Citation Nr: 21009200 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 17-59 833 DATE: February 19, 2021 REMANDED Entitlement to a disability evaluation in excess of 20 percent for tendinopathy with rotator cuff tear of the left shoulder (also claimed as joint pain) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 2004 until November 2014. In February 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. This decision is being prepared under the Board’s “one touch” program; a transcript of that hearing will be added to the Veteran’s file in the normal course of business. Entitlement to a disability evaluation in excess of 20 percent for tendinopathy with rotator cuff tear of the left shoulder (also claimed as joint pain) is remanded. The Veteran asserts that the assigned 20 percent rating does not accurately reflect the severity of disability caused by his left shoulder condition. The claim must be remanded for a new examination. The Veteran was last provided with a VA examination for his left shoulder disability in September 2017. The record contains notations that the Veteran was scheduled for a VA examination in January 2018 and March 2018 but both were canceled when the Veteran failed to report. There is no indication in the record the Veteran was notified of the pending examination appointments. The matter must be remanded in order to obtain a new VA medical examination to evaluate the current severity of disability and identify all manifestations of the shoulder disability, including the Veteran’s reports of increased pain, loss of feeling in his left hand, and loss of sleep caused by the pain. The matters are REMANDED for the following action: 1. Ask the Veteran to identify any providers who treated him for left shoulder complaints since October 2017. Take all appropriate action to obtain records from identified providers. 2. After completion of the above, schedule the Veteran for an examination by an appropriate clinician to determine all manifestations and current severity of his service-connected left shoulder condition. The examiner should provide a full description of the disability, including all diagnoses, and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. 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). The examiner is notified that the Veteran is competent to report symptoms he has experienced. The examiner should consider, and discuss as appropriate, the Veteran’s report of increased pain, loss of feeling and/or tingling in his left hand, and loss of sleep due to pain and other manifestations of his left shoulder condition. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. Collins, 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.