Citation Nr: 20022576 Decision Date: 04/01/20 Archive Date: 04/01/20 DOCKET NO. 16-13 193 DATE: April 1, 2020 REMANDED Entitlement to an evaluation in excess of 20 percent for right shoulder degenerative joint disease (DJD) is remanded. REASONS FOR REMAND The Veteran had active military service from April 1980 to May 1988. The Board notes that the March 2019 Board remand included the following issues: (1) entitlement to service connection for numbing sensations of the bilateral upper extremities, to include as due to Guillain-Barre syndrome (GBS), (2) entitlement to a disability rating in excess of 20 percent for neuropathy of the right lower extremity, to include as due to GBS, and (3) entitlement to a disability rating in excess of 20 percent for neuropathy of the left lower extremity, to include as due to GBS. In the February 2020 rating decision, the RO granted service connection for right and left upper extremity numbness, residuals of GBS; and granted increased evaluations of 40 percent for the Veteran’s bilateral lower extremity disabilities. According to the Veteran’s April 2014 Notice of Disagreement (NOD) these were the outcomes and evaluations sought by the Veteran on those issues or exceeded the desired evaluation levels. Based on these facts, the RO determined that its decisions constituted a full grant of the benefits sought regarding those issues. The Board agrees with this finding, leaving only the issue of entitlement to an increased rating for right shoulder DJD on appeal. For the issue of entitlement to an increased rating for right shoulder DJD, the Board finds that the RO did not substantially comply with its directives, and remand is required. In the Board’s March 2019 decision, the Board discussed the Veteran’s representative’s contention that the Veteran was entitled to separate ratings for Muscle Groups IV and V in the Veteran’s right upper arm/shoulder. See also April 2014 NOD. In its remand directives, the Board stated that the examiner should note pertinent medical complaints, symptoms, and clinical findings, if any, specific to muscle groups IV and V in the Veteran’s right upper arm. The May 2019 VA examination for shoulder and arm conditions only included standard findings regarding potential muscle atrophy and strength testing, with no explicit discussion of potential injuries to muscle groups IV and V. Additionally, the June 2019 VA examination for shoulder and arm conditions provided similar findings, with no explicit discussion of the alleged injuries. While these examinations were negative for evidence of any muscle involvement in the right shoulder to warrant consideration of a higher evaluation or separate evaluations based on muscle groups/injuries, they did not explicitly discuss the alleged conditions, which included tendon injuries, the medical records discussed by the Veteran’s representative, or the possibility that the Veteran had suffered from such conditions earlier in the period on appeal. Accordingly, the May 2019 and June 2019 VA examinations did not fulfill the Board’s remand directives, and this issue must again be remanded in order to fully comply with those directives as outlined in the March 2019 remand. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following actions: 1. Make efforts to obtain all outstanding medical records in accordance with the duties set forth in 38 C.F.R. § 3.159(c). 2. Schedule the Veteran for a VA shoulder examination to determine the current severity of his service-connected DJD of the right shoulder as well as the nature and etiology of any conditions of Muscle Groups IV and V, as defined under 38 C.F.R. § 4.73, DCs 5304 and 5305. The entire claims file must be reviewed by the examiner. All indicated tests and studies should be conducted. Consideration should be given to the April 2014 NOD and the medical records it discusses. After a complete review of the record, the examiner is asked to address the following: (a.) Identify whether the Veteran has suffered from injuries or conditions related to Muscle Groups IV or V (DC 5304 and DC 5305) at any point during the period on appeal or recent thereto. (b.) If so, for each identified injury or condition, opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s condition arose during or as a result of his active service. (c.) For each identified injury or condition, opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s condition was caused or aggravated (worsened beyond its natural progression) by his service-connected disabilities, notably the service-connected right shoulder disorder. A complete rationale should be provided for all conclusions. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Hicks, 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.