Citation Nr: 21031466 Decision Date: 05/22/21 Archive Date: 05/22/21 DOCKET NO. 10-38 877 DATE: May 22, 2021 ORDER 1. A 30 percent (but no higher) rating is granted for a post-total knee replacement (TKR) left knee disability throughout, subject to the regulations governing payment of monetary awards. REMANDED 2. Entitlement to increases in the staged (0 percent prior to February 10, 2020, and 10 percent from that date) ratings assigned for a right shoulder disability is remanded. FINDING OF FACT Throughout, the Veteran's post-TKR left knee disability was manifested by complaints of pain, stiffness, and limitation of flexion; extension was normal, the knee was not ankylosed, nonunion of tibia or fibula was not shown, and a preponderance of the evidence is against a finding of chronic residuals consisting of severe painful motion and weakness. CONCLUSION OF LAW A 30 percent (but no higher) rating is warranted for the Veteran's post-TKR left knee disability throughout; deduction for pre-existing disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.322, 4.1, 4.3, 4.7, 4.10, 4.22, 4.40, 4.45, 4.71a, Diagnostic Codes (Codes) 5055, 5256-5263; 85 Fed. Reg. 76457 (Feb 7, 2021). REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from January 2004 to January 2008, and from February 2009 to November 2009. These matters are before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision which granted service connection for left knee and right shoulder disabilities, rated 0 percent each, effective January 22, 2008. An August 2010 rating decision increased the left knee rating to 20 percent, effective January 22, 2008, and continued a 0 percent rating for the right shoulder disability. [That rating decision explained that the 20 percent rating assigned for left knee post-TKR disability was based on a formulation of a (minimum, post TKR) schedular 30 percent rating less 10 percent deducted for the pre-service level of disability. Similarly, the right shoulder disability was assigned a 0 percent rating based on a formulation of a 10 percent rating less the 10 percent pre-service level of disability. Notably, no ratings were assigned for the disabilities when the Veteran returned to active duty from February 18, 2009 through November 6, 2009.] In April 2015, a Travel Board hearing was held before the undersigned; a transcript is in his record. In July 2015, the case was remanded for additional development. A December 2017 Board decision denied ratings in excess of 20 percent for the left knee disability and 0 percent for the right shoulder disability. [The December 2017 Board decision also remanded claims seeking service connection for a low back disability, asthma, carpal tunnel syndrome of each wrist, sleep apnea, and trigger thumb for additional development. The Veteran opted those issues into the modernized (AMA) appeal system, and they were addressed in a separate September 2020 AMA Board decision (and are not currently before the Board.] The Veteran appealed the Board's December 2017 decision to the United States Court of Appeals for Veterans Claims (CAVC), resulting in a November 2018 Joint Motion for Partial Remand (JMPR) by the parties. A November 2018 CAVC Order remanded the matter for compliance with the JMPR instructions. In June 2019, the claims were remanded for additional development. An interim (February 2021) rating decision increased the right shoulder rating from 0 to 10 percent, effective February 10, 2020. The rating was based on assignment of a 20 percent (minimum compensable rating under 38 C.F.R. § 4.59 for functional loss due to painful motion) rating less 10 percent deducted for pre-existing [service] level of disability. 1. A 30 percent rating (but no higher) is granted throughout for the Veteran's post-TKR left knee disability. Legal Criteria Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where, as here, the appeal is from the initial rating assigned with an award of service connection, the severity of the disability during the entire period from the award of service connection to the present, and the possibility of "staged" ratings for distinct periods of time when varying degrees of disability were shown, must be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. The Board observes that the schedular criteria for evaluating disabilities of the musculoskeletal system, including the knee, have been revised during the pendency of this appeal, effective February 7, 2021. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Post-TKR knee disability is rated under Code 5055. Prior to February 7, 2021, a 100 percent rating was to be assigned for 1-year following implantation of a prosthesis. Following expiration of the 1-year period, a 30 percent rating was the minimum rating to be assigned. Effective February 7, 2021, the new regulations provide for a 100 percent rating for 4 months following implantation of prosthesis or resurfacing; a 30 percent (minimum) rating is warranted thereafter for total replacement only. Under the old and new regulations, a 60 percent [maximum schedular] rating is warranted for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Codes 5256 (for ankylosis), 5261 (for limitation of extension), or 5262 (for impairment of the tibia and fibula). 38 C.F.R. § 4.71a. Under Code 5256, a 30 percent rating is assigned for ankylosis of a knee at a favorable angle (in full extension or in slight flexion between 0 degrees and 10 degrees). A 40 percent rating is assigned for ankylosis in flexion between 10 degrees and 20 degrees. A 50 percent rating is assigned for ankylosis between 20 degrees and 45 degrees. A 60 percent rating is assigned for extremely unfavorable ankylosis (in flexion at 45 degrees or more). Under Code 5261, limitation of extension of the leg warrants a 0 percent rating when limited at 5 degrees; a 10 percent rating when limited at 10 degrees; a 20 percent rating when limited at 15 degrees; a 30 percent rating when limited at 20 degrees; a 40 percent rating when limited at 30 degrees; and a (maximum) 50 percent rating when limited at 45 degrees. Under Code 5262, for impairment of the tibia and fibula, a 30 percent rating is assigned for malunion with marked knee or ankle disability, and a (maximum) 40 percent rating is assigned for nonunion with loose motion requiring a brace. Normal or full ROM of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In determining the degree of limitation of motion, the provisions of 38 U.S.C. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran underwent a left total knee replacement surgery in March 2006 (during active duty service). A 20 percent rating (based on a formulation of a (minimum) 30 percent schedular rating for post-TKR knee disability less the 10 percent pre-existing [service] level of disability) was assigned from January 22, 2018 to February 17, 2009 and from November 7, 2009, the day following separation from service. Factual Background The Veteran underwent a left total knee arthroplasty in March 2006. A June 2007 private medical statement notes that he had diagnoses of "advanced degenerative osteoarthritis in both knees and right shoulder." In April 2008, the Veteran reported some "very transient" burning in the left knee lateral patellofemoral joint region. There was no swelling, locking, or giving way; ROM was "excellent"; there was no tenderness or effusion; he walked well. The examiner stated that he saw no evidence of left knee abnormality, and noted the Veteran has been "able to run a little and walk over five miles without any problem." On June 2008 VA joints examination, the Veteran reported left knee limited ROM, pain with prolonged activity, and stiffness and swelling after extended activity. He reported a precipitating factor is walking more than 2 or 3 miles. He denied dislocation/recurrent subluxation; he denied use of an assistive device (such as a brace, cane, or corrective shoes). Examination of the left knee found that ROM was from 0 to 105 degrees. The knee was stable with varus/valgus stress; Lachman's and McMurray's tests were negative. There was no effusion. There was discomfort at the terminal limits of motion. There was no pain with repetitive motion. Fatigue, weakness, lack of endurance and incoordination were not present. There was no objective evidence of painful motion, edema, effusion, instability, tenderness, redness, heat, abnormal movement or guarding of movement. The diagnosis was left TKR. A February 2010 private PT record notes left knee active ROM was 6 to 144 degrees. Strength tests were all 4/5. In a September 2010 VA Form 9, the Veteran disagreed with the ratings assigned for his left knee disability; he reported that such disability had worsened since the June 2008 examination. He reported that his left knee disability limits his ability to run, bike, swim, climb, and/or walk. He requested that the left knee be rated 50% or, alternatively, that VA schedule a new examination to reevaluate the condition. A May 2012 private PT record (following a right knee surgery) notes that left knee ROM was -2 to 110 degrees. A June 2012 record repeats the recorded May 2012 ROM and noted that strength was 5/5 and the knees were "painfree (sic) throughout." On August 2013 VA knee examination (focused primarily on the right knee), the Veteran's left knee flexion was to 110 degrees. There was no objective evidence of pain on motion. Following repetitive use testing flexion was to 90 degrees and extension was to 0 degrees (no limitation). Functional impairment was manifested by less movement that normal, weakened movement, excess fatigability, atrophy of disuse, instability, swelling, deformity, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. Tenderness was noted. Muscle strength testing was 5/5 on flexion and extension. Stability tests were normal. There was no evidence or history of recurrent patellar subluxation or dislocation. He had frequent episodes of joint pain. The examiner checked the respective boxes to indicate that the Veteran had intermediate degrees of residual weakness, pain or limitation of motion and chronic residuals that consisted of severe painful motion or weakness. The Veteran did not use an assistive device. The examiner opined that his knee disabilities do not impact his ability to work. An October 2013 private treatment record notes the left knee flexion was to 110 degrees. A January 2014 private treatment record notes that left knee flexion was to 112 degrees passively. On March 2014 VA knee examination, the Veteran stated he had left knee problems and pain following November 2013 right knee surgery. Examination found that left knee ROM was from 0 to 110 degrees, with pain at 110 degrees. He was able to perform repetitive use testing with no change in left knee range of motion. The functional loss consisted of less movement than normal. He did not have tenderness or pain to palpation of the left knee. Muscle strength testing was 5/5 on flexion and extension. The examiner was unable to test for joint stability. There was no evidence or history of recurrent patellar subluxation or dislocation. The diagnosis was status post left TKR. The residuals were "as described above" and not specifically severe painful motion and weakness. The Veteran did not use an assistive device. The functional impairment was not such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The examiner opined that his knee disabilities do not impact his ability to work. A May 2014 private medical record notes the Veteran's report that his left knee "does not have excellent flexibility but there is really no pain." A July 2014 record notes left knee ROM was 0 to 100 degrees. At his April 2015 Board hearing, the Veteran testified that that his left knee has good and bad days. He related that he can no longer run, but does try to maintain physical fitness. He reported treatment including taking Celebrex (daily for "overall arthritis"), PT, and massage (which provides only temporary relief). He testified that he can no longer climb (a ladder) and has difficulty scrunching his body to put his pants on. A May 2015 private treatment record notes that left knee ROM was from 0 to 95 degrees, "perhaps 100 at the most." On December 2015 VA knee examination, the Veteran complained of a "burning sensation" in the left lateral knee; he denied having any pain. He denied locking, buckling, redness, and swelling. He reported that his bilateral knee braces make him uncomfortable; he occasionally rides his bike and uses the elliptical machine. Examination found that left knee ROM was from 0 to 110 degrees, with pain on flexion. There was no evidence of pain with weight-bearing. Repetitive use testing did not result in additional loss of function or ROM. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of crepitus. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups. Muscle strength testing was 5/5 on flexion and extension. There was no muscle atrophy or ankylosis. Joint stability tests were normal. The examiner noted that the Veteran had intermediate degrees of residual weakness, pain, or limitation of motion. [She did not select the box to indicate chronic residuals consisting of severe painful motion or weakness.] X-rays showed no acute fracture or dislocation; the left knee arthroplasty hardware is in "near-anatomic alignment." The diagnosis was post-TKR left knee disability. The examiner opined that, due to his left and right knee disabilities, the Veteran should avoid kneeling, squatting, climbing ladders, crawling, and overhead lifting and carrying. An October 2016 VA knee examination report (focused primarily on the right knee) notes that there was no history of left knee recurrent subluxation or lateral instability. A December 2017 Board decision denied ratings in excess of 20 percent for left post-TKR knee disability [and in excess of 0 percent for the right shoulder disability]. The Veteran appealed the December 2017 Board decision to the CAVC, resulting in the November 2018 JMPR. The parties agreed that the Board erred when it did not ensure compliance with its July 2015 remand order; specifically, the parties found that the Board failed to make any findings as to whether the December 2015 examinations were adequate under Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 34-35 (2017). On February 2020 VA (fee basis) knee examination, left knee osteoarthritis and DJD, status post-TKR left knee osteoarthritis and DJD, status post-TKR was diagnosed. The Veteran reported limited ROM in both knees; he stated that they hurt when descending stairs, kneeling, or with long walking. He said the knees "feel like they are on fire." He endorsed daily stiffness and sharp pain across the front of both knees. He denied flare-ups. He took one naproxen a day. Initial ROM testing showed flexion to 110 degrees and extension to 0 degrees. Pain was noted on flexion and causes functional loss. There was "moderate tenderness to palpation" along the "peripatella." There was no evidence of pain with weight-bearing or of crepitus. Repetitive use testing did not result in additional loss of function or ROM. The examiner found no other factors that contributed to the disability. Muscle strength testing was normal (5/5). There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was normal. The examiner acknowledged the prior TKR surgery and found that the residuals included "Residual chronic pain and limited motion of the left knee." There was not functional impairment such that no effective functions remain other than that which would be equally served by an amputation with prosthesis. The examiner opined that, although the Veteran was still working (in a non-physical occupation), his bilateral knee disability limits his ability to descend stairs, kneel, or walk for prolonged periods. The examiner clarified that there is objective evidence of left knee pain on non-weight bearing and on passive ROM testing. In a separate February 2020 statement, the knee [and shoulder] examiner opined that the Veteran can perform light work. In an October 2020 addendum, a different provider reviewed the Veteran's record, including his statements and the findings on February 2020 examination, and opined that the Veteran's left knee pain is "Mild to Moderate based on his ability to ambulate but 'not walk for long,' 30 degrees loss in Flexion and normal muscle strength with no reported flare-ups to Left knee. Pain is major limiting factor in reducing mobility versus weakness as normal muscle strength and no joint instability are recorded and observed for the Left knee." In a January 2021 addendum, the February 2020 knee examiner opined that there is no evidence of left knee severe pain or weakness. She noted that examination findings included moderate tenderness to palpation of the left patella; however, there was no objective evidence of limb weakness, ankylosis, instability; "muscle strength is normal with no atrophy." Analysis The Veteran's post-TKR left knee disability has been assigned a 20 percent rating, based on a formulation of a (minimum, post TKR) schedular 30 percent rating less the 10 percent pre-existing [service] level of disability. See August 2010 rating decision. The record shows that, prior to service, the Veteran underwent multiple left knee arthroscopic debridements and, notably, an August 1997 left knee partial lateral meniscectomy. As noted in prior remands/decisions, his service treatment records (STRs) are unavailable. See November 2008 Formal Finding on the Unavailability of STRs. VA consequently has a heightened duty to assist in the development of the claim. At the outset, the Board must consider the Regional Office's (RO's) conclusory application of 38 C.F.R. § 3.322(a) and 4.22, deducting (without adequate explanation) 10 percent for pre-existing disability from the rating for the Veteran's post-TKR left knee disability throughout, when it is not clear from the record (as it currently stands) whether the disability level existing at entrance in active service was fully ascertainable. Generally, when service connection for a disability is granted on the basis that the disability pre-existed, but was aggravated by, service the rating assigned for such disability is derived by deducting from the rating warranted for the present degree of disability the rating, if ascertainable, the degree of such disability existing at entrance into active service, "except that if the disability is total (100 percent) no deduction will be made." 38 C.F.R. §§ 3.322(a), 4.22; see also Cotant v. Principi, 17 Vet. App. 116, 129 (2003). The Board finds that the general rule providing for deduction for pre-existing disability does not apply at any point because a post-TRK disability is fundamentally different from the Veteran's service pre-existing left knee disability, and must be evaluated under different diagnostic codes. See Williams v. Shinseki, No. 08-1714, 2010 U.S. App. Vet. Claims LEXIS 1192, at *5-7 (Vet. App. June 30, 2010) ("If the preservice injury is rated under a different DC from the present condition, then the reduction of his disability rating due to the pre-service injury may well be improper."). Here, the Veteran's post-TKR left knee disability is rated under Code 5055, which governs evaluation of a knee disability following implantation of a prosthesis. Application of this Code reflects surgical removal of the pre-existing [service] knee disability, which would have been rated under Code 5259, for symptomatic removal of semilunar cartilage. See 38 C.F.R. § 4.71a. Affording the Veteran the benefit of the doubt, the pre-existing [service] level of disability is not fully ascertainable from the current record. Furthermore, as his now post-TKR left knee disability is a fundamentally different disability than his pre-service osteoarthritis (post meniscectomy), the Board finds that deduction of 10 percent for pre-existing disability from the rating warranted for the post-TRK left knee disability is improper. See Williams, 2010 U.S. App. Vet. Claims LEXIS 1192, at *5-7. Accordingly, a minimum schedular 30 percent under Code 5055 is warranted throughout, without deduction for a pre-existing [service] disability. The Board next turns to consideration of whether the disability warrants a schedular 60 percent rating under Code 5055 for knee replacement chronic residuals consisting of severe painful motion or weakness in the affected extremity, and finds it does not. The Board acknowledges the Veteran's reports of pain and stiffness, including particularly his February 2020 reports of daily sharp pain across the front of both knees and a "burning sensation" in the knees. However, on longitudinal review of the record, the Board finds that the preponderance of the competent medical evidence is against a finding of severe painful motion. On June 2008 examination, he reported left knee pain with prolonged activity; there was no pain with repetitive motion. A May 2012 clinical record notes the knee was pain-free throughout the ROM. On August 2013 examination, there was no objective evidence of pain on motion. On March 2014 examination, pain was noted at 110 degrees flexion. A May 2014 clinical record notes the Veteran reported ROM limitation, "but there is really no pain." On December 2015 VA examination, he denied pain at rest and reported pain on flexion. Although the August 2013 examiner (contradictorily) opined that the Veteran's left knee disability manifested in intermediate degrees of residual weakness, pain or limitation of motion and chronic residuals that consisted of severe painful motion or weakness, examiners in June 2008, March 2014, December 2015, and February 2020 (with October 2020 and January 2021 addendum opinions) did not opine that the Veteran's post-TKR left knee disability manifests in chronic residuals consisting of severe painful motion or weakness in the affected extremity. Accordingly, the Board finds that throughout, the Veteran's post-TKR left knee disability most closely approximated the criteria for the 30 percent rating now assigned, and that a 60 percent schedular rating under Code 5055 for severe painful motion or weakness is not warranted. The Board has considered whether the evidence warrants an intermediate rating (between 30 and 60 percent) based on combination of ratings under Codes 5256, 5261, or 5262, pursuant to Code 5055. A higher (40 percent) rating under Code 5256 is warranted for ankylosis at 10 to 20 degrees. It is not alleged, nor did any medical examination find, that the left knee was ankylosed. Consequently, a rating by analogy to Code 5256 is not warranted. Under Code 5261, a rating in excess of 30 percent (40 percent) is warranted when extension is limited at 30 degrees. Even with factors of pain, fatigability, weakness, and incoordination considered, including over time with repeated use and during flare-ups, extension was consistently to 0 degrees (normal). The Board acknowledges a February 2010 clinical notation of extension to 6 degrees; however, such would not warrant a compensable rating. Consequently, rating under Code 5261 would be of no benefit to the Veteran. Under Code 5262 a 40 percent (maximum) rating is warranted for nonunion of tibia/fibula with loose motion, requiring a brace. The Veteran does not allege, and no examination has found, nonunion (or equivalent post-TKR pathology) requiring wearing of a brace. Notably, December 2015 x-rays showed the left knee arthroplasty hardware is in "near-anatomic alignment." Accordingly, an intermediate (between 30 and 60 percent) rating is not warranted by analogy to (or combination of) the schedular criteria specified for consideration throughout. Finally, the matter of entitlement to a total disability rating based on individual unemployability (TDIU) is not raised by the record in the context of the instant claim for increase. The Veteran does not contend, nor has an examiner opined, that his left knee disability renders him unemployable. Examination reports and treatment records show that he has maintained substantially gainful employment throughout the appeal period. REASONS FOR REMAND 2. Entitlement to increases in the staged ratings assigned for a right shoulder disability The Veteran underwent a right shoulder hemiarthroplasty (not total arthroplasty) in December 2005 (during a period of active duty service). The August 2010 rating decision granted service connection for a right shoulder disability on the basis that pre-existing [service] right shoulder osteoarthritis "worsened incrementally" on active duty service, requiring surgery. That rating decision explained that the right shoulder disability was assigned a 0 percent rating based on a formulation of a 10 percent rating less the 10 percent pre-service level of disability. The February 2021 rating decision increased the right shoulder rating from 0 to 10 percent, effective February 10, 2020, based on an assignment of a 20 percent (minimum compensable rating under 38 C.F.R. § 4.59 for functional loss due to painful motion) rating less the 10 percent pre-service level of disability. Remand is necessary to attempt to reconcile apparent inconsistencies in the record. The Board notes that service connection for a right shoulder disability was granted based on aggravation of a pre-existing (pre-service) disability. However, the August 2010 rating decision assigned a 0 percent rating based on findings that the Veteran then had a 10 percent level of disability from which 10 percent for pre-service level of disability was deducted; such a conclusion is inconsistent with the finding the disability was aggravated by (worsened in severity during) service. Furthermore, based on the assigned "staged" ratings assigned, it appears that the RO may not have considered the application of 38 C.F.R. § 4.59 throughout the appeal period (but rather only since February 10, 2020). While the Veteran's STRs have been determined to be unavailable, the Board notes that the Veteran's service personnel records are not associated with the record, and do not appear to have been sought. As service personnel records are constructively of record, they must be secured prior to adjudication of the claim. Such records may be helpful in determining whether the degree of the pre-existing [service] right shoulder disability is ascertainable, and therefore may be pertinent evidence in rating the Veteran's current right shoulder disability. Specifically, the personnel records may be the best alternate source evidence as they may show whether he had a pre-existing [service] right shoulder disability that was waived (or was found not to have a disabling pre-existing right shoulder condition on entrance), and may include reports of any periodic examinations during service. Remand is necessary for development of additional medical evidence to properly adjudicate the claim. In Hudgens v. McDonald, 823 F.3d 620, 637 (2016), the United States Court of Appeals for the Federal Circuit found, contrary to the holding of the CAVC, that VA regulations pertaining to the ratings for total knee replacements did not unambiguously exclude consideration of partial knee replacements, and therefore these regulations must be considered when assigning a rating for a veteran who had undergone a partial knee replacement. Although the Federal Circuit did not address shoulder joint replacements, the Federal Circuit's analysis in Hudgens may impact on the evaluation of the Veteran's right shoulder (post hemiarthroplasty) disability. Accordingly, further medical guidance is necessary. The matter is REMANDED for the following: 1. Secure for the record updated (to the present, any not already associated with the record) complete clinical records of all VA evaluations and treatment the Veteran has received for his right shoulder. 2. Arrange for an exhaustive search to secure for the record the Veteran's complete service personnel records, including any Reserve records. The search should encompass all storage facilities where such records may have been retired. If any records are unavailable because they have been irretrievably lost or destroyed, the AOJ should so certify (describing the extent of the development completed), and the Veteran should be so notified and asked to provide copies of all personnel records he has in his possession. 3. Arrange for the Veteran's record to be returned to the February 2020 VA (fee basis) shoulder examiner for review and an addendum opinion regarding the nature and severity of the Veteran's current right shoulder disability. [If that provider is unavailable or unable to provide the opinions sought, arrange for the record to be forwarded to another appropriate clinician for review and the opinions sought (and if in such circumstance further examination of the Veteran is deemed necessary, such should be arranged).] Upon review of the record, the consulting provider should: (a) Explain briefly the difference between a shoulder hemiarthroplasty and a total shoulder arthroplasty. (b) Based on review of the record, including the February 2020 shoulder examination, opine whether the functional impairment following the Veteran's 2005 right shoulder hemiarthroplasty is the functional equivalent to the level of pathology and impairment following a total shoulder joint replacement surgery. If not, explain what symptoms or functional impairment which would follow a total shoulder joint replacement are not shown. All opinions must include a complete explanation of rationale. If an opinion sought cannot be provided without resort to mere speculation, it must be so stated, with explanation why speculation is required. The provider must indicate whether further available information or testing is necessary for a determination on the matter (or whether the state of current medical knowledge is such that no provider could offer an opinion in the matter given the facts shown). GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dupont, 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.