Citation Nr: 21077098 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 17-04 610 DATE: December 28, 2021 REMANDED Entitlement to a rating in excess of 20 percent for right shoulder strain is remanded. Entitlement to a rating in excess of 20 percent for left shoulder strain is remanded. Entitlement to a rating in excess of 10 percent for right hip strain is remanded. REASONS FOR REMAND The Veteran served in the United States Army from July 1971 to October 1971; June 1985 to May 2004; and September 2008 to December 2009. The Veteran had active-duty service and a deployment to Kosovo, where he injured his shoulders and hip, which the Department of Veterans Affairs (VA) has found to be service connected. This matter now comes before the Board of Veterans' Appeals (Board) from a December 2016 rating decision issued by the VA Regional Office (RO). In August 2021, the Veteran had a hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript has been associated with the electronic claims file. The record was also held open for 90 days to allow the Veteran to submit additional evidence. The Veteran timely submitted additional medical records and waived his right to agency of original jurisdiction (AOJ) review of the records. The Board sincerely regrets the delay in fully adjudicating this claim, but a remand is necessary to ensure full development of the record. 1. Entitlement to a rating in excess of 20 percent for right shoulder strain is remanded. 2. Entitlement to a rating in excess of 20 percent for left shoulder strain is remanded. The Veteran contends that he is due ratings in excess of 20 percent for his right and left shoulder strain. The most recent examination to assess the nature and severity of the Veteran's right and left shoulder strain occurred in January 2015, more than six years ago. Since that time, the Veteran has submitted records from the Oakhurst Community Based Outpatient Clinic (CBOC), the Fresno VA Medical Center (VAMC), and Coarsegold Physical Therapy. Additionally, the Veteran has testified in an August 2021 hearing before the undersigned VLJ. After a full review of these records, the Board finds that the evidence indicates that his bilateral shoulder strain may have worsened in severity. Specifically, in December 2015, the Veteran reported at the Oakhurst CBOC that he was suffering from chronic shoulder pain due to his active-duty service in Kosovo. The Veteran also reported tenderness on palpation of the anterior shoulder joint with full extension. He completed physical therapy in 2016. The notes from that visit indicate that the Veteran made excellent progress in all aspects for his bilateral shoulders with no pain, normal strength, and normal range of motion upon his discharge from physical therapy in May 2016. However, in April 2018 and November 2018 the Veteran was seen at the Fresno VAMC and Oakhurst VA Clinic where shoulder pain was still noted as an active problem. In May 2019, the Veteran returned to Coarsegold physical therapy with pain in his right shoulder. The Veteran entered a 6-week physical therapy regimen for his right shoulder, assessed by the physical therapist as impingement syndrome. By September 2019, the Veteran reported that his shoulder was doing really good, and he was able to work overhead with no pain or stiffness. In August 2021, the Veteran testified at the Board hearing that his shoulders have worsened since the last VA examination, as the pain is more frequent rather than more intense. He reported that overhead work is the most sensitive for both of his shoulders and at the current frequency, the pain in his shoulders interrupts his work. The Veteran stated that he can feel the sensation in his shoulders at 45 degrees, specifically in the muscle and joint. Anything above that becomes increasingly painful and sensitive for him. He also testifies that he can sense it when reaching into a cabinet in the kitchen or while scrubbing his back or washing his hair in the shower. He also reports that at times he feels the shoulder catch which will stop him in his tracks. He stated that at times he will have take a couple days of rest for the pain to fully subside before he can get back to work. He also stated that he wakes up with tension in the shoulders that he has to stretch out to reduce tightness. The evidence of record, including the Veteran's testimony, indicates that his right and left shoulder strain may have worsened from his last VA examination. Accordingly, remand is necessary to obtain contemporaneous VA examination for this disability. Snuffer v. Gober, 10 Vet. App. 400 (1997). As such, the Board finds that a more contemporaneous examination is needed to fully and fairly evaluate the Veteran's service connected right and left shoulder strains. 3. Entitlement to a rating in excess of 10 percent for right hip strain is remanded. The Veteran also seeks entitlement to a rating in excess of 10 percent for his right hip strain. As noted above, the most recent examination to assess the nature and severity of the Veteran's right hip occurred in January 2015, more than six years ago. Since that time, the Veteran has submitted records from the Oakhurst Community Based Outpatient Clinic (CBOC), the Fresno VA medical center (VAMC), and Coarsegold Physical Therapy. Additionally, the Veteran has testified in an August 2021 board hearing before the undersigned VLJ. After a full review of these record, the Board finds that the evidence indicates that his right hip disability may have worsened in severity. In December 2015 at Oakhurst CBOC, the Veteran was noted to be an avid runner, but he reported that he was no longer running due to his hip pain. In April 2017, the Veteran began physical therapy for his hip at Coarsegold PT. The Veteran described the pain in the hip to be frequent and aggravated with prolonged standing and walking. The physical therapist assessed the Veteran's condition as right trochanteric bursitis which limited his ability to stand or walk for more than 30 minutes. In May 2017, the Veteran was found to have progressed well with physical therapy with decreased pain and improvement in strength of the hip. In November 2017 the Veteran reported high levels of success with physical therapy on his hip. However, in April 2018 and November 2018 at the Fresno VAMC and Oakhurst VA Clinic, the hip was noted on his active problems list. In March 2021, the Veteran returned to Coarsegold physical therapy, reporting frequent pain in the right hip, which was aggravated by going up and down ladders, walking hills, and carrying wheelbarrow loads. His right hip abduction, internal rotation, and external rotation all showed mild loss of strength. The physical therapist found the Veteran to have mild right hip hypomobility, pain and inflammation, limited range of motion and joint mobility, weakness in the hip muscles and difficulty walking up and down stairs and hills. After engaging in a physical therapy regimen at Coarsegold PT, the Veteran was discharged in June 2021, in which he reported the right hip to feel much better. In August 2021, the Veteran testified at the Board hearing. The Veteran testified that his right hip made ladder work difficult for him and impacted his balance as well. He also reported that when pain strikes his hip it is temporarily immobilizing and can take several days of rest until the pain subsides. He admitted that physical therapy is helpful but that the frequency of pain has increased as he has gotten older. The Veteran also stated at the hearing that he can no longer sleep on his right side due to the hip pain. He wakes up in the morning and must stretch out his hip to reduce tightness. The Veteran also testified that the hip causes a slow, burning sensation when sitting or resting and when doing ladder work or using stairs it emits a higher level of pain. He also reported that he always feels the hip, even while sitting in the hearing. The Veteran also claimed that the more weight he puts on it, the more it hurts, even when he steps down and puts weight on it, it affects his balance as he quickly tries to shift off of his right side as quickly as possible. He also reported that the hip is acting up frequently and will put him down for a couple of days. He claimed that the physical therapy will carry him for a couple of months at a time before it flares up again. The evidence of record, to include the Veteran's testimony, indicates that his right hip disability may have worsened from his last VA examination. Accordingly, remand is necessary to obtain contemporaneous VA examination for this disability. Snuffer v. Gober, 10 Vet. App. 400 (1997). As such, the Board finds that a more contemporaneous examination is needed to fully and fairly evaluate the Veteran's service-connected right hip strain. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left shoulder strain, right shoulder strain, and right hip strain. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain in both shoulders and both hips with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement 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 medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Correia v. McDonald, 28 Vet. App. 158 (2016). 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. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement 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 medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Sharp v. Shulkin, 29 Vet. App. 26 (2017). Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.L. Aumiller, 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.