Citation Nr: 21031087 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 10-16 347 DATE: May 20, 2021 ORDER Entitlement to service connection for insomnia is granted. Entitlement to an initial rating of 10 percent, but no higher, after July 9, 2014 and an initial rating of 30 percent, but no higher, after November 18, 2020 for diplopia, status post strabismus surgery is granted. Entitlement to a compensable rating for bilateral hearing loss is denied. REMANDED The issue of whether a separate evaluation for headaches, to include as secondary to the service-connected diplopia, is warranted is remanded. The issue of entitlement to a rating in excess of 20 percent for degenerative joint disease with history of suprascapular muscle spasms of the right shoulder (right shoulder disability) is remanded. The issue of entitlement to a rating in excess of 20 percent for degenerative joint disease with history of suprascapular muscle spasms of the left shoulder (left shoulder disability) is remanded. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran's insomnia began during active service. 2. After July 9, 2014, the Veteran's diplopia affected the area within 31 degrees to 40 degrees in a lateral direction and his best corrected visual acuity was 20/25 in either eye. 3. After November 18, 2020, the Veteran's diplopia affected the area within central 20 degrees and his best corrected visual acuity was 20/40 in either eye. 4. The Veteran's right ear hearing loss is not manifested by hearing acuity worse than Level III, and his left ear hearing loss is not manifested by hearing acuity worse than Level I. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, the criteria for service connection for insomnia have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. With resolution of reasonable doubt in the Veteran's favor, the criteria for an initial evaluation of 10 percent, but no higher, after July 9, 2014 for bilateral diplopia have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.78-79, Diagnostic Code 6090-6066. 3. With resolution of reasonable doubt in the Veteran's favor, the criteria for an initial evaluation of 30 percent, but no higher, after November 18, 2020 for bilateral diplopia have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.78-79, Diagnostic Code 6090-6065. 4. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85 Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1981 to July 2001. The Board previously remanded the issue of increased rating for diplopia for further development in October 2013, July 2016, and November 2018. The case has now been returned to the Board for appellate review. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish entitlement to service-connected compensation benefits, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease initially diagnosed after service 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). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id; see also 38 C.F.R. § 3.310 (b). In its determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 ; 38 C.F.R. § 3.102 ; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Service connection for insomnia The Veteran maintains that he has insomnia as a result of having worked at night on shift work while in service. He reported that he would work at night from 7 pm to 7 am for four days and then take two days off per week, for close to 20 years, and he did not realize that he had sleep problems until he started working on normal hours during the day after he retired from the military. See, e.g., February 2020 Veteran's Statement, September 2018 VA Examination Report. The Veteran has a current diagnosis of insomnia according to the DSM-5 criteria, as found in a September 2018 VA examination. Although his night shift work was not noted in his military documents, the Veteran is able to report his experience of working night hours for a prolonged period of times as a meteorologist and his statement concerning this in-service experience has been consistent over time. Thus, the Board finds his report of having extensive experience of working night shifts while in service credible. Thus, the issue is whether his current insomnia is at least as likely as not related to his in-service night shift work, or otherwise proximately due to his service-connected disability. Here, the Board finds that the evidence is in equipoise as to whether the Veteran's insomnia is at least as likely as not related to his service or aggravated beyond its natural progression by service-connected musculoskeletal disabilities, in particular, lumbar spine disability. An earliest documentation of his sleep difficulty is found in a March 2002 treatment record, where he sought treatment for back pain and reported decrease in sleep. Then, later in the same year, a November 2002 medical treatment record indicates that the Veteran reported having insomnia for the past 8 years since he had been working night shifts. An October 2004 medical treatment record notes the Veteran's report that his sleep problem had started when he did shift work in the 1980's. He also reported that he would wake up at night partly due to pain from the back. A November 2004 treatment record indicates that he was prescribed with Cymbalta and Valium for muscle spasm and sleep. Treatment for insomnia since then, alone or in connection with pain from musculoskeletal disabilities later to include shoulder pain in addition to the back pain, has been documented well in the evidence of record. A June 2005 sleep study was negative for a diagnosis of sleep apnea. Most recently, the Veteran reported that pain from shoulder and neck has worsened the insomnia. See June 2016 Veteran's Statement. As such, the evidence is evenly balanced as to whether the Veteran's insomnia had its onset while in service and pain from his lumbar spine and/or shoulder disabilities has been interfering with his sleep as early as the beginning of 2002 within a year since he retired from his military service to the present. The Board finds that the medical treatment records for sleep problems, dating from March 2002, tend to support the Veteran's claim and are consistent with the Veteran's report of symptomatology, though they do not directly establish an etiology of insomnia. These records also document the pain from service-connected disabilities has aggravated the Veteran's sleep problems and the Veteran reported as such to his treating clinicians. On the other hand, a September 2018 examiner provided a negative opinion for direct service connection. The examiner provided a summary of treatment for the Veteran's insomnia as well as the Veteran's lay statements. The rationale provided is that it is not possible to determine without speculation whether the shift work during the service contributed to his sleep disturbances because he did not report any sleep difficulties while in service. Moreover, the examiner noted that there was insufficient evidence to determine whether the insomnia began in service. The examiner did not provide any opinion concerning theory of secondary service connection. The Board affords less probative weight on the September 2018 opinion, for it is based solely on the examiner's finding that a sleep complaint was reported in the service treatment records. The examiner did not note the Veteran's complaint of sleep problems within one year of retirement, and as such, it is not clear if the examiner reviewed the entire evidence of record as thoroughly as possible. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). This opinion is the only evidence against the Veteran's claim. Accordingly, with resolution of reasonable doubt in the Veteran's favor, the claim is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). 2. Initial rating for diplopia, status post strabismus surgery The Veteran reports that he had diplopia when he saw Dr. R. in August 2006 and at that time, episodes of diplopia occurred several times a week. Since then, the incidents increased in number, and now, diplopia occurs numerous times a day. He maintains that he is entitled to a higher rating for his diplopia. Evaluations of visual impairment of muscle function is based on the degree of diplopia. 38 C.F.R. § 4.78. The examiner must record test results for the four major quadrants (upward, downward, and right and left lateral) and the central field (20 degrees or less). 38 C.F.R. § 4.78 (a). Diplopia in the central field (20 degrees or less) of any of the four major quadrants equates to 5/200 visual acuity. From 21 to 30 degrees, diplopia in the down quadrant equates to 15/200 visual acuity, diplopia in either lateral quadrant equates to 20/100 visual acuity, and diplopia in the up quadrant equates to 20/70 visual acuity. From 31 to 40 degrees, diplopia in the down quadrant equates to 20/200 visual acuity, diplopia in either lateral quadrant equates to 20/70 visual acuity, and diplopia in the up quadrant equates to 20/40 visual acuity. An evaluation for diplopia will be assigned to only one eye. When a claimant has both diplopia and decreased visual acuity or visual field defect, the rater will assign a level of corrected visual acuity for the poorer eye (or the affected eye, if disability of only one eye is service-connected) that is: one step poorer than it would otherwise warrant if the evaluation for diplopia under Diagnostic Code 6090 is 20/70 or 20/100; two steps poorer if the evaluation under Diagnostic Code 6090 is 20/200 or 15/200; or three steps poorer if the evaluation under Diagnostic Code 6090 is 5/200. This adjusted level of corrected visual acuity cannot exceed a level of 5/200. The rater will apply the adjusted visual acuity for the poorer eye and the corrected visual acuity for the better eye to Diagnostic Codes 6065-66 in the table of Impairment of Central Visual Acuity to determine the rating. 38 C.F.R. § 4.78 (b)(1). When diplopia extends beyond more than one quadrant or range of degrees, evaluate diplopia based on the quadrant and degree range that provides the highest evaluation. 38 C.F.R. § 4.78 (b)(2). When diplopia exists in two separate areas of the same eye, increase the equivalent visual acuity under Diagnostic Code 6090 to the next poorer level of visual acuity, not to exceed 5/200. 38 C.F.R. § 4.78(b)(3). In essence, the rating criteria for diplopia establish an equivalent visual acuity to the degree of diplopia present, with that acuity then utilized in applying the table for rating central visual acuity impairment. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § § 4.76 (b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. The rater will first locate the step that matches the visual acuity of the poorer eye. Within that step, the rater will then locate the subsection that matches the visual acuity of the better eye, which will produce the corresponding rating. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § § 4.76 (c). Subject to the provisions of § 3.383(a), if visual impairment of only one eye is service connected, the visual acuity of the other eye will be considered to be 20/40 for purposes of evaluating the service-connected visual impairment. 38 C.F.R. § 4.75 (c). The lowest visual acuity equivalent provided for under Diagnostic Code 6090 is 5/200 for diplopia in the central 20 degrees of vision. Thus, for rating purposes vision in the poorer eye is considered to be 5/200 and vision in the other eye is 20/40. See 38 C.F.R. § 4.78 (b)(1), Diagnostic Code 6090 (stating that diplopia ratings must be applied to the poorer eye while the better eye is rated according to the best corrected visual acuity or visual field). The table for rating central visual acuity impairment provides for a 30 percent rating when vision in the one eye is 5/200 and vision in the other eye is 20/40. The evaluation for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye. 38 C.F.R. § 4.75 (d). The evaluation for visual impairment of one eye should be combined with other disabilities of the same eye that are not based on visual impairment (e.g., disfigurement under Diagnostic Code 7800). 38 C.F.R. § 4.75 (d). The Board notes that the rating criteria for eye disabilities have been revised twice during the appeal period, in December 2008 and May 2018. However, the pertinent rating criteria for diplopia, visual acuity, and visual field have not changed substantively. Turning to the evidence, a September 2001 VA examination reflects a finding of corrected distance visual acuity of 20/20 for the right eye and 20/20 for the left eye. No visual field defect or diplopia was noted. Diagnoses were residual of strabismus (esotropia, hypertropia) status post strabismus surgery and astigmatism. In a September 2002 statement, the Veteran reported that he had double vision and blurred vision when tired or during night driving after the strabismus surgery. In a May 2003 statement, the Veteran reported that post-surgery diplopia never disappeared and was prevalent when driving during the night or when sitting in front of the computer for any length of time. Same situation applied to blurred vision. In a January 2004 statement, the Veteran reported the occurrence of double vision and blurred vision increased significantly in the past three years. While in the military, both occurred once a week. Over the past three years, the occurrence had increased to about 6 to 8 times a week, with duration lasting from a few minutes to an hour. Originally, they only lasted less than 5 minutes. In an August 2006 letter, Dr. A.R. reported that the Veteran's visual acuity was 20/20 in the right eye and 20/25 in the left eye. He had a vertical strabismus called a left hypotropia of 16 diopters or approximate 8 degrees and an outward deviation or exotropia of 4 diopters or 2 degrees. Using a red lens, he gave appropriate responses demonstrating double vision for this deviation. The clinician also noted that the Veteran could bring the images close together with prisms, but he could not fuse or combine the images to eliminate the double vision. Finally, the clinician stated that the Veteran's double vision occurred only intermittently and occasionally. A January 2007 VA examination reflects symptoms of watering/tearing, blurred vision, halos around lights, and double vision. Only uncorrected distance visual acuity was reported with a finding of 20/25 in each eye. The Veteran's diplopia was noted intermittent in all distances, and not correctable. The examiner noted "positive" for central 20 degrees, 21 to 30 degrees, and 31 to 40 degrees as sectors of visual field affected by diplopia. The examination form asked the examiner to provide the Goldmann Perimeter Chart for diplopia; however, such chart is not associated with the examination. The examiner did provide a Goldmann chart for the regular visual field and noted that visual field was full. This examiner neither reviewed any medical records for the Veteran at the examination. An April 2008 VA examination reflects symptoms of watering/tearing, blurred vision, halos around lights, loss of night vision, and double vision, in both eyes. The examiner noted that the Veteran had Lasik surgery in 2003 for both eyes and strabismus repair in 2000. Corrected distance visual acuity was 20/20-2 for the right eye and 20/30-1 for the left eye. The examiner did not find diplopia. However, in a July 2008 addendum opinion, the examiner determined that the Veteran had intermittent exotropia/diplopia. In a February 2009 decision, the Board found that the Veteran's diplopia was related to his service, but watering/tearing, blurred vision, halos around lights and loss of night vision was not the result of an injury superimposed over strabismus, his congenital defect or was otherwise related to service. In an August 2009 statement, which was received in April 2010, the Veteran reported that at the time of retirement, which was 8 years ago, his diplopia was intermittent, but now it occurred daily and many times a day and he was concerned with driving at night. He also reported that he had headaches, which could be related to his eye problems. A May 2010 VA examination reflects symptoms of blurred vision, halos around lights, loss of night vision and diplopia. The corrected visual acuity for distance was 20/25 in the right eye and 20/30 in the left eye. The Veteran reported that he had double vision almost all the time with one object higher than the other. Blinking a few times or closing one eye made the double vision go away temporarily. The Veteran reported horizontal and vertical diplopia. The assessment was symptomatic diplopia. The medical history noted migraines/headaches. A July 2014 VA examination reflects corrected distance visual acuity of 20/25 in the right eye and 20/25-2 in the left eye. The Veteran reported that diplopia was worse now than it was this time last year. The diplopia visual field test showed 50 degrees in down, 30 degrees in up, and 40 degrees and 50 degrees in lateral. The examiner noted that the diplopia was in four cardinal fields of gaze and was not correctable with spectacles. An October 2017 VA examination reflects a diagnosis of bilateral nuclear cataracts and peripheral corneal scars from LASIK surgery. The examiner noted that the Veteran did not have diplopia with correction. Corrected visual acuity for distance was 20/40 or better in each eye. There was no visual field defect. There was no scar pertaining to the eyes. No incapacitating episodes during the past 12 months were noted. A November 2020 VA examination incorporates a review of private treatment records from Lusk Eye Center ranging from 2004 to 2018 with recent treatment showing inability to fuse images with prism. The examiner also referred to the July 2014 diplopia visual field result, stating it showed occasional diplopia from 31 to 54 degrees. The corrected distance visual acuity was 20/40 in each eye. Diplopia was noted and it was constantly present within central 20 degrees in the visual field. The Veteran's diplopia was not correctable with standard spectacle correction or special prismatic correction. A visual field defect was noted. Bilateral dry eye began after the Lasik surgery. No incapacitating episodes during the past 12 months were noted. The examiner confirmed the presence of diplopia and stated that dry eye syndrome and epiphora are both new and separate diagnosis unrelated to diplopia. Moreover, the examiner stated that the visual field defect noted on visual field testing was due to lid defect or poor test taking ability, considering normal optic nerve and confrontation visual field. The examiner confirmed worsening symptomatology of diplopia in comparison with the records in 2006. The examiner reported that the current examination reflected the current severity of diplopia. Based on a review of the evidence, the Board finds that for the entire period, the Veteran's corrected visual acuity for distance was 20/25 at worst and 20/20 in the most recent examination in each eye. Moreover, the Veteran's diplopia has not resulted in defect of visual field for the entire appeal period. Thus, a compensable rating is not available for impairment of visual acuity or impairment of visual field. However, the evidence shows that the Veteran has had diplopia after the strabismus surgery, which was intermittent in the beginning, but has progressed to the point where it occurs multiple times daily. In particular, at the July 2014 examination, the Goldmann visual field chart indicated the presence of diplopia at 30 degrees in the up direction for the first time during the appeal period. Moreover, the evidence also confirms that the Veteran's diplopia indeed has gotten worse to the point where diplopia impacted the Veteran's central vision within 20 degrees, as found in the most recent November 2020 examination. Application of Diagnostic Codes 6090 and 6066 to the July 2014 examination finding results in a 10 percent evaluation after July 9, 2014, corresponding to the visual acuity equivalent to the severity of diplopia of 20/70 and the best corrected visual acuity of 20/40 in either eye. And application of Diagnostic Code 6090 and 6065 to the November 2020 examination finding results in a 30 percent evaluation after November 18, 2020, for the visual acuity corresponding to the severity of diplopia here is 5/200 and the best corrected visual acuity of 20/40 in either eye. A higher evaluation is not warranted for either period because the Veteran's diplopia has not resulted in impairment of visual acuity or visual field and the evidence does not show that diplopia exists in two separate areas of one eye. A compensable rating prior to July 9, 2014 is not warranted, for the evidence does not indicate that the Veteran's diplopia affected the area within 31 degrees to 40 degrees in a lateral direction or within 21 degrees to 30 degrees in the up direction given that his corrected visual acuity was at worst 20/25 in either eye. Diagnostic Codes 6090, 6065, 6066, 38 C.F.R. § 4.79. 3. Increased rating for bilateral hearing loss The Veteran contends that his hearing impairment has gotten to the point where it is affecting his work because he needs to ask individual to repeat themselves or not understanding someone is saying due to the tone of the voice they are using. He also reported that it is next to impossible to have a conversation with someone with a lot of background noise. He states that his hearing is okay when there is no background noise as shown by the hearing test, but under normal circumstances, he is more often than not asking someone to repeat themselves. See February 2020 Veteran's Statement. The Veteran's claim for increased rating for hearing loss was received on October 29, 2015. As such, the Board will consider the evidence of record since October 2014. Hearing impairment is evaluated under 38 C.F.R. § 4.85, and is determined by comparing the results of controlled speech discrimination tests with the average hearing threshold level. The hearing threshold levels are measured by pure tone audiometry tests in the frequencies of 1,000, 2,000, 3,000 and 4,000 Hertz (cycles per second). The Rating Schedule allows for such audiometric test results to be translated into a numeric designation, which range from Level I for essentially normal acuity to Level XI for profound deafness. Based on the level of hearing impairment, a percentage evaluation is assigned to determine the level of compensation, ranging from noncompensable to 100 percent. Disability ratings for hearing impairment are derived by the mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). At a September 2018 audiology examination, pure tone thresholds were as follows: 20 decibels (dB) at 1000 Hertz (Hz), 55 dB at 2000 Hz, 90 dB at 3000 Hz, 100 dB at 4000 Hz, with average 66.25 Hz for the right ear and 20 dB at 1000 Hz, 60 dB at 2000 Hz, 65 dB at 3000 Hz, 70 dB at 4000 Hz, with average 53.75 dB for the left ear. Speech audiometry revealed speech recognition ability of 84 percent for the right ear and 100 % for the left ear. The Veteran reported he could not hear in background noise or soft talkers. Applying these findings to Table VI shows a numeral of Level III for the right ear and Level I for the left ear. Applying those results to 38 C.F.R. § 4.85, Table VII, a noncompensable evaluation is derived. Functional loss due to hearing loss reported by the Veteran pertains hearing difficulty. As a result, the currently assigned noncompensable disability rating for the Veteran's bilateral ear hearing loss is accurate under the rating criteria and appropriately reflects this disability under the provisions of 38 C.F.R. § 4.85. The pure tone thresholds do not qualify as an exceptional pattern of hearing, as the Veteran did not have pure tone thresholds of 55 decibels or more at each of the frequencies of 1000, 2000, 3000 and 4000 hertz or a pure tone threshold of 30 decibels or less at 1000 hertz and 70 decibels or more at 2000 hertz. As a result, use of Table VIA is not warranted. See 38 C.F.R. § 4.86. REASONS FOR REMAND 1. The issue of entitlement to a separate compensable rating for headaches, due to service connected vision problems is remanded. The Veteran has indicated that he has migraines or headaches as a result of his eye disability. See August 2009 Veteran's Statement, May 2010 VA Examination Report, January 2017 VA Treatment Record. As such, he might be entitled to a separate rating for migraines or headaches as secondary to diplopia. This issue has been raised by the record and is in need of development and initial review at the originating agency. Upon remand, a VA examination must be scheduled and a medical opinion concerning whether headaches are a symptom of diplopia. 2. The issue of entitlement to a rating in excess of 20 percent for the right shoulder disability is remanded. 3. The issue of entitlement to a rating in excess of 20 percent for the left shoulder disability is remanded. At a September 2018 VA examination, the Veteran reported that he gets Botox injections on both sides of his neck to treat his shoulder disabilities. He stated that the shoulder condition is worsening and that at times, his spasms can be severe enough that he is unable to turn his head to the left. The examination reflects decreased range of motion in flexion and abduction and limitations in lifting and working above the head. The imaging study showed acromioclavicular (AC) joint arthropathy, grade II AC joint, and supraspinatus tendinosis. In a June 2016 statement, the Veteran reported that he was seeing Dr. K. from Ricer Cities Pain Management in Shreveport, LA for the neck and shoulder pain. The Veteran indicates that the pain was originating from the neck. Due to insufficient information in the evidence, the Board is unable to ascertain the current severity of the Veteran's shoulder disabilities. In particular, it is not clear whether the spasm impacting his movement of his head is related to the shoulder disabilities or a cervical spine disability. Upon remand, the Veteran must be afforded a VA examination for his shoulders to set out all functional impairment. In addition, the Agency of Original Jurisdiction (AOJ) must obtain treatment records from River Cities Pain Management with proper release authorization from the Veteran. The matters are REMANDED for the following action: 1. Obtain VA treatment records since March 2018 to the Present. 2. Ask the Veteran to complete a VA Form 21-4142 for Dr. Knowles from River Cities Pain Management in Shreveport, LA. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. All attempts to obtain records should be documented in the claims folder. 3. Schedule the Veteran for a VA examination for his headaches. The examiner must review the claims file. The examiner must provide an opinion as to whether the Veteran's headache is at least as likely as not related to service and whether it is at least as likely as not proximately due to or aggravated beyond natural progression by a service connected disability, to include diplopia. That is, are the headaches a symptom of or made worse by the vision impairment. All opinions expressed must accompany sufficient rationales. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his shoulder disabilities. The examiner should provide a full description of the disability 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. 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 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). All opinions expressed must accompany sufficient rationales. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Taylor 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.