Citation Nr: 21071275 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-48 581 DATE: November 30, 2021 REMANDED Entitlement to a rating in excess of 20 percent for degenerative joint disease, left shoulder is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Navy from November 1986 to October 1990. This issue comes before the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. The Veteran contends that he is entitled to a higher rating than the 20 percent currently assigned for his left shoulder disability. The Board notes that this matter was remanded in April 2021 for a VA examination to determine the currently severity of the left shoulder disability. A VA examination was conducted in August 2021. The Veteran was diagnosed with degenerative joint disease of the left shoulder. He reported experiencing worsening symptoms and flare ups of sharp, stabbing pain occurring "just about every day" and lasting "a few hours at a time." He also endorsed additional functional loss of the left shoulder based on difficulty engaging in activities which involved raising his arms over the shoulder level, such as lifting, grooming, and self-care. The examiner was unable to test active and passive range of motion (ROM) due to the Veteran's pain complaints. He also noted pain on nonweight-bearing, on rest/non-movement causing functional loss in that the Veteran could not lift, work overhead, reach behind or complete ROM testing. The examiner was unable to provide an opinion regarding additional ROM limitations due to repeated use or flare ups. He explained that since the Veteran declined to complete initial ROM testing, there was no basis to estimate ROM during repeated use or flare ups. Additionally, the examiner noted that the Veteran would have moderate restricted use of the left arm overhead, reaching behind, lifting heavy objects or repetitive use of the left arm and would experience shoulder/arm fatigue and weakness with prolonged use. Ankylosis and muscle atrophy were not found on examination. The examiner noted a suspected rotator cuff condition due to the Veteran's pain description, but was unable to test it. He also found no evidence of malunion of the humerus with moderate or marked deformity. Finally, the examiner found that the left shoulder impacted the Veteran's ability to work due to difficulty engaging in activities which involved raising arms over the shoulder level. The Board finds another VA examination is required. The Veteran did not indicate why he was unable to perform range of motion testing in August 2021. This may have been due to symptomology the Veteran was experiencing on that day only. The Board notes that the Veteran testified several months prior as to his ability to move his shoulder and it was not as limited as presented at the August 2021 examination. The clinical records contemporaneous to the VA examination to include those dated several years prior do not include any complaints of, diagnosis of or treatment for shoulder problems. They are also negative for any evidence that the Veteran has been prescribed any medication to treat the disability. An opinion is required to address this discrepancy. The examiner suspected that the Veteran may have had a torn rotator cuff. Service connection is not in effect for this disorder. A determination must be made as to the extent of disability associated solely with the service connected degenerative joint disease of the left shoulder. The examiner opined that the service connected functional impact of the shoulder disability was difficulty engaging in activities which involved raising the arms over shoulder level. It is not apparent upon what basis this opinion rests as the Veteran refused to perform range of motion testing. A rational should be provided. The matter is REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Obtain updated VA and/or private treatment records to the extent possible. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 3. Schedule the Veteran for a VA examination to determine the extent of disability associated with the service connected left shoulder. The examination should be conducted using the most recent examination form. The claims file must be reviewed and noted by the examiner on the medical report. If the Veteran does not appear for the examination the examiner is requested to provide opinions based on the medical evidence of record when addressing the questions below. Based on a review of the record, and a new examination if necessary, the examiner is to address the following: (a.) Conduct a left shoulder examination using the most recent DBQ form. Please determine range of motion measurements for the Veteran's left shoulder on active and passive testing. If the Veteran is unable to be tested please provide an opinion based on a review of the record. The examiner should only evaluate the symptoms associated with degenerative joint disease of the left shoulder. If the examiner is unable to differentiate the left shoulder degenerative joint disease symptomology from any other shoulder symptomology, the examiner should so state and provide a rationale to support that determination. (b.) the examiner must provide an estimate of functional loss in terms of range of motion based on the Veteran's statements, available medical records, and other relevant sources. The examiner must attempt to ascertain information, such as frequency, duration, characteristics, severity, and functional loss (due to pain, weakness, fatigability, or incoordination) regarding any flare-ups to the extent possible by observation and by alternative means. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. The examiner is not to improperly discount the Veteran's lay statements or rely solely on an absence of medical evidence in the record to support his or her conclusions. (Continued on the next page) A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.T. Massey, 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.