Citation Nr: 21010330 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 14-31 157A DATE: February 24, 2021 ORDER Entitlement to a rating in excess of 30 percent for right wrist strain, status post carpal tunnel release is denied. REMANDED Entitlement to a rating in excess of 20 percent for left shoulder degenerative joint disease, prior to November 2, 2015 is remanded. FINDING OF FACT The Veteran’s right wrist strain, status post carpal tunnel release was manifested by no more than moderate incomplete paralysis of all radicular groups. CONCLUSION OF LAW The criteria for a rating higher than 30 percent for right wrist strain, status post carpal tunnel release are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8515. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1977 to August 1999. In October 2018, the Veteran testified in front of the undersigned Veterans Law Judge (VLJ) during a Board of Veterans’ Appeals (Board) hearing. A transcript of the hearing is associated with the claims file. The Board denied the Veteran’s claims in a July 2019 decision, which the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a June 2020 Order granting a Joint Motion for Partial Remand (JMPR), the Court vacated parts of the Board’s decision and remanded the claims to the Board for action consistent with the terms of the JMPR. See July 2020 JMPR. In the JMPR, the parties agreed that the Board failed to provide an adequate statement of reasons and bases in denying a rating in excess of 30 percent for the Veteran’s right wrist status post carpal tunnel release disability. With regard to the Veteran’s left shoulder rating claim, the parties agreed that the Board relied upon the August 2014 VA examination report which provided an inadequate discussion of additional limitations during flare ups or repeated use pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017) and failed to provide range of motion results that comply with Correia v. McDonald, 28 Vet. App. 158 (2016). This decision has been written in order to comply with the JMPR. 1. Right wrist strain, status post carpal tunnel release The primary issue that returns to the Board is the proper evaluation of the Veteran’s right wrist strain, status post carpal tunnel release under DC 8515, specifically whether his symptoms are moderate, severe, or worse. Notably, the parties in the JMPR agreed that the Board did not identify the standard it used for defining the terms moderate and severe incomplete paralysis in denying a rating in excess of 30 percent for his right wrist strain, status post carpal tunnel release (hereafter referred as right carpal tunnel (CTS) disability). See July 2020 JMPR. The parties also agreed that the Board did not address whether the February 2013 finding of give-way weakness in bilateral upper extremities constituted severe incomplete paralysis. Id. The Veteran is currently receiving a 30 percent rating for his right wrist CTS pursuant to the General Rating Formula for the Nervous System. 38 C.F.R. § 4.124a, DC 8515. Under DC 8515, a 30 percent rating is warranted for incomplete paralysis of the major median nerve that is moderate. Id. A 40 percent rating is warranted for incomplete paralysis of the minor median nerve that is severe. Id. A 50 percent rating is warranted for incomplete paralysis of the major median nerve that is severe. Id. A 60 percent rating is warranted for complete paralysis of the minor median nerve that results in the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. See 38 C.F.R. § 4.124a, DC 8515. A 70 percent rating is warranted for complete paralysis of the major median nerve that results in the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. Id. The term “incomplete paralysis” used in reference to evaluation of peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied levels of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words “slight,” “moderate” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Factual Background The Veteran’s claim for an increased rating stems from a May 2013 rating decision which reduced the Veteran’s disability rating for a right CTS to 10 percent from 30 percent. See May 2013 Rating Decision. In the July 2019 Board decision, the Board restored the 30 percent rating effective August 2013. The Board noted the rating period on appeal began in May 2012. See July 2019 Board Decision. In September 2012, the Veteran underwent a VA peripheral nerve examination. See September 2012 VA Peripheral Nerves Conditions DBQ. The Veteran denied any symptoms of right upper extremity constant pain, intermittent pain, numbness, or paresthesias and/or dysesthesias. Id. The Veteran has normal muscle strength, reflex, and sensory examination findings for all of his extremities. Id. However, he had positive Tinel’s sign of his right hand indicating median nerve compression consistent with CTS. He also had a positive Phalen’s sign test. The examiner notes the Veteran experienced functional impairment from his right CTS resulting in difficulty holding objections with right hand. Id. Two months later, in December 2012, the Veteran reported symptoms of tingling and numbness in both of his arms. See December 2012 VA primary care record in CAPRI received August 2013. He was referred to a VA neurologist for consideration of neurosurgical evaluation. Id. The Veteran was seen by a VA Neurologist for complaint of tingling and pain in his upper extremities in February 2013. See VA Neurology Consult in CAPRI received February 2013. The Veteran presented to Neurology clinic for complaint of bilateral upper extremity pain and tingling dating back to his 2004 cervical spine fusion. The neurologist noted that a magnetic resonance imaging (MRI) of the Veteran’s cervical spine from November 2011 which showed multilevel degenerative joint disease (DJD) worse at C3 nerve root and C6 nerve root. Id. The physical examination revealed that the Veteran had nonreproducible pinprick examination of his bilateral upper extremities as well as decreased temperature throughout both hands and give-way weakness. Id. The Veteran’s median nerve was intact on sensory examination. The VA neurologist further noted that the Veteran’s finger spreading was give-way but found that the Veteran was able to grip paper with fingers at full strength. The neurologist noted that the Veteran had positive Tinel’s and Phalen’s signs assessed the Veteran with carpal tunnel syndrome. The Veteran’s was also diagnosed with cervical neural foraminal stenosis. In his assessment, the VA neurologist noted that “given time course of complaints (since 2004), would expect some visual atrophy and consistent dermatomal sensory loss which is not clear on examination…. In short, no clear dermatomal deficits, no clear correspondence to motor deficit or reflex deficit, and fluctuating sensory examination + give way upper extremity weakness.” Id. The neurologist noted that the give-way weakness of bilateral upper extremities included “possible very mild triceps weakness bilaterally.” Id. Regarding the Veteran’s CTS, the examiner noted that the examination did not “fit distribution of median nerve and also involves palmar aspect and ulnar aspect of bilateral hands.” Id. He further noted that an Electromyography (EMG) was required to assess the radicular deficits. A February 2013 nerve conduction study indicated normal findings and noted that there was no evidence of nerve entrapment or peripheral neuropathy. See February 2013 VA Neurology Inpatient Note, in CAPRI received March 2014. Similarly, an April 2013 VA Electromyography (EMG) was normal and found no electrophysiological evidence of nerve entrapment or peripheral neuropathy. See April 2013 VA EMG Report in CAPRI received August 2013. Significantly, the VA physician noted that the Veteran’s “symptoms are most likely related to his cervical radiculopathy.” Id. The Veteran underwent a preoperative examination for his cervical spine surgery in September 2013. The Veteran endorsed occasional weakness in his upper extremities when pain was severe. See September 2013 Private Treatment Record. He also reported a history of dropping items but reported no trouble with fine motor skills. Id. On muscle strength testing, the Veteran displayed full muscle strength (5/5) on his right wrist extension. Following a cervical spine laminectomy, in September 2013 the Veteran reported increased neck pain and left arm pain. See September 2013 VA Occupational Therapy Consult in CAPRI received March. 2014. He also endorsed symptoms of finger numbness which caused him to drop objects. On physical examination, the Veteran displayed grip strength within functional limits, normal sensory findings, as well as normal fine motor coordination. The Veteran’s medical records are generally silent for complaints of peripheral nerve pain from March 2014 until the October 2017. However, he was seen by a neurologist for his cervical spine condition. In August 2014, the Veteran was seen in the VA neurosurgery clinic for follow up for his status post cervical spine surgery. See August 2016 VA Neurosurgery Clinic Note. He endorsed neck and upper back pain resulting in headaches and the inability to lay on his sides. He also reported his whole arm goes numb when he lays on his side. Id. There were no complaints related to his right CTS. The physical examination showed normal muscle bulk and tone. He displayed full 5/5 muscle strength for wrist extension (C6) bilaterally. Id. On follow up in January 2015 for his neck pain, the Veteran reported that his hand function improved after his last surgery and that he no longer had problems with his hands. See January 2015 Neurology Outpatient Note in CAPRI received January 2015. The Veteran underwent a VA peripheral nerve examination in October 2017. See October 2017 VA Peripheral Nerves Conditions DBQ. The Veteran reported that his condition had gotten worse and endorsed loss of strength, tenderness, and tingling. Id. He also endorsed trouble opening and closing his hands. The Veteran reported moderate intermittent pain, moderate constant pain, moderate paresthesias and/or dysesthesias, and mild numbness. The Veteran’s right CTS affected his dominant hand. There was no atrophy or trophic changes. The muscle strength testing was slightly diminished with four out of five (4/5). However, the sensory and reflex examinations were normal. Id. Testing of the median nerve revealed negative Phalen’s sign and positive Tinel’s sign. The examiner found that the Veteran’s right wrist strain status post carpal tunnel release was manifested by mild numbness. The examiner also found that the functional impact of the Veteran’s right CTS was pain and numbness. The Veteran testified before the undersigned at the October 2018 Board hearing that he experienced pain and tingling in his hands and was unable to pick up items with his hands. See October 2018 Hearing Transcript. He also stated that he was unable to grasp items such as holding a pot. The Veteran also stated he wore a brace which caused his fingers to curve. However, he did not report any worsening right hand or CTS conditions since the October 2017 VA examination. Analysis Upon review, the Board finds that a 30 percent rating for moderate incomplete paralysis best approximates the Veteran’s right CTS based on the evidence of record. The evidence of record demonstrates that the Veteran reported pain and numbness at moderate levels, which supports a continued 30 percent disability rating. Specifically, during the October 2017 VA examination, the Veteran endorsed moderate intermittent pain, moderate constant pain, moderate paresthesias and/or dysesthesias, and mild numbness. See October 2017 VA Peripheral Nerves Conditions DBQ. The Board acknowledges the Veteran’s reports of his right CTS symptoms, which include pain, numbness and tingling, and decreased grip strength. As to his lay statement of decreased grip strength, the evidence of record does not reflect severe symptoms, where normal grip strength is shown on objective testing and there is a lack of evidence demonstrating muscle atrophy or abnormal muscle tone. See September 2013 VA Occupational Therapy Consult in CAPRI received March. 2014 (finding grip strength within functional limits). The Board considered the findings of the February 2013 VA neurology consult as directed by the JMPR. Specifically, the VA neurologist noted that the Veteran had nonreproducible pinprick examination of his bilateral upper extremities as well as decreased temperature throughout both hands and give-way weakness. See VA Neurology Consult in CAPRI received February 2013. Nonetheless, the neurologist also found that the Veteran was able to grip paper with his fingers at full strength despite give-way weakness and noted that there was “no clear dermatomal deficits, no clear correspondence to motor deficit or reflex deficit, and fluctuating sensory examination + give way upper extremity weakness.” Id. The Board notes that “moderate” is defined as tending toward the mean or average amount of dimension, or not violent, severe or intense. MERRIAM-WEBSTER, “Moderate,” https://www.merriam-webster.com/dictionary/moderate (last visited February 2, 2021). “Severe” is defined as very painful or harmful, or of a great degree. MERRIAM-WEBSTER, “Severe,” https://www.merriam-webster.com/dictionary/severe (last visited February 2, 2021). Here, the Veteran’s symptoms of pain, tingling, and give-way weakness noted in the February 2013 neurologist consult were not described as severe because there is no evidence that his symptoms were very painful, harmful, or of great degree. In fact, the VA neurologist noted bilateral upper extremity give-way weakness with very mild bilateral triceps weakness. See VA Neurology Consult in CAPRI received February 2013. The neurologist also noted normal muscle bulk and tone, and no trophic changes, as such the Veteran’s symptoms are at most consistent with moderate severity because the Veteran’s motor impairment such as give-way weakness and sensory impairment including decreased pinprick sensation did not reach the frequency, severity, and duration required for severe incomplete paralysis. Specifically, the record demonstrates that the Veteran reported such symptoms only twice during the February 2013 and May 2013 VA neurology consults. Indeed, the VA neurologist noted that the give-way weakness was very mild. Moreover, the neurologist indicated there was no associated muscle atrophy or trophic change. Notably, in September 2013, the Veteran endorsed occasional weakness in his upper extremities when pain is severe. See September 2013 Private Treatment Record. And in January 2015, the Veteran reported he no longer had problems with his hands since cervical spine surgery. See January 2015 Neurology Outpatient Note in CAPRI received January 2015. This evidence suggests that while the Veteran’s symptoms do cause a wide array of symptoms, including weakness, the symptoms are not severe or long in duration. As such, the frequency, severity, and duration of the Veteran’s right CTS is consistent with moderate severity. Additionally, VA treatment records suggest that the Veteran’s right-hand symptoms of weakness and decreased pinprick sensation are due to nonservice-connected cervical spine DJD and degenerative disc disease. The February 2013 VA neurology consult noted that the Veteran had cervical spine DJD worse at C6 nerve root and noted intact median nerve on sensory examination. Additionally, the VA physician interpreting the Veteran’s EMG noted that the Veteran’s “symptoms are most likely related to his cervical radiculopathy.” See April 2013 VA EMG Report in CAPRI received August 2013. Notably, the Veteran reported he no longer had problems with his hands following his cervical spine surgery. See January 2015 Neurology Outpatient Note in CAPRI received January 2015. The Board also notes that the cervical radiculopathy and CTS can present with similar symptoms. For example, upper extremity motor weakness was noted to be more consistent with cervical radiculopathy, whereas weakness in the thumb abductor is associated with CTS. Id. Thus, based on the above, the evidence suggests that the Veteran’s bilateral upper extremity is consistent with cervical spine disabilities as opposed to his right CTS because there was no thumb weakness noted. See April 2013 VA EMG Report in CAPRI received August 2013 (stating symptoms likely due to cervical radiculopathy). Thus, to the extent that the Veteran’s symptoms of decreased pinprick sensation and give-way weakness were caused by the Veteran’s nonservice-connected cervical spine disability, such symptoms cannot serve as a basis for a higher rating under DC 8515 which rates impairment of the median nerve. There is no medical evidence indicating that cervical spine disability is otherwise interrelated to service-connected right CTS. Mittleider v. West, 11 Vet. App. 181 (1998). Given this background, the Board considers the additional right upper extremity symptoms to be outside the purview of the service-connected right CTS disability currently on appeal. The Board observes that the October 2017 VA examination noted moderate intermittent pain, moderate paresthesias and/or dysesthesias, and mild numbness, but there were no findings indicative of severe incomplete paralysis, such as constant radiating pain, trophic changes, severe numbness, or marked muscular atrophy. Similarly, the VA examiner noted slightly reduced strength (4/5), but found that the right wrist was within normal limits. The Board considered the Veteran’s reports of symptoms, such as difficulty grasping and dropping items, positive Tinel’s sign in finding moderate disability. However, the Board finds the October 2017 examination results and April 2013 EMG report highly probative that the Veteran’s symptom presentation is not analogous to severe impairment. The objective testing shows normal functioning. The weight of the evidence does not support a finding of severe impairment of the right upper extremity. Severe peripheral neuropathy involves more than sensory findings which are evidenced by atrophy, weakness, and diminished reflexes. Here, the evidence does not demonstrate that the Veteran experienced atrophy, weakness, and diminished reflexes of the frequency, severity, and duration consistent with severe incomplete paralysis as noted above the Veteran reported these symptoms twice during the appeal period, and such symptoms were associated with non-service connected cervical spine disability. However, the Court in Miller v. Shulkin, stated that “although § 4.124a provides only a maximum disability rating for wholly sensory of incomplete paralysis of a peripheral nerve… it does not follow that any claimant who also exhibits non-sensory manifestations must necessarily be rated at a higher level.” See Miller v. Shulkin, 28 Vet. App. 376 (2017). Thus, even if the Board considered the Veteran’s non-sensory symptoms including give-way weakness, the Veteran’s overall CTS symptoms do not rise to the level of severe incomplete paralysis. While the Veteran has complained of decreased grip strength, objective testing has demonstrated normal grip strength and there is no evidence of muscle atrophy or abnormal muscle tone. The Board finds that this evidence suggests that the Veteran’s right CTS is most consistent nerve involvement that is wholly sensory, as muscle weakness has not been objectively shown, which calls for, at most, a moderate rating. 38 C.F.R. § 4.124a. Even considering the Veteran’s subjective complaints, the Board does not find that decreased strength rises to the level of a severe disability, because the objective testing revealed normal grip strength and at most slightly diminished strength. Notably, the only functional limitations caused by his right CTS as noted by the October 2017 VA examiner were pain and numbness. The Board has considered the Veteran’s lay statements. He is competent and is credible to report symptoms, such as pain and tingling, that are capable of lay observation. For example, during the October 2017 VA examination, he reported that his condition had gotten worse and endorsed loss of strength, tenderness, and tingling. See October 2017 VA Peripheral Nerves Conditions DBQ. He also endorsed trouble opening and closing his hands. Additionally, the Veteran testified before the undersigned at the October 2018 Board hearing that he experienced pain and tingling in his hands and was unable to pick up items with his hands. See October 2018 Hearing Transcript. However, to the extent the Veteran’s reports his symptoms are severe, the Board finds his statements are subjective and are inconsistent with his reports of mild numbness, moderate pain, paresthesias, and dysesthesias during the October 2017 VA examination. Conversely, the Board places greater weight on the competent, probative medical evidence of record, which is thorough, consistent with the medical evidence of record and provides enough detail to rate the Veteran under relevant rating criteria. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Board notes that the September 2012 examiner found that the Veteran’s functional impairment resulting from his right CTS was that he had difficulty holding objections with right hand. See September 2012 VA Peripheral Nerves Conditions DBQ. However, the Board notes that this finding was based solely on the Veteran’s subjective reports and are inconsistent with the examination findings including noting that the Veteran denied any symptoms of right upper extremity constant pain, intermittent pain, numbness, or paresthesias and/or dysesthesias. Id. The examiner also found that Veteran has normal muscle strength, reflex, and sensory examination findings for all of his extremities. Id. As such, little probative weight is given to the September 2012 VA examiner’s finding that the Veteran’s right CTS resulted in difficulty holding objects. The Board considered the applicability of other DCs but notes that the October 2017 VA examiner found that the Veteran’s right CTS involved the median nerve. There was no evidence any other nerves were involved. Therefore, consideration of a higher rating under DC 8512 (lower radicular group) or any other diagnostic code is not warranted. The Board also finds no evidence suggestive of complete paralysis. Indeed, the Veteran does not have a “griffin claw,” there is no evidence of atrophy or an inability to spread or fully extend the fingers or adduct the thumb, and weakened flexion of the wrist has not been shown. Additionally, the evidence of record does not show loss of muscle strength, absent reflexes, trophic changes or muscle atrophy in the Veteran’s wrist that is associated with more severe neurological impairment. VA treatment records include a limited neurological evaluation, but it would be expected that more severe neurological disturbances would be noted. Molitor v. Shulkin, 28 Vet. App. 397, 410 (2017) (“The absence of evidence only tends to prove the nonexistence of a fact if the fact would ordinarily have been recorded”). Moreover, the Veteran’s lay statements do not otherwise indicate the presence of muscle atrophy, sensory loss or trophic changes. The Veteran’s primary complaint is pain, tingling, and weakness from right CTS and it is reasonably encompassed by the ratings for moderate incomplete paralysis of the median. 38 C.F.R. §§ 4.20, 4.120, 4.124a, DC 8515. In sum, the preponderance of the evidence is against the claim for a rating in excess of 30 percent for moderate incomplete paralysis for service-connected right CTS. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for a rating in excess of 20 percent for right CTS must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND 1. Left shoulder disability rating prior to November 2, 2015 In its July 2019 decision, the Board denied the Veteran’s claim for a rating in excess of 20 percent based on the August 2014 VA examination report. As stated in the introduction, the parties to the June 2020 JMPR agreed that the August 2014 VA examination was inadequate because the report does not include range of motion testing with both passive and active motion, and with and without weight-bearing in compliance with Correia v. McDonald, 28 Vet. App. 158 (2016). See June 2020 JMPR. The parties further agreed that the August 2014 failed to comply with Sharp v. Shulkin, 29 Vet. App. 26 (2017) by failing to provide an opinion on additional functional loss during flare-ups or on repeated use over time. In Correia, the Court held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing, and, if possible, with range of motion measurements of the opposite undamaged joint. Correia, 28 Vet. App. at 168. Here, as noted in the JMPR, the August 2014 VA examiner did not include both active or passive range of motion testing and failed to provide range of motion on weight-bearing and non-weight bearing. See August 2014 VA Shoulder and Arm Conditions DBQ. Additionally, in Sharp, the Court held that, pursuant to VA regulations and the VA Clinician’s Guide, when conducting evaluations for musculoskeletal disabilities, VA examiners are obligated to inquire whether there are periods of flare-ups and, if the answer is yes, to state their severity, frequency, and duration, name the precipitating and alleviating factors, and estimate, per the veteran, to what extent, if any, flare-ups and repetitive use over time affect functional impact. Sharp, 29 Vet. App. at 26. Further, VA examiners are expected to offer opinions on functional loss that would occur during flare-ups and repetitive use over time based on estimates derived from relevant sources, including the Veteran’s lay statements. Id. at 34. In other words, stating that the examination was not conducted during a flare-up or following repetitive use over time as the sole rationale for not addressing the functional impacts of such is not sufficient. During the August 2014 VA examination, the Veteran endorsed flare-ups of his left shoulder disability which he rated as 10 out 10 pain, resulting in an inability to left objects more than five pounds, and inability to flex or abduct his left shoulder, or lift his left arm above his head. However, the examiner did not address the functional impacts of repetitive use over time and during flare-ups. See August 2014 VA Shoulder and Arm Conditions DBQ. Thus, the August 2014 VA examination did not fully satisfy the requirements of 38 C.F.R. § 4.59, Correia, or Sharp. Accordingly, the Board finds that a remand is necessary to obtain a retrospective opinion for the period from January 22, 2013 to November 1, 2015 regarding the severity of his service-connected left shoulder disability that is compliant with Correia and Sharp and consistent with the JMPR. The matters are REMANDED for the following action: 1. Return the record to the VA examiner who conducted the August 2014 VA examination, if available. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. If the August 2014 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. 2. The Board recognizes the potential practical difficulties in scheduling an examination in light of the COVID-19 epidemic and requests flexibility and understanding in affording the Veteran any warranted examination. 3. The examiner is requested to review the August 2014 VA examination report pertinent to the Veteran’s left shoulders and provide A RETROSPECTIVE OPINION as follows; (a.) Report all signs and symptoms necessary for evaluating the Veteran’s service-connected left shoulder disability for the period from January 22, 2013 to November 1, 2015. (b.) Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the VA examiner should provide a RETROSPECTIVE OPINION to include complete range of motion findings for the left shoulder. Range of motion measurement must be provided in active motion, passive motion, weight-bearing, and nonweight-bearing positions (as appropriate). Additionally, the examiner must document all functional loss of the left shoulder disability, including due to pain on use, weakness, repetitive motion, flare-ups, fatigue, and incoordination. Any functional loss must be documented in terms of additional lost degrees of range of motion. (c.) Pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017), the VA examiner shall inquire as to periods of flare-up, and note the frequency and duration of any such flare-ups from January 22, 2013 to November 2, 2015. Any additional impairment on use or in connection with flare-ups should be described in terms of the degree of additional range of motion loss. The examiner(s) should provide a RETROSPECTIVE OPINION specifically describing the severity, frequency, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the Veteran, to what extent, if any, such flare-ups affect functional impairment. (d.) If the examiner is unable to provide a RETROSPECIVE opinion in terms of range of motion, s/he should state why and provide a reasoned explanation for the determination. 4. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Lilly, Associate Attorney 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.