Citation Nr: 21023071 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 14-36 821 DATE: April 20, 2021 REMANDED Entitlement to a rating in excess of 10 percent for a right shoulder strain is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2004 to April 2008. This matter comes before the Board on appeal from a July 2013 Regional Office (RO) rating decision. In January 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. 1. Entitlement to a rating in excess of 10 percent for a right shoulder strain is remanded. The Veteran last underwent a VA examination for his service-connected right shoulder disability in June 2014. He contends that his disability has worsened since that examination. The Board will therefore remand this claim so that he may undergo a new examination to determine the current severity of the Veteran’s right shoulder disability. On examination, joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). In addition, estimates of additional functional impairment during flare-ups, if any, are to be recorded, or an explanation with adequate rationale must be given as to why such estimates are not possible. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board also notes that the Veteran suggested at his January 2021 Board hearing that he may be experiencing neurologic symptoms due to his right shoulder disability. (See Board hearing transcript, page 5.) On remand, the Veteran should be scheduled for a neurologic examination to determine whether the Veteran currently has neurologic damage that is due to his right shoulder disability and, if so, the severity of this impairment. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran’s records were last obtained. 2. Afford the Veteran a VA examination to determine the current severity of his right shoulder disability. The Veteran should be interviewed, and all indicated tests and studies should be accomplished. All findings should be reported in detail. The Veteran’s claims folder must be reviewed by the examiner. (a) Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion (1) on BOTH active and passive motion, (2) in weight-bearing and non-weight-bearing, AND (3) with the range of the opposite undamaged joint. If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. The examiner must note whether the Veteran demonstrates objective evidence of pain on motion and, if so, at what degree of motion he demonstrates such objective evidence (e.g., 0 to 90 degrees with pain at 80 degrees). (b) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups assessed in terms of the degree of additional range of motion loss. In regard to flare-ups, if the Veteran is not currently experiencing a flare-up and if he reports that he does experience flare-ups, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran’s functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. [The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran.] (c) The examiner should also determine whether a diagnosis of a neurologic impairment of the right upper extremity is warranted and should opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any such diagnosis is caused OR aggravated by the service-connected right shoulder disability. Please provide a complete medical rationale that includes a discussion of the facts of the Veteran’s case and pertinent medical principles. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.