Citation Nr: 21074850 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 20-05 311 DATE: December 16, 2021 REMANDED Entitlement to a rating in excess of 20 percent for recurrent dislocation of the left shoulder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1961 to November 1962. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. While the Veteran initially requested a hearing before a Veterans Law Judge upon return of the completed VA Form 9, he later withdrew this request in March 2021. The Veteran was most recently issued a Supplemental Statement of the Case on November 12, 2021. The Board asserts jurisdiction accordingly. This appeal has been advanced on the Board's docket on account of advanced age. 38 U.S.C. § 7107(a)(2). 38 C.F.R. § 20.900(c). Entitlement to a rating in excess of 20 percent for recurrent dislocation of the left shoulder is remanded. In short, the Veteran's claim was previously remanded on May 20, 2021 because March 2018 and May 2019 VA examination findings concluded that the Veteran did not have loss of head, nonunion, or fibrous union of the left humerus, but failed to address a Dr. M.B.'s findings that "it appears that he may have a fibrous union on some of the bones at the superior aspect of the left glenoid." The Veteran underwent an examination on June 21, 2021, but this report also failed to address the relevance or lack thereof of Dr. M.B.'s findings. For this reason, the Board had no choice except to remand the claim once again on September 29, 2021. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran then submitted to another examination on November 9, 2021. In addition, there is a discrepancy in the reported findings of the most recent examinations. Examinations conducted on March 13, 2018 and May 13, 2019 characterize the Veteran as right-handed, meaning that the left shoulder on appeal would be rated on the minor axis as non-dominant. On the other hand, the June 21, 2021 and November 9, 2021 examinations appear to characterize the Veteran as left-handed. The Board requires that this discrepancy be reconciled, because for the major axis only, there is an intermediate rating between the 20 percent as currently rated and a rating consistent with a fibrous union. As such, the Board concludes that it has no choice but to remand for an addendum. The Board sincerely regrets additional delay in this matter. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, arrange for an appropriate health care provider to review the Veteran's claims file. A copy of this Remand should be provided to the examiner. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. Then, obtain an opinion regarding the severity and manifestations of the Veteran's left shoulder recurrent dislocation, to include whether the Veteran has a fibrous union, the frequency of episodes of dislocation, and whether guarding of left arm movement is of all arm movements or whether guarding is only at shoulder level. (Continued on the next page) The examiner should specifically indicate which hand is the Veteran's dominant hand. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael B. Engle, 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.