Citation Nr: 21071816 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 16-30 641 DATE: December 1, 2021 REMANDED Entitlement to a disability evaluation in excess of 20 percent for service-connected left shoulder calcific tendonitis effective April 12, 2013, is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities prior to December 9, 2014, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1973 to January 1993. This matter again comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board previously remanded this matter in October 2018. As a preliminary matter, the Board acknowledges that in a September 2021 rating decision, the RO granted entitlement to a 20 percent disability evaluation for the Veteran's service-connected left shoulder calcific tendonitis effective April 12, 2013, and entitlement to a TDIU effective December 9, 2014. 1. Left Shoulder Calcific Tendonitis Regarding the Veteran's claim for an increased disability evaluation for his left shoulder, the Board notes that the record is currently incomplete to determine this issue. First, some of the Veteran's VA primary care notes and a September 2014 VA Orthopedic Surgery Note indicate that the Veteran's left shoulder exhibited a decreased range of motion. However, no such measurements were included. See August 2013 VA Primary Care Note; May 2014 VA Primary Care Note; August 2014 VA Primary Care Note; September 2014 VA Orthopedic Surgery Note. On remand, the Board requests that any and all specific range of motion measurements taken during the above-mentioned VA visits be obtained and associated with the claims file. Additionally, the Veteran's October 2019 VA examination report reflects that the Veteran sought physical therapy as treatment for his left shoulder condition. Nevertheless, no physical therapy records for the left shoulder are affiliated with the claims file. Consequently, the RO should request the Veteran's physical therapy records that relate to his left shoulder condition on remand. Finally, the Board notes that during the March 2014 and July 2015 VA examinations, the Veteran reported flare-ups of the left shoulder. Since those examinations, the United States Court of Appeals for Veterans Claims (Court) ruled that when flare-ups are reported the examiner should elicit information as to the severity, frequency, duration, precipitating, and alleviating factors associated with said flare-ups and estimate, per the Veteran, any additional loss in terms of additional range of motion if the examination is not being conducted during a flare-up. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). Therefore, the Board finds that a retrospective opinion should be obtained as to the severity of the Veteran's left shoulder calcific tendonitis. See Chotta v. Peake, 22 Vet. App. 80 (2008) (when there is an absence of medical evidence during a certain time period, a retrospective medical evaluation may be warranted). 2. TDIU Prior To December 9, 2014 As established in the Board's October 2018 decision, the issue of entitlement to a TDIU prior to December 9, 2014, is inextricably intertwined with the issue of entitlement to an increased rating for the Veteran's left shoulder calcific tendonitis. See October 2018 Board Decision; Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). Furthermore, the Board notes that in an April 2013 Statement in Support of Claim, the Veteran stated that his left shoulder disability prevented him from working. See April 2013 VA Form 21-4138. The Veteran also submitted a statement from his previous employer regarding not only accommodations made in light of the Veteran's service-connected disabilities, but also how his service-connected disabilities stopped him from carrying out his full duties. See March 2014 Statement by M.T.M. (Veteran's former employer, labeled Third Party Correspondence); August 2014 Statement by M.T.M. (Veteran's former employer, labeled Correspondence). Therefore, the issue of entitlement to a TDIU prior to December 9, 2014, must also be remanded. The matters are REMANDED for the following action: 1. The RO should request the Veteran to identify any and all outstanding VA and/or private medical records related to physical therapy treatment for his service-connected left shoulder calcific tendonitis. Appropriate efforts must be made to obtain these records if he has adequately identified them and authorized their release (with respect to any private medical records). He should also be invited to submit these records himself. All actions to obtain the requested records should be fully documented in the claims file. If they cannot be located or no such records exist, the Veteran should be so notified in writing. 2. The RO should obtain the range of motion measurements taken during an August 2013 VA Primary Care visit, May 2014 VA Primary Care visit, August 2014 VA Primary Care visit, and September 2014 VA Orthopedic Surgery visit. 3. Then, forward the claims file to an appropriate clinician to determine the nature and severity of the Veteran's service-connected left shoulder calcific tendonitis from April 12, 2012, to the present. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be provided. If a new contemporaneous examination is provided, the clinician must test the Veteran's active motion, passive motion, and pain in weight-bearing and nonweight-bearing circumstances. The examiner must also attempt to elicit information regarding the severity, frequency, duration, precipitating factors, and alleviating factors of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the Veteran's left shoulder calcific tendonitis alone and the effect of such on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given the medical science and known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Based on review of the claims file, including the Veteran's VA and private medical records and lay statements regarding his left shoulder symptomatology, the examiner should render an opinion addressing whether, at any point from April 12, 2012, to the present, the record reflects any change(s) in the severity of the Veteran's left shoulder calcific tendonitis, and, if so, the approximate date(s) of any such change(s), including the degrees of additional range of motion lost during flare-ups, if possible, and range of motion measurements for active motion, passive motion, and in weight-bearing and nonweight-bearing circumstances. If the clinician cannot provide this retrospective and/or current opinion, the clinician should state why and provide a reasoned explanation for the determination. 4. Subsequently, the RO should readjudicate the issues on appeal. 5. If any of the above-sought benefits remain denied, the RO should issue a Supplemental Statement of the Case (SSOC) to the Veteran. An appropriate period of time should be allowed for response before returning the appeal to the Board. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Hoffman 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.