Citation Nr: 21015812 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-06 443 DATE: March 18, 2021 REMANDED Entitlement to rating in excess of 10 percent prior to April 1, 2015 for right shoulder osteoarthritis; supraspinatus syndrome and subacromial bursitis is remanded. Entitlement to rating in excess of 20 percent from April 1, 2015 for right shoulder osteoarthritis; supraspinatus syndrome and subacromial bursitis is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Army from September 1990 to February 2004. He is a Gulf War Era veteran. This matter is before the Board of Veterans’ Appeals (BVA) from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Board notes that a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes substantial compliance with the Board’s directives and the appeal is appropriate for adjudication. The Veteran requested a videoconference hearing in this matter which was scheduled by VA for March 19, 2019. On March 13, 2019 the Veteran called VA indicating that he would not attend the hearing and that he wanted the appeal to continue with the evidence of record. Accordingly, the request for a hearing has been withdrawn. Entitlement to rating in excess of 10 percent prior to April 1, 2015 for right shoulder osteoarthritis; supraspinatus syndrome and subacromial bursitis Entitlement to rating in excess of 20 percent from April 1, 2015 for right shoulder osteoarthritis; supraspinatus syndrome and subacromial bursitis The Veteran contends that the symptoms of his right shoulder osteoarthritis are more severe than contemplated by the 10 percent disability rating prior to April 1, 2015 and the 20 percent disability rating from April 1, 2015. The Veteran was afforded shoulder and arm examinations in March 2011, October 2012, April 2015, December 2016 and January 2020. The examinations each reflected measurements of the range of motion of both shoulders including where pain started, with repetitive motion and flare-ups except for the December 2016 examination. Other musculoskeletal testing was performed and documented. In July 2012 the Veteran was seen in the emergency department after he was reaching for an item in the cabinet with his right arm and heard a snapping and a popping sound in his right shoulder with a sharp pain radiating from his shoulder to his elbow. The pain had improved with rest and Ibuprofen by the October 2012 VA examination however, the Veteran still heard noises and felt resistance in the shoulder when moving it up and down. Despite this history in the October 2012 examination, the examiner indicated that there was no history of mechanical symptoms (i.e., clicking and catching). The examiner documented a positive Hawkins impingement test for the right shoulder and a positive cross body adduction test for both shoulders. Moderate degenerative changes of the acromioclavicular joint were noted. In a January 2013 visit to the orthopedic clinic MRI results demonstrated a large retracted rotator cuff tear that was managed conservatively. In his April 1, 2015 shoulder examination, the examiner documented range of motion limitations, mild subacromial tenderness to palpation for both shoulders, a positive Hawkins impingement test, positive cross body adduction test for both shoulders and endorsed a suspected right acromioclavicular joint condition or other impairment of the clavicle or scapula but did not provide a diagnosis. The Veteran provided a lay statement regarding the intolerable pain that occurred during the examination. In the January 2020 shoulder examination Hawkins impingement, empty can, and external rotation infraspinatus strength tests were positive for the right shoulder. Shoulder instability, dislocation or labral pathology was suspected. The examiner endorsed a history of mechanical symptoms of clicking and catching for both shoulders and the crank apprehension and relocation test was positive for only the right shoulder. Cross body adduction was positive for both shoulders and a clavicle or scapula condition was noted to affect the range of motion of the shoulder joints. Based upon findings in the 2012, 2015 and the 2020 shoulder examinations, an opinion is needed to clarify whether there is an additional diagnosis for the clavicle or scapula that should be rated for the right shoulder. The matter is REMANDED for the following action: 1. Appropriate efforts should be made to obtain and associate with this case file any outstanding VA medical records after June 2020. 2. Arrange for an addendum opinion to the January 2020 shoulder examination by an orthopedic surgeon or other appropriate physician to determine whether the Veteran has dislocation, malunion or nonunion of the right clavicle or scapula. It is left to the discretion of the examiner whether an in-person examination is necessary. All appropriate tests and studies should be conducted. 3. Thereafter, readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded a period of time in which to respond before returning the appeal to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Adams Hill, 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.