Citation Nr: 21065454 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 13-34 186A DATE: October 26, 2021 REMANDED Entitlement to a rating in excess of 20 percent for right sternoclavicular joint dislocation and reduction residuals is remanded. REASONS FOR REMAND The Veteran had active service from May 2007 to May 2011. Entitlement to a rating in excess of 20 percent for right sternoclavicular joint dislocation and reduction residuals is remanded. In its May 2021 Remand instruction, the Board of Veterans' Appeals (Board) directed that the Veteran be afforded further Department of Veterans Affairs (VA) muscle and orthopedic evaluation to determine the current severity of the service connected right sternoclavicular joint disability. The examiner was requested to "state whether there is any evidence of muscle injuries found on examination that are related to the Veteran's in-service injury, or that are considered secondary to his service-connected orthopedic disability of the right shoulder." The report of an August 2021 shoulder and arm examination conducted for VA states that the Veteran was diagnosed with right shoulder strain, impingement syndrome, and glenohumeral joint dislocation. The examining nurse practitioner did not address the right sternoclavicular joint or whether there was any muscle disability "related to the Veteran's in-service injury, or that are considered secondary to his service-connected orthopedic disability of the right shoulder." In light of the cited deficiencies, the Board finds that the examination report is of limited probative value. A September 2021 addendum to the August 2021 VA examination report clarifies that: "all current diagnoses pertain to the shoulder joint and the associated soft tissues/muscle and not the sternoclavicular joint, and represent a new condition arising post-service, and likely acutely;" "the Veteran's currently diagnosed shoulder and muscle injuries are less likely than not due to the events in service involving the sternoclavicular joint;" "this is all but unequivocal;" and "they are anatomically and pathophysiologically unrelated and there was no evidence of said injuries at the time of the in-service injury or for several years post-service." The requested VA examination addressing the right sternoclavicular joint dislocation and reduction residuals has not been conducted. The Agency of Original Jurisdiction compliance with the Board's remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). Clinical documentation dated after March 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the right sternoclavicular joint disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after March 2020. 3. Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected right sternoclavicular joint dislocation and reduction residuals. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Identify all right sternoclavicular joint dislocation and reduction residuals found. If no recurrent residuals are observed, the examiner should expressly state that fact. (b) Identify the specific muscle groups affected by the service connected right sternoclavicular joint dislocation and reduction residuals. If no muscle groups are affected, the examiner should expressly state that fact. (Continued on the next page) (c) Provide ranges of motion for passive and active motion, and for weight-bearing and nonweight-bearing, of the right upper extremity. The degree at which pain is elicited should be specifically noted. (d) State whether there is any additional loss of right upper extremity function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.