean information regarding the flares’ severity, frequency, duration, and functional loss manifestations from the Veteran, medical records, and other available sources. Efforts to obtain such information must be documented. If there is no pain and/or no limitation of function, such facts must be noted in the report. (c.) Identify all muscle group injuries associated with the Veteran’s service-connected right shoulder disability, to include the right shoulder rotator cuff tear, throughout the appeal period (from August 2008). (d.) For each muscle group injury, comment as to whether the disability would be considered slight, moderate, moderately severe, or severe throughout the appeal period (from August 2008), if possible. (e.) Reconcile the April and October 2017 findings that the Veteran does not have muscle atrophy with the medical record showing repeated accounts of atrophy. See, e.g. Jan. 2013 VA exam report, April 2010 VA treatment records, November 2009 VA treatment records. If the examiner cannot reconcile this inconsistency they should explain in as much detail as possible why they are not able to reconcile these findings. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rekowski 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.