Citation Nr: 22013267
Decision Date: 03/09/22	Archive Date: 03/09/22

DOCKET NO. 19-14 783
DATE: March 9, 2022

REMANDED

Entitlement to a rating in excess of 30 percent for total right shoulder replacement is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Army from December 1968 to December 1971.  

This matter comes before the Board of Veterans Appeals (Board) on appeal from a February 2019 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).  

At a November 2021 hearing, the Veteran testified before the undersigned Veterans Law Judge.  A transcript of the proceeding has been associated with the claims file.  

Entitlement to a rating in excess of 30 percent for total right shoulder replacement is remanded.

Service connection for right shoulder bursitis with impingement syndrome was granted at 20 percent disabling, effective February 21, 2012, in a January 2013 rating decision under 38 C.F.R. § 4.71a, DC 5003-5201.  The Veteran underwent a right shoulder replacement surgery in March 2017 and submitted a claim for increase in April 2017.  A 100 percent rating was awarded for the surgery and convalescence from March 13, 2017, to May 1, 2018.  Thereafter, a 30 percent rating was awarded under 38 C.F.R. § 4.71a, DC 5051.  The Veteran submitted a claim for increase in November 2018.  

The Veteran most recently underwent a VA examination in December 2018.  At the hearing, he testified that his right shoulder symptoms had worsened since that evaluation, including resulting in intermittent ankylosis.  Given the evidence of worsening, the Board finds that a new VA examination is needed before a decision may be rendered on the claim.  See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997).

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA shoulder examination to assess the current extent and severity of his service-connected total right shoulder replacement.  

(a.) The examiner should test the Veteran's active motion, passive motion, and pain with weight-bearing and nonweight-bearing.  The examiner should attempt to elicit information regarding the severity, frequency, and duration of any flare-ups and the degree of functional loss during flare-ups.  To the extent possible, the examiner should identify any symptoms and functional impairments due to the right shoulder replacement and the effect of the disability on any occupational functioning and activities of daily living.  If it is not possible to provide a specific measurement or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner should 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).  

(b.) Make a determination as to whether the Veteran's right shoulder has chronic residuals consisting of severe, painful motion or weakness in the extremity and whether the shoulder results in favorable or unfavorable ankylosis or the functional equivalent thereof.  The examiner should address the Veteran's testimony regarding intermittent ankylosis and "freezing" of his shoulder.  

2. Ensure that the requested examination report is associated with the claims file.  After completing the above, and any additionally indicated development, readjudicate the claim.  

 

 

SHEREEN M. MARCUS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Rachel E. Jensen, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.