Citation Nr: 21021828 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 14-32 324A DATE: April 14, 2021 ORDER Entitlement to service connection for a right shoulder disability, to include as secondary to left shoulder acromioclavicular (AC) joint separation, is denied. Entitlement to service-connection for chronic fatigue syndrome, to include as secondary to service-connected posttraumatic stress disorder (PTSD) or as due to undiagnosed illness or medically unexplained chronic multisymptom illness, is denied. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, is denied. REMANDED Entitlement to a rating in excess of 20 percent for left AC joint separation is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. A right shoulder disability did not manifest in service or for many years thereafter and is not otherwise related to service. 2. A right shoulder disability is not caused or aggravated by service-connected left AC joint separation. 3. The Veteran does not have chronic fatigue syndrome; fatigue is not a symptom of an undiagnosed or medically unexplained chronic multisymptom illness, including chronic fatigue syndrome. 4. Sleep apnea did not manifest in service and is not otherwise related to service. 5. Sleep apnea is not caused or aggravated by service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right shoulder disability, to include as secondary to left shoulder AC separation, have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). 2. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317 (2020). 3. The criteria for entitlement to service connection for sleep apnea to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1982 to March 1992. This appeal initially came before the Board of Veterans’ Appeals (Board) on appeal from February 2012, January 2013, and December 2015 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2017, the Veteran testified at a Board hearing before a Veterans Law Judge (VLJ). The VLJ who conducted the hearing is no longer employed at the Board. In January 2021, the Veteran was afforded the opportunity for another hearing with a VLJ who would participate in the decision on appeal. the Veteran responded in February 2021 that he did not want another hearing. The Board will accordingly proceed with appellate disposition on this matter. In September 2019, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. With respect to those issues herein decided, the AOJ afforded an opportunity to submit authorization to obtain additional treatment records as well as VA examinations and opinions, in compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In a September 2020 rating decision, the AOJ awarded service connection for erectile dysfunction, representing a full grant of this issue previously on appeal. Accordingly, it is no longer before the Board. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). However, 38 C.F.R. § 3.303 (b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. With respect to the current appeal, this list includes arthritis. See 38 C.F.R. § 3.309(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). However, in order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable (10 percent) degree within one year of separation from service. See 38 C.F.R. § 3.307. Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b). Service connection can be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A "qualifying chronic disability" includes an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 38 C.F.R. § 3.317(a)(2). An "undiagnosed illness" is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). In the case of claims based on undiagnosed illness, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. Manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to fatigue; signs or symptoms involving skin; headache; muscle pain; joint pain; neurological signs or symptoms; neuropsychological signs or symptoms; signs or symptoms involving the respiratory system (upper or lower); sleep disturbances; gastrointestinal signs or symptoms; cardiovascular signs or symptoms; abnormal weight loss; and menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(3), (4). As a threshold issue, it is undisputed that the Veteran served in Southwest Asia. Accordingly, he is a "Persian Gulf" veteran within the meaning of § 3.317. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a right shoulder disability, to include as secondary to left shoulder AC joint separation The Veteran contends that his right shoulder disability is related to in-service injury, or, in the alternative, is caused or aggravated by overuse of his right shoulder stemming from his service-connected left shoulder disability. The Veteran’s service treatment records reflect that he complained of pain in the right shoulder blade area in January 1983. He was assessed with a muscle strain of the right shoulder area near the shoulder blade. In November 1984, he fell on his left shoulder while playing football, but there was no complaint related to the right shoulder noted at that time. Complete left AC joint separation was diagnosed. No right shoulder abnormalities were indicated on 1988 periodic examination. On separation examination in March 1992, no abnormalities with respect to the right shoulder were noted. The Veteran denied painful or trick shoulder or elbow on March 1992 report of medical history. Following discharge from service, the Veteran presented for VA treatment with complaint of pain in the back, shoulders, and generalized arthralgias in 2001. Examination of the shoulders was negative. It was indicated that he “may have some impingement.” A September 2005 private report from Dr. S. indicates that he Veteran reported left shoulder injury in service and underwent injection for the left shoulder. No history of injury to the right shoulder was indicated. In a May 2009 VA opinion, a VA examiner indicated that a review of the orthopedic literature revealed no peer reviewed studies that support the contention that posttraumatic degenerative changes of one joint may induce degenerative changes in another joint either of the ipsilateral or contralateral extremity. Therefore, he found that any right shoulder condition would not be caused by or a result of his service-connected left shoulder condition. On VA examination pertaining to the lefts shoulder in November 2011, the Veteran reported that his right shoulder had begun to give him problems, with symptoms of stiffness and pain, possibly due to over-compensation for his left shoulder. X-ray showed degenerative changes of both AC joints. A March 2012 VA physical medicine rehab consult reflects the Veteran’s report of right shoulder pain starting gradually about 5 years prior, without any injury. A May 2012 VA examination report noted that while 2001 examination was normal, x-rays done in 2011 showed bilateral degenerative joint disease of the AC joint, left greater than right. Since that time, he had received bilateral shoulder injections for presumed rotator cuff tendinitis. The examiner found that none of this was related to the AC joint separation in service; rather, his bilateral limitation of motion was due to impingement from AC joint spurring and rotator cuff inflammation—the rotator cuff problem could only be seen on MRI studies. Therefore, in his opinion, he did not believe that the right shoulder problem was due to overcompensation for his left shoulder problems. Rather, he had bilateral impingement with degenerative joint disease due to wear and tear on his shoulders from his current postal service job. Private treatment records in 2014 indicate complaint of pain in the neck and right upper extremity stemming from a workplace accident. A January 2015 report evaluation notes that the Veteran presented for therapy and treatment of lumbar spine sprain, right knee pain, and right shoulder pain. The mechanism of injury was secondary to a work-related injury in November 2014. January 2015 MRI of the shoulder revealed mild distal supraspinatus tendinosis with minor partial bursa surface tearing or fraying at the distal attachment. There was also minimal subacromial subdeltoid bursitis and mild acromioclavicular joint arthropathy. In January 2016, right shoulder rotator cuff bursitis and superior glenoid labrum lesion was assessed. During the Veteran’s October 2017 Board hearing, the Veteran testified that, while he was treated for a left shoulder injury in service, as he fell on that shoulder, he was actually struck on the right shoulder. He endorsed right shoulder pain since service, but noted that his left shoulder injury was more severe and he was more concerned about getting the left shoulder treated in service. On VA examination in March 2020, the examiner diagnosed right shoulder impingement syndrome, labral tear, AC joint separation, and degenerative arthritis. After review of the record, interview of the Veteran and physical examination, the examiner opined that the claimed right shoulder disorder was less likely than not incurred in or caused by the claimed in-service injury, event or illness. In so finding, the examiner indicated that a review of the records did not support a nexus to service, but rather than he sustained a right shoulder injury on the job while in 2014. A right shoulder evaluation or diagnosis was not indicated in service. In addition, the examiner opined that a right shoulder disorder was not aggravated by the left shoulder, to include overuse of the shoulder during employment duties requiring heavy lifting. He noted that there was no orthopedic peer review literature that supported the contention that degenerative arthritis in one joint causes degenerative arthritis in an adjacent or nonadjacent joint. His right shoulder condition was more likely due to the result of degenerative changes due to aging and/or civilian employment since separation from service. With respect to direct service connection, there is no credible evidence that the Veteran’s right shoulder disability had its onset in or is otherwise related to service. While there is one report of pain/muscle strain in the shoulder blade area in service, no right shoulder disability was noted thereafter. Post-service treatment records do not document a diagnosis related to the right shoulder until 2011. The Board notes that the passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and any medical complaints or documentation of a claimed disability is a factor that weighs against a claim for service connection). See 38 C.F.R. § 3.303(b). Moreover, the only pertinent medical opinion of record is that of the 2020 VA examiner, who had a thorough review of all pertinent evidence and found it less likely than not that the Veteran’s right shoulder disability had its onset in service or is otherwise related to service, to include the Veteran’s report of injury therein. Thus, the only credible, probative opinions of record weigh against the claim, and the Veteran has not presented or identified any medical opinion or other competent evidence that, in fact, supports his claim for service connection on a direct basis. The record establishes that arthritis was not "noted" during service or within one year of separation. Furthermore, the objective evidence establishes that he did not have characteristic manifestations of the disease during service. 38 C.F.R. § 3.303(b). While there is one complaint of right shoulder blade pain in service, no further findings with respect to the shoulder were noted in service, and the right shoulder was normal at discharge from service. The Board has considered the Veteran’s contentions that he injured his right shoulder in service and had continued pain since service. The Veteran is competent to testify as to his observations, but this testimony must be weighed against the other evidence of record. In this case, the Veteran’s current recollections are not consistent with service treatment records, which do not indicate right shoulder injury, and post-service records, including the 2012 report in which the Veteran reported more recent onset of pain and the 2014 report of workplace injury, which did not reflect earlier onset. The VA examiner also reviewed these records and concluded that the disability did not likely onset in service. Accordingly, this statement is of no probative value. The Board places greater probative weight to the VA opinion as this examiner has greater training and expertise than the Veteran to determine whether the Veteran’s right shoulder disability first manifest in service. With respect to service connection on a secondary basis, none of the available treatment records suggests a relationship between the Veteran's right shoulder disability and his left shoulder disability, and the only pertinent medical opinions of record are that of the 2009, 2012, and 2020 VA examiners, who had a thorough review of all pertinent evidence and found it less likely than not that the Veteran's right shoulder disability was due to or aggravated by the service-connected left shoulder disability. Thus, the only probative opinions regarding secondary service connection weigh against the claim, and the Veteran has not presented or identified any medical opinion or other competent evidence that, in fact, supports his claim. To the extent that the Veteran advances his own interpretation of his medical condition indicating that his current right shoulder disability is due to his service-connected left shoulder disability, to include due to overcompensation and overuse of the right shoulder, the Board acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). In any event, the probative value of the Veteran's general assertions in this regard is outweighed by the probative value of the specific, reasoned opinion of the examiners who provided the VA opinions against the claim for service connection on a secondary basis. Based on the foregoing, the preponderance of the evidence is against the claim for service connection for a right shoulder disability. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). 2. Entitlement to service-connection for chronic fatigue syndrome, to include as secondary to service-connected PTSD or as due to undiagnosed illness The Veteran contends that he has chronic fatigue syndrome as a result of his Persian Gulf War service, or as secondary to his service-connected PTSD. The Veteran’s service treatment records do note assessment of chronic fatigue syndrome. A December 2014 VA Gulf War General Medical examination reflects that the Veteran had numerous complaints including sleep problems and muscle and joint pains, hips pains, ankle pains. He noted that “these conditions are undiagnosed illness and the reasons for these complaints were unsure.” The examiner further noted that the Veteran was already service-connected for shoulder, back, PTSD, irritable bowel, hemorrhoids, sciatic nerve problems, and they were not related to the Gulf War or undiagnosed illness. The Veteran’s report of chronic fatigue syndrome was not indicated at that time. On VA examination in October 2015, the Veteran denied being diagnosed with chronic fatigue syndrome, but felt that he had it because of poor sleep, exhaustion, joint pains, forgetfulness, and headaches. He indicated that these symptoms were near constant since he returned home from Saudi Arabia in 1991. After interview and examination, the examiner indicate that a diagnosis of chronic fatigue syndrome was not appropriate as he did not meet the clinical criteria. He did have diagnoses for his symptoms, including ankylosing spondylitis and a psychiatric disorder. VA treatment records and examinations also indicate report of fatigue, largely associated with other disabilities. For example, a 2011 VA gastroesophageal examination indicates that the Veteran’s heartburn with regurgitation affected his ability to sleep, and therefore he was fatigued during the day. On sleep apnea examination in December 2015, the examiner indicated that an impact of sleep apnea was daytime fatigue. Fatigue and loss of energy was indicated on April 2014 psychiatric consult. Joint pain was report as associated with the Veteran’s ankylosing spondylitis. There is also indication the record of lumbar and cervical spine dysfunction, knee osteoarthritis, and right shoulder diagnosis as indicated above. The Veteran is also service-connected for low back strain and related radiculopathy and a left shoulder disability. Based the competent and credible evidence of record, the Board finds that the claimed chronic fatigue has been competently and credibly associated with a known etiology and diagnoses, namely the Veteran's psychiatric disorder and various joint disorders, and therefore service connection based on the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service is not warranted. 38 C.F.R. § 3.317. Otherwise, the VA examiner indicated that that a diagnosis of chronic fatigue syndrome was not indicated, and there is no indication otherwise in the record of a diagnosis of chronic fatigue syndrome. The Veteran also reported during the Board hearing that he had not been diagnosed with this disability. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, where, as here, competent medical evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As there is no disability, the Board does not reach the issue of whether the claimed disability is related to service or to service-connected PTSD. The Board has considered the Veteran's lay statements regarding his symptomatology. As a lay person, the Veteran is competent to report on that which he has personal knowledge, including symptoms such as fatigue, and the Board deems him credible in that regard. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Indeed, in this case, the medical evidence reveals that the Veteran's fatigue has been related to other disabilities. The Board has considered the Veterans’ representative’s contention in the October 2020 informal hearing presentation that examination is warranted; however, examination that include consideration of the Veteran’s history and complaints has already been conducted, as noted above. In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Fagan, 573 F.3d at 1282. 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD The Veteran also contends that his sleep apnea first manifest in service or is secondary to his service-connected PTSD. The Veteran’s service treatment records include no complaint, finding or diagnosis with respect to the claimed sleep apnea. The Veteran denied frequent trouble sleeping on his March 1992 report of medical history at discharge. Following service, the Veteran reported “sleep disturbances” on January 2006 Gulf War examination. A March 2012 VA treatment report reflects the Veteran report of sleep difficulties. He admitted to snoring, not feeling rested, waking up gasping for air, which the treatment provided indicated suggested the presence of sleep apnea. The Veteran underwent sleep study in February 2014, with results showing mild sleep apnea. On VA examination in December 2015, the examiner diagnosed sleep apnea and noted a date of diagnosis of February 2014. With respect to whether the claimed sleep apnea is related to the service-connected PTSD, the examiner found such a relationship less likely than not. In so finding, the examiner indicated that PTSD is not a recognized risk factor for the development of sleep apnea. Although PTSD was known to cause another type of sleep disturbance, this was unrelated to obstructive sleep apnea. Therefore, he found it was less likely than not that the Veteran’s sleep apnea is secondary to, or caused by, his PTSD. During the Veteran’s October 2017 Board hearing, the Veteran reported that he was diagnosed with sleep apnea in 2012, but had sleep problems in service. After the hearing, the Veteran submitted statements in support of his claim from his ex-wife and his mother, both of whom indicated that they had observed symptoms of loud snoring and difficulty breathing upon his return from Desert Storm. On VA examination in March 2020, the examiner reviewed the record and examined the Veteran, indicating diagnosis of sleep apnea. The examiner opined that he claimed sleep apnea was less likely than not incurred in or caused by the in-service injury, event, or illness. In so finding, the examiner noted that the service treatment records were silent for complaints of snoring, insomnia, trouble sleeping, and/or sleep apnea in service. He noted that although the Veteran’s family members reported sleep disturbances since his return from the Persian Gulf, the Veteran was treated at VA in 2001 with no complaint of snoring, insomnia, trouble sleeping, stopping breathing while asleep and/or sleep apnea. There were no related complaints noted until 2006, approximately 14 years after service. He did not get a sleep study done until 2014, after recommendation in 2012. The examiner also opined that the Veteran’s sleep apnea was not aggravated by his service-connected PTSD. In so finding, the examiner cited to medical literature discussing the risk factors for sleep apnea, and indicating that it was often comorbid with PTSD. As noted above, the record reflects current diagnosis of sleep apnea. The Veteran has provided evidence of snoring, insomnia, and difficulty breathing in service; however, there is no medical evidence that the Veteran suffered from sleep apnea during service, and the Veteran denied trouble sleeping on his report of medical history. Indeed, the first evidence of an actual diagnosis of sleep apnea is in 2012, earlier complaint as early as 2006, several years after the Veteran's discharge from service in 1992. See Maxson, 230 F.3d at 1333. Moreover, the preponderance of the evidence is against a finding of nexus. In that regard, the only pertinent medical nexus opinion of record is that of the 2020 VA examiner, who had a thorough review of all pertinent evidence and found it not likely that the Veteran's sleep apnea is related to service. To the extent that the Veteran advances his own interpretation of his medical condition indicating that his current sleep apnea is related to service or to service-connected disability, the Board again acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316. In any event, the probative value of the Veteran's general assertions in this regard is outweighed by the probative value of the specific, reasoned opinion of the physician who performed the 2020 VA examination. With respect to service connection on a secondary basis, none of the available treatment records suggests a relationship between the Veteran’s sleep apnea disability and his PTSD, and the only pertinent medical opinions of record are that of the 2015 and 2020 VA examiners, who had a thorough review of all pertinent evidence and found it less likely than not that the Veteran’s sleep apnea was due to or aggravated by the service-connected PTSD. Thus, the only probative opinions regarding secondary service connection weigh against the claim, and the Veteran has not presented or identified any medical opinion or other competent evidence that, in fact, supports his claim. As to the Veteran’s general assertions relating his sleep apnea to his PTSD, the probative value of the Veteran’s general assertions in this regard is outweighed by the probative value of the specific, reasoned opinion of the examiners who provided the VA opinions against the claim for service connection on a secondary basis. Based on the foregoing, the preponderance of the evidence is against the claim for service connection for sleep apnea. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan, 573 F.3d at 1282. REASONS FOR REMAND Although the Board regrets the additional delay, upon review of the claims file, the Board believes that additional development on the remaining claims on appeal is warranted. 1. Entitlement to a rating in excess of 20 percent for left AC joint separation In September 2019, the Board remanded the issue of entitlement to an increased rating for left AC joint separation for additional examination. The examiner was requested to discussion functional lass due to pain or other symptoms during flare-ups or with repeated use, and to the extent possible, express any such additional functional loss in terms of additional degrees of limited motion. The Veteran was afforded a VA examination in March 2020, at that time, the examiner indicated that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time and during flare-up. However, the examiner indicated that she was unable to describe in terms of range of motion with the reasoning that “after examination of the Veteran, listening to [his] complete history and current subjective complaints, combined with review of the available records, I have no basis to offer additional loss of function or motion when it comes to repetitive use or during a flare-up.” In Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court found that direct observation of functional impairment during a flare-up is not a prerequisite to offering an opinion as to the degree of such impairment in applying the principles enumerated in DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, the examiner should provide an estimate, to include in terms of loss of range of motion if possible, based on all procurable and assembled medical evidence, to include eliciting relevant information from the veteran as to the flare-i.e. the frequency, duration, characteristics, severity, or functional loss. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation - whether based on lack of expertise, insufficient information, or unprocured testing of the individual examiner. In this case, the Board finds the examiner’s rationale to be insufficient—the examiner indicated what factors were considered, but did not explain why those factors rendered her unable to provide an estimate as to range of motion during flare-up or after repeated use. In addition, it does not appear that the examiner did not conduct range of motion findings in passive range of motion, as was also instructed in the remand. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In addition, as noted above, the Court has held that a remand Board confers on the veteran a right to compliance with the remand orders. Stegall, 11 Vet. App. at 271. The Board therefore believes that remand for additional examination is warranted. 2. Entitlement to a TDIU The law provides that a TDIU may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for individual unemployability is part of an increased rating claim when such claim is raised by the record. In this case, the Veteran filed a VA Form 21-8940 in August 2017 seeking entitlement to a TDIU and indicating that his service-connected left shoulder, in part, prevented him from working. Thus, a claim for TDIU is a component of the increased rating claim on appeal before the Board, which stems from a 2011 claim. Accordingly, the Board has jurisdiction over this issue in the current appeal, even though the Veteran did not appeal the April 2018 rating decision denying entitlement to a TDIU. Moreover, although the Veteran is in receipt of a 100 percent schedular disability evaluation for his service-connected disabilities, this does not necessarily moot the issue of entitlement to a TDIU. Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, Bradley recognized that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation under 38 U.S.C. § 1114(s). Bradley, 22 Vet. App. at 293-94. As any development on the claim for increased rating for the left shoulder disability may impact the Veteran’s claim for TDIU, remand of this matter is warranted as well. The matters are REMANDED for the following action: 1. Assist the Veteran was obtaining any outstanding treatment record pertaining to the left shoulder. 2. Schedule the Veteran for a VA examinations to ascertain the current severity and manifestations of the Veteran’s service-connected left shoulder disability. The claims file should be made available to the examiner(s) for review in connection with the examination. In particular, the examiner should be directed to perform range of motion testing to determine the extent of limitation of motion. Additionally, the examiner must include range of motion testing in the following areas: Active motion, passive motion, weight-bearing, and non-weight-bearing. The examiner should indicate whether range of motion is additionally limited due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the left shoulder is used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. The examiner should specifically indicate whether, and at what point during, the range of motion the Veteran experienced any limitation of motion that was specifically attributable to pain. If the examiner is unable to conduct the required testing or provide the requested estimates, or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE, THE EXAMINER MUST GLEAN INFORMATION REGARDING THE FLARES’ SEVERITY, FREQUENCY, DURATION, AND FUNCTIONAL LOSS MANIFESTATIONS FROM THE VETERAN, MEDICAL RECORDS, AND OTHER AVAILABLE SOURCES. EFFORTS TO OBTAIN SUCH INFORMATION MUST BE DOCUMENTED. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner must provide a complete rationale for all the findings and opinions. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. E. Wilkerson, 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.