Citation Nr: 21004961 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 08-30 097 DATE: January 28, 2021 ORDER Entitlement to an initial rating in excess of 20 percent for tendinopathy/tendinosis of the right shoulder, excluding the period of the temporary 100 percent rating under Paragraph 4.30, from November 7, 2006 to January 1, 2007, is denied. REMANDED Entitlement to service connection for left shoulder disability is remanded. Entitlement to an initial compensable rating prior to June 22, 2019, and in excess or 30 percent thereafter for headaches is remanded. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease (DJD) of the cervical spine is remanded. FINDINGS OF FACT 1. The most probative evidence does not demonstrate reduced range of motion in the right shoulder to at least midway between the side and shoulder level (45 degrees), even after considering factors such as pain on motion. 2. The Veteran’s right shoulder post-surgical scar is well-healed and stable, small (less than 39 sq. cm.), not deep, not tender on examination, and does not cause limitation of motion or other function of the shoulder. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 20 percent for the Veteran’s right shoulder tendinopathy/tendinosis have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5201. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from March 1966 to September 1968 and from April 1985 to April 2001. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In a March 2017 decision, the Board denied the Veteran’s claims of entitlement to service connection for a left shoulder disability, as well as entitlement to higher initial ratings for right shoulder tendinopathy/tendinosis (hereinafter “right shoulder disability”), DJD of the cervical spine (hereinafter “cervical spine disability”), and headaches. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court/CAVC). In a March 2018 Order, granting a Joint Motion for Partial Remand (JMPR), the Court vacated the Board’s March 2017 decision and remanded the case for further development in compliance with the directives specified in the Joint Motion. Per the March 2018 Order, the Board remanded the issues on appeal for additional development in October 2018. During the pendency of the appeal, in a July 2020 rating decision, the RO granted an increased rating for the service-connected headaches from 0 percent to 30 percent, effective June 22, 2019. However, since the maximum rating allowable has not been granted throughout the pendency of the appeal, this matter remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Preliminarily, the Board notes that the issues of increased rating for the service-connected cervical spine disability and headache disability were remanded, in part, to obtain pertinent treatment records not yet associated with the claims file. However, the aforementioned outstanding treatment records were referenced in the June 2019 VA cervical spine and headache examinations and have been specified as related to the Veteran’s service-connected cervical spine disability and headache disability. The Veteran has not reported nor does the evidence of record indicate that any such treatment records are pertinent to the right shoulder disability claim decided herein. Instead, as noted in the June 2019 VA examination, the Veteran denied any additional injuries since 2006 and reported that she has not undergone any treatment or additional surgeries for her right shoulder. She had been advised that she was not a candidate for further intervention. See June 2019 C&P Exam. As such, the Board may proceed with a decision as related to the increased rating claim for the service-connected right shoulder disability without prejudice to the Veteran. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Entitlement to an initial rating in excess of 20 percent for right shoulder disability, excluding the period of the temporary 100 percent rating under Paragraph 4.30, from November 7, 2006 to January 1, 2007. The Veteran’s right shoulder tendinopathy/tendinosis, status-post right rotator cuff repair, has been initially rated at 20 percent, under 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5024-5201, effective from June 27, 2005, the date of claim for service connection. Here, the most closely analogous diagnostic code is 38 C.F.R. § 4.71a, DC 5024, for tenosynovitis. DCs 5013 to 5024, as here, will be rated as degenerative arthritis under DC 5003 on limitation of motion of affected parts. 38 C.F.R. § 4.71a. DC 5201 represents limitation of motion of the major arm. 38 C.F.R. § 4.71a. The Veteran’s dominant hand/arm is the right side, and as such, the Veteran’s right shoulder is rated under disabilities of the major (dominant) arm. Under DC 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. The movement of the shoulder and arm joint is covered in the regulations by 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 to 180 degrees, abduction from 0 to 180 degrees, and both internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. Concerning this, under DC 5201, limitation of motion of the major (dominant) arm at the shoulder level (90 degrees) provides a 20 percent rating. Limitation of motion to midway between the side and shoulder level (45 degrees) is assigned a 30 percent evaluation. A 40 percent evaluation is warranted for the arm when motion is limited to 25 degrees from the side. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Factual Background During the January 2006 VA examination, the Veteran demonstrated flexion in her right shoulder from 0 to 180 degrees, limited to 90 degrees with pain; abduction from 0 to 180 degrees, limited to 90 degrees with pain; external rotation to 90 degrees, limited to 80 degrees with pain; and internal rotation to 90 degrees, limited to 75 degrees with pain. There was no additional limitation of motion on repetitive use noted. See January 2006 VA examination. An April 2006 private treatment record noted the Veteran’s limited active right shoulder flexion and abduction range of motion to 150 degree, but noted she displayed a painful arc from 80 degrees to 120 degrees. See August 2008 Medical Treatment Record – Non-Government Facility. June 2006 and August 2006 private treatment records noted the Veteran’s pain with overhead movement. See id. As indicated above, this appeal for higher initial rating for the service-connected right shoulder disability is exclusive of the temporary total evaluation under Paragraph 4.30, from November 7, 2006 to December 31, 2006, which compensated her for convalescence from surgical repair of a torn rotator cuff in her right shoulder on November 7, 2006. At the August 2007 VA examination of her right shoulder, the Veteran reported that her right shoulder hurt daily at 4/10, flared up three days a week depending on activity, was treated by pain medication, but she denied assistive devices. See August 2007 VA Examination. On physical evaluation, the examiner noted a well-healed surgical scar that was vertical between neck and shoulder with no tenderness to palpation. Manual muscle strength testing results were 5/5 and there was normal capillary circulation of the fingers noted. The examiner noted the Veteran’s functional impairment of the right shoulder was between moderately severe and severe, but found there was no weakness, fatigability, or incoordination. Range of motion testing was done with complaints of pain noted on the motions, showing flexion to 70 degrees, abduction to 60, and internal rotation and external rotation to 85 degrees each. Each movement was tested three times. The examiner noted extension to 35 degrees. At the October 2014 VA examination, the Veteran was diagnosed with right rotator cuff tendonitis. See December 2014 C&P Exam. The Veteran reported that since her November 2006 rotator cuff surgery, she had very limited use of her right upper extremity. She denied any pain in the right shoulder, unless she attempted to raise her arm above her shoulder. She denied flare-ups. She reported functional impairment due to her right shoulder’s decreased ability to forward flex, abduct, and internally/externally rotate her right shoulder. Range of motion testing showed all motion limited by pain, as follows: flexion to 75 degrees, with pain; abduction to 75 degrees, with pain; external rotation to 20 degrees, without pain; and internal rotation to 60 degrees, without pain. There was no additional limitation of motion noted on repetitive motion testing. There was no evidence of pain with weight bearing noted. Also, there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue noted. There was no right shoulder ankylosis noted. There was no right shoulder instability noted, no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint conditions noted, no conditions or impairments of the humerus noted, and no use of any assistive devices noted for the right shoulder. The examiner noted that the Veteran had a right shoulder scar that measured 6.5 cm by 0.2 cm. The examiner noted the scar was not painful, not unstable, did not have a total area equal to or greater than 39 square cm, and was not located on the head, face, or neck. In a March 2018 JMPR, in pertinent part, the parties agreed the March 2017 Board decision relied on inadequate VA examinations in denying higher initial ratings for service-connected right shoulder disability. Specifically, the parties asserted that the Board erred in relying on VA examinations that did not fully satisfy the requirements of Correia, Mitchell, and 38 C.F.R. § 4.59. Subsequently in October 2018, the Board remanded for VA examinations that fully satisfy the requirements of Correia, Mitchell, Sharp, and 38 C.F.R.§ 4.59. Pursuant to the October 2018 Board remand, the Veteran was afforded another VA examination for her right shoulder disability in June 2019. See June 2019 C&P Exam. The examiner diagnosed right shoulder tendinopathy, tendinosis, status post right rotator cuff repair. During examination, the Veteran reported that her right shoulder has been painful since her military service. She reported that around 2006 she fell, and this injury led to her right shoulder rotator cuff surgery in November 2006. She reported that since the surgery, she has had very limited use of her right upper extremity although the surgery helped alleviate most of her pain. She denied any pain in the right shoulder unless she attempted to raise her arm above her shoulder. She reported additional falls since 2006 but denied additional injuries to her right shoulder. The Veteran reported that since the prior examination, her right shoulder was about the same and that she had not undergone any treatment or additional surgeries for her right shoulder. She reported that she has been advised that she is not a candidate for further intervention. She reported taking Percocet for generalized pain, to include her neck pain, and she finds that this was effective to provide pain control. She reported that in the past, she tried physical therapy but that did not seem effective at increasing her range of motion. She denied any history of dislocation and denied radicular pains, but she reported her shoulder clicks and pops from time to time. The Veteran did not report flare-ups of the shoulder. Regarding functional loss or impairment, the Veteran reported right and left shoulder pain and decreased range of motion with little use of the right and left upper extremities above the shoulder level. Range of motion testing of the right arm revealed flexion to 60 degrees, abduction to 60 degrees, external rotation to 45 degrees, and internal rotation to 55 degrees. The examiner noted pain was noted on examination and caused functional loss. The examiner noted that as soon as the Veteran felt pain, range of motion for the particular plane was discontinued and reiterated that the Veteran did not report flare ups. There was no evidence of pain with weightbearing and no objective evidence of crepitus and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue noted in the right shoulder. The examiner noted that in the right shoulder, the Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or range of motion. The examiner found that pain, weakness, fatiguability, or incoordination in the right shoulder did not significantly limit functional ability with repeated use over a period of time. Muscle strength was 4/5 and there was no muscle atrophy noted in the right shoulder. No ankylosis was noted. There was no right shoulder instability noted, no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint conditions noted, no conditions or impairments of the humerus noted, and no use of any assistive devices noted. The examiner noted that the Veteran had a right shoulder scar that measured 6 cm by 0.2 cm. The examiner noted the scar was not painful, not unstable, did not have a total area equal to or greater than 39 square cm, and was not located on the head, face, or neck. The examiner noted that for the right shoulder, the contralateral joint was not uninjured or normal, there was no pain noted with non-weight bearing and no pain noted with weight bearing, and testing for pain on passive range of motion could not be performed or was not medically appropriate. The examiner noted that after examination of the Veteran and listening to her complete history and current subjective complaints, combined with a review of the available records, the examiner had no basis to offer additional losses of function or motion when it came to repetitive use or during flare-up. Analysis On review of the VA examination reports and private treatment records, the most probative evidence does not show that she demonstrated reduced range of motion to at least midway between the side and shoulder level (45 degrees) to warrant a higher 30 percent evaluation, let alone even greater limitation of motion to warrant the maximum 40 percent schedular rating under DC 5201 even after considering additional limitations of motion caused by pain or functional loss. The Board highlights the Veteran’s contentions in the June 2019 VA examination that her limitations began at the shoulder level and above. She had maintained in both the October 2014 and June 2019 VA examinations that she denied any pain in the right shoulder unless she attempts to raise her arm above her shoulder. The October 2014 and June 2019 VA examiner also highlighted that the Veteran did not report flare-ups. During range of motion testing in the June 2019 VA examination, as soon as the Veteran felt pain, range of motion for the particular plane was discontinued. The October 2014 and June 2019 VA examiners also noted that there was no additional loss of range of motion or additional functional loss after repetitive use testing. The Board also notes that the Veteran reported during the June 2019 VA examination that since the last VA examination, her right shoulder was about the same, thus indicating no significant worsening or improvement that would warrant any change in the assigned 20 percent evaluation since the October 2014 VA examination. The evidence prior to October 2014 also indicates that overall, the service-connected right shoulder disability is not shown to have range of motion limited to at least midway between the side and shoulder level (45 degrees) or worse. Considering the above, the most probative evidence of record demonstrates that any functional loss present is adequately compensated by the 20 percent rating already assigned. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206. As such, the Board does not find that the Veteran’s range of motion in her right shoulder is so functionally limited so as to warrant a rating in excess of the 20 percent that is already assigned. The Board acknowledges that shortly following the convalescence period from November 7, 2006 to January 1, 2007, private treatment records in January 2007 noted the Veteran demonstrated 40 degrees flexion and less than 20 degrees abduction on January 22, 2007 and January 24, 2007; and then later that month, found 45 degrees flexion and 55 degrees abduction on January 29, 2007. See August 2008 Medical Treatment Record – Non-Government Facility. Nonetheless, these appear to be isolated findings as her range of motion improved significantly within a few weeks thereafter due to ongoing physical therapy. Specifically, private treatment records by Dr. A.W., noted forward flexion improved to 55 degrees and abduction to 60 degrees when tested again in February 2007 and again in March 2007. See id. Considering this noted improvement soon after the convalescence period, the January 2007 right shoulder range of motion findings are outliers and not representative of the overall right shoulder disability picture, and the private treatment records did not indicate usage of a goniometer during range of motion testing, the Board finds these isolated findings are not probative evidence in support of a higher rating. VA regulation states that the use of a goniometer in the measurement of limitation of motion is indispensable. 38 C.F.R. § 4.46. In sum, the Board finds that overall, the service-connected right shoulder disability picture is not shown to have range of motion limited to at least midway between the side and shoulder level (45 degrees) or worse at anytime for the applicable appeal period. The Board has also considered if there is another other diagnostic code (DC) that is applicable for the service-connected right shoulder disability and finds there are not any that are warranted. There is no indication by the Veteran or by the record that she had ankylosis of the scapulohumeral joint, so DC 5200 is not applicable. DC 5202 also is not applicable, as the evidence of record, to include the October 2014 VA examination and June 2019 VA examination, did not show there was malunion of the humerus, recurrent dislocation of the humerus, fibrous union or nonunion or loss of head of the humerus. Finally, none of the medical records indicated any impairment of the clavicle or scapula. As such, DC 5203 is also not applicable. Next, the Board also considers whether the Veteran warrants a separate compensable rating for her right shoulder surgical scar. Here, the Veteran’s claim was filed in June 2005. During the pendency of this appeal, the regulations on skin/scar disabilities were revised twice, once effective October 23, 2008, and a second revision effective August 13, 2018. Where a law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted VA to do otherwise and VA did so. See VAOGCPREC 7-2003. The Board will therefore consider the Veteran’s right shoulder scar under both the old and new criteria, keeping in mind that the revised criteria may not be applied to any time period before the effective date of the change. See 38 U.S.C. §§ 5110(g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Board will discuss all periods of regulations in order to determine if a compensable rating is warranted under the applicable criteria during that time period. Prior to October 23, 2008, scars (other than those involving the head, face, or neck) that are deep or that cause limited motion warranted a 10 percent rating for an area or areas exceeding 6 square inches (39 sq. cm.). A 20 percent rating was warranted for an area or areas of such scars exceeding 12 square inches (77 sq.cm.). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2007). Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, were separately rated and combined in accordance with 38 C.F.R. § 4.25. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1) (2007). A deep scar was one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2) (2007). A 10 percent rating was also warranted for scars (other than those on the head, face, or neck) that were superficial and that did not cause limited motion, provided that they covered an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2007). A 10 percent rating was warranted for each scar which was superficial and unstable. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2007). An unstable scar was one where, for any reason, there was frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2007). Finally, a 10 percent rating was warranted for each superficial scar which was painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007). Other scars were rated based on the limitation of function of the affected part or parts. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2007). Under the criteria from October 23, 2008 to August 13, 2018, Diagnostic Code 7804 pertains to evaluation of scars that are unstable or painful, with the assignment of a 10 percent rating for one or two such scars, a 20 percent rating for three or four scars, and a 30 percent rating for five or more scars. Note 1 defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provides that where one or more scars are both unstable and painful, 10 percent should be added to the evaluation that is based on the total number of unstable or painful scars. Note 3 states that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under 7804 when applicable. 38 C.F.R. § 4.118 (2017). Diagnostic Codes 7801 and 7802 continue to provide for assignment of disability evaluations on the basis of surface area of the affected scars. The revised Diagnostic Code 7805 applies to other scars (including linear scars) and other effects of scars are evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. A rating is to be assigned on the basis of any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under another appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2017). The Board notes that effective August 13, 2018, VA again revised the criteria for the evaluation of skin disabilities. 83 Fed. Reg. 32,592-601 (July 13, 2018). Pertaining to this claim, Diagnostic Codes 7801 and 7802 were modified but still retain the same surface area requirements for ratings. Diagnostic Code 7805 underwent non-substantive changes. The amendment also clarified the difference between topical and systemic therapy, as well as when skin conditions may be combined. The remainder of the changes were to diagnostic codes not implicated in this case. On review of the VA examination results and private right shoulder treatment records, there is no probative evidence to support that the scar is deep (the August 2007 VA examiner found a well-healed scar); causes limited motion or exceeds 39 sq. cm. (October 2014 and June 2019 VA examiners measured a singular scar as less than 7 sq. cm.), is unstable (October 2014 and June 2019 VA examiners found it is not unstable), is painful on examination (August 2007 VA examiner found no tenderness to palpation; and October 2014 and June 2019 VA examiners found the right shoulder scar not painful), or otherwise causes limited right shoulder function (October 2014 and June 2019 VA examiners found no other signs or symptoms). The criteria for dermatitis or eczema (DC 7806) appear inapplicable. There are also no relevant lay statements to consider. Thus, she does not warrant a compensable rating for the right shoulder surgical scar under any revised criteria. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The appeal is denied, as there is no reasonable doubt to resolve in her favor. REASONS FOR REMAND Entitlement to service connection for left shoulder disability is remanded. The Veteran was afforded a VA examination for her left shoulder disability in June 2019. The June 2019 VA examiner diagnosed left rotator cuff tendonitis with atrophy and provided a negative etiological opinion. See June 2019 C&P Exam. However, as highlighted by the Veteran’s representative in the September 2020 appellate brief, the June 2019 VA examiner inaccurately noted that the service treatment records (STRs) were absent for objective medical evidence of chronic left shoulder condition. The examiner did not consider the numerous reports of left shoulder-related complaints throughout the Veteran’s latter period of active service. See September 2020 Appellate Brief. A review of the relevant treatment records noted that following a motor vehicle accident in September 1986 during active service, the Veteran complained of left shoulder pain with ecchymotic areas to the left clavicle area. See June 2005 Medical Treatment Record – Government Facility. An October 1986 STR noted the Veteran’s continued pain following the vehicle accident, to include pain about the left scapula. See August 2014 STR – Medical – Photocopy. A subsequent October 1986 STR noted that during the September 1986 motor vehicle accident, the Veteran had struck her head, chest, knees and abdomen but was wearing a seat belt. The Veteran reported continued pain in the back through the shoulder blades, especially when reaching up on the left. The record noted the Veteran was tender to both rotator cups and left bicep. See June 2005 Medical Treatment Record – Government Facility. A July 1987 STR noted the Veteran was still experiencing a tight squeezing feeling at the base of the skulls all the time and that her neck and upper shoulders got very tight. The record noted a thickened left rotator cuff. An April 1988 STR noted the Veteran’s complaints in her left shoulder and that the Veteran had tender, indurated left trapezius ridge of the medial scapula. An October 1988 STR noted the Veteran’s complaints of pain on the left side of her neck protruding down her shoulder. A January 1989 STR noted that pain on the left side of neck and shoulder persisted. A March 1989 STR noted the Veteran’s tender indurated left trapezius muscle. An April 1989 STR noted the Veteran’s neck and shoulder pain status post auto accident in 1986. See June 2005 Medical Treatment Record – Government Facility. An April 1989 private treatment record noted the Veteran’s tenderness in the left shoulder area in April 1988. See June 2005 Medical Treatment Record – Government Facility. An April 1989 STR noted the Veteran’s tender left upper trapezius and that she had abnormal range of motion in the bilateral shoulders with slight pain on the left. See August 2014 STR – Medical – Photocopy. A subsequent April 1989 STR noted the Veteran’s pulled muscle in the left side of neck and shoulder. An October 1990 STR noted the Veteran’s accident four years ago and that she had been taking Motrin since that time for pain in her left shoulder, neck, and right flank. See August 2014 STR – Medical – Photocopy. Considering the above, the June 2019 VA examiner’s opinion was based on an inaccurate factual premise, and as such, is inadequate. See Reonal v. Brown, 5 Vet. 458, 461 (1993) (a medical opinion based upon an inaccurate factual premise is inadequate). Accordingly, remand is warranted for a new VA opinion to address the etiology of the Veteran’s left shoulder disability that considers the aforementioned evidence of record. Entitlement to an initial rating in excess of 10 percent for cervical spine disability is remanded. The Veteran was provided another VA examination in June 2019 for her cervical spine disability. See June 2019 C&P Exam. However, upon review of the examination report, there are outstanding treatment records that are pertinent to this particular issue that have not been associated with the claims file. Specifically, the June 2019 VA examiner noted the Veteran had undergone a cervical fusion with Dr. Steve Chang in June 2013, that she fell about 12 weeks after the surgery, and referenced notes that indicated the Veteran did not damage her neck in the fall, but that the pain returned. The examiner also noted the Veteran’s fall in October 2018 and had sustained a closed fracture to C1 and C2 and that the Veteran had been taken to the hospital where she stayed for a prolonged period of time to recover. The Veteran also reported seeing Dr. Potter for pain management who had treated her with radioablation a few years ago for pain in her neck. The Veteran also reported seeing “neuro” every three to four months and that she had been given a bone stimulator for three months in an attempt to help heal the cervical fracture. Apart from VA examinations in October 2014 and June 2019, there have been no additional treatment records since 2012 that have been associated with the evidence of record, to include the aforementioned treatment records pertaining to the June 2013 cervical spine surgery, the October 2018 fall resulting in a closed fracture to C1 and C2 that required prolonged hospitalization, ongoing treatment with Dr. Potter for pain management in her neck, and ongoing treatment with neuro for her neck. To ensure that all due process requirements are met, and that the record is complete, on remand, the AOJ should undertake appropriate action to obtain all pertinent, outstanding records. The Board also notes that during the June 2019 VA examination, the examiner was unable to test the Veteran’s cervical spine range of motion since she was advised to wear a cervical collar continuously for the rest of her life. However, the examiner noted that the Veteran has not been able to move her neck since she fell and broke her first two cervical vertebrate. In light of such limitations, the Board finds that on remand, a contemporaneous VA examination with a medical opinion should be obtained to determine to whether her current cervical spine symptoms are equivalent to unfavorable/favorable ankylosis. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine at Note 5. Entitlement to an initial compensable rating prior to June 22, 2019, and in excess of 30 percent thereafter for headaches is remanded. The Veteran was provided a VA examination in June 2019 for her migraine headaches. See June 2019 C&P Exam. The examiner noted the Veteran’s two types of headache diagnoses as tension headaches and post-concussion headaches, noting the Veteran’s tension headaches are not incapacitating but noted the Veteran’s post-concussion headaches as more severe. The examiner found that the Veteran experienced characteristic prostrating attacks of migraine/non-migraine headache pain once every month over the last several months. However, the Board notes that in an October 2014 VA examination, the examiner also noted two types of headache diagnoses, tension headaches and post-concussion headaches. The October 2014 VA examiner specifically found that the Veteran’s service-connected headaches were separate from the more severe post-concussive headaches that developed a year prior following a fall in 2013 where she sustained a concussion and neck injury. The examiner described the post-concussive headaches as severe and limited her ability to work due to the intensity. The examiner noted that since the 2013 fall, she had been followed by a pain management specialist and underwent radiofrequency ablation and physical therapy. The examiner noted that prior to the 2013 head injury, the Veteran only had mild occasional headaches and did not have any severe or incapacitating episodes of headaches. As indicated above, these treatment records are not associated with the claims file and will be obtained on remand. Considering the October 2014 VA examiner’s specific finding that the Veteran’s more severe post-concussive headaches are separate from the Veteran’s service-connected headaches and the June 2019 VA examiner’s finding that the Veteran’s tension headaches are not incapacitating, clarification is needed as to whether the Veteran’s characteristic prostrating attacks of migraine/non-migraine headache pain that was noted by the June 2019 VA examiner is due to the service-connected headaches or is otherwise not distinguishable. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (impairment of a part due to other causes which are distinguishable in their symptoms from those of the service-connected disability should not be attributed to the service-connected disability for purposes of assigning a disability rating). If the Veteran’s headache symptoms are not distinguishable, then the examiner should address the severity of the Veteran’s symptoms in the October 2014 VA examination and note whether such symptoms during the prior examination are characteristic prostrating attacks of migraine/non-migraine headache pain and note the frequency of any such attacks. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and any pertinent private treatment records not yet associated with the claims file, to include treatment records pertaining to the cervical spine fusion in 2013 with Dr. Chang and subsequent fall 12 weeks later, treatment records pertaining the October 2018 fall that required prolonged hospitalization and resulted in a closed fracture in the cervical spine and ongoing post-concussive headaches, treatment records related to pain management for the neck and headaches and radioablation with Dr. Potter, and ongoing treatment with neuro as related to the cervical spine and headache disabilities. 2. After all available records are associated with the claims file, send the Veteran’s claims file to an appropriate medical professional to obtain an addendum to the June 2019 VA opinion regarding the nature and etiology of the left shoulder disability. The Veteran’s claims file must be made accessible to the designated professional for review. A complete rationale for any opinion expressed should be provided. Following review of the claims file, the examiner is then requested to respond to the following: Is it at least as likely as not (50 percent probability or greater) that her left shoulder disability had its clinical onset during service, or is attributable to any in-service disease, event, or injury, to include the September 1986 motor vehicle accident? The examiner should consider the service treatment records and private treatment records during active service that noted the Veteran’s left shoulder-related complaints in September 1986, October 1986, July 1987, April 1988, October 1988, January 1989, March 1989, April 1989, and October 1990. 3. After all available records are associated with the claims file, schedule the Veteran for an examination of the current severity of her cervical spine disability. The Veteran’s claims file must be made accessible to the designated professional for review. A complete rationale for any opinion expressed should be provided. Following review of the claims file, the examiner is then requested to complete the following: (a) To the extent possible, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. (b) The examiner must also provide an opinion as to whether the Veteran’s service-connected cervical spine symptoms are equivalent to favorable or unfavorable ankylosis. The examiner must address the Veteran’s reports that she is not able to move her neck during the June 2019 VA examination, where the examiner was unable to perform ranges of motion due to the required use of the cervical collar. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment based on direct observation, the examiner should provide an estimate, if at all possible, based on the other evidence of record and the Veteran’s statements. 4. After all available records are associated with the claims file, schedule the Veteran for a VA examination for the purpose of determining the current severity of her service-connected headaches. The Veteran’s claims file must be made accessible to the designated professional for review. A complete rationale for any opinion expressed should be provided. Following review of the claims file, the examiner is then requested to complete the following: (a) The examiner should provide a detailed account of all manifestations of the service-connected headaches found to be present. The examiner should then render an opinion regarding the frequency of the Veteran’s headaches, and how often these headaches could be described as “prostrating.” (b) The examiner must also provide an opinion as to whether the Veteran’s characteristic prostrating attacks of migraine/non-migraine headache pain, to include as noted by the June 2019 VA examiner, is due to the service-connected headaches or is otherwise not distinguishable. The examiner should address the October 2014 VA examiner’s finding that the Veteran’s service-connected headaches were separate from the more severe post-concussive headaches. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Cheng, 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.