Citation Nr: 21002169 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 15-34 895 DATE: January 12, 2021 REMANDED Entitlement to a disability rating in excess of 20 percent for left shoulder strain status post arthroscopy, to include on an extraschedular basis, is remanded. REASONS FOR REMAND The Veteran served in the Air Force from July 1999 to August 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) following cessation of the Veteran’s 100 percent convalescence rating after her arthroscopic surgery. In January 2019, the Veteran presented testimony at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is on record. In May 2019, the Board remanded the claim to provide the Veteran a VA examination on the current nature and severity of her left shoulder disability. Entitlement to a disability rating in excess of 20 percent for left shoulder strain status post arthroscopy, to include on an extraschedular basis, is remanded. The Veteran seeks an increased disability rating for her left shoulder disability. The Board finds that further development is necessary to provide the Veteran with an adequate VA examination. In DeLuca v. Brown, 8 Vet. App. 202 (1995), which addressed the adequacy of a VA examination investigating the severity of a disability rated under the same diagnostic code at issue here, the Court held, to comply with 38 C.F.R. § 4.40, examiners must “express an opinion on whether pain could significantly limit functional ability during flare-ups or when the arm is used repeatedly over a period of time.” Id. at 206. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves or evidence on record, when a flare-up is not observable at the time of examination. Moreover, when VA undertakes to provide a medical examination or obtain a medical opinion, VA must ensure that the examination is fully cognizant of the Veteran’s prior medical history. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, pursuant to the Board’s remand, the Veteran was afforded a VA examination in December 2019. At the examination, the Veteran reported flare ups manifested by increased soreness, heaviness, weakness, and difficulty with grip. However, the examiner did not estimate the severity, frequency, duration, precipitating and alleviating factors, nor the extent of functional impairment of the Veteran’s flare ups. Indeed, contrary to the Veteran’s reported increased flare up symptoms, the examiner indicated that pain, weakness, fatigability, and incoordination did not significantly limit the Veteran during flare ups. The examiner also did not address whether pain could significantly limit ability after repetitive use over time. Moreover, medical records from April 2019 indicate the Veteran also experienced numbness and tingling from the back of her bicep to the elbow, down to her pinky and half of her ring finger. However, the examiner indicated that no additional factors contributed to the Veteran’s left shoulder disability. Thus, because the examination report did not address potential functional loss during flare ups or after repetitive use over time, contained internal inconsistencies, and did not consider the Veteran’s prior medical history, the VA examination is inadequate. Additionally, the Board remand requested that both shoulders be tested in both active and passive motion, on weight-bearing and non-weight-bearing, which was not done. Accordingly, the Veteran must be provided another examination. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matter is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to determine the current nature and severity of her left shoulder disability. Both shoulders must be tested in both active and passive motion, on weight-bearing and non-weight-bearing. The examiner is asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flare-ups or repetitive use over time, and if so, the examiner must estimate range of motion during flare-ups or repetitive use over time based upon relevant information elicited from the Veteran, review of the claims file, and the current examination results pertaining to the frequency, duration, characteristics, severity, and functional loss during flare-ups and repetitive use over time. If the Veteran describes experiencing flare ups, identify the: frequency; duration; precipitating factors; and alleviating factors. The examiner must also opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s left arm numbness and tingling are proximately due to or aggravated by the Veteran’s left shoulder disability. The examiner must provide separate findings and rationales relating to causation and aggravation.   Aggravation under 38 C.F.R. § 3.310 (b) does not require that there be “permanent” worsening of the nonservice connected disability. If it is found that the Veteran’s left arm numbness and tingling are secondary to the Veteran’s service-connected left shoulder disability, the examiner must also complete a VA nerve examination using the appropriate Disability Benefits Questionnaire for upper extremity nerve disabilities. A complete rationale for any opinion must be provided. A complete rationale is one that contains clear conclusions with supporting data and a reasoned medical explanation connecting the two. 2. Then, readjudicate the claim on appeal. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P.A. Infante 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.