Citation Nr: 22013733 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 22-00 051 DATE: March 10, 2022 REMANDED The claim of entitlement to an initial rating higher than 20 percent for left shoulder disability is remanded. The claim of entitlement to an initial rating higher than 10 percent prior to October 24, 2017, and higher than 20 percent since then, for thoracolumbar spine disability, is remanded. The claim of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1967 to March 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal of a rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's attorney raised the TDIU claim as part of the claims of entitlement to higher initial ratings on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). A remand of the claims is necessary for additional medical inquiry. The claims on appeal stem from claims of entitlement to service connection filed in July 2006. The Veteran appealed the RO's June 2007 denial of the claims. During the appeal period, in the December 2018 rating decision on appeal, the RO granted the claims and assigned the initial ratings at issue here. The Veteran underwent VA examinations of his left shoulder and back in July 2012, October 2017, and November 2018. The latter two reports are not clear with regard to limitation following repeated use over time. Further, the 2018 examinations were conducted over four years ago and the Veteran's attorney indicates that the disorders have worsened significantly since then, to such an extent that they now interfere with the ability to maintain gainful employment. See Green v. Derwinski, 1 Vet. App. 121 (1991). A current examination is required. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Include in the electronic claims file any outstanding VA treatment records and identified pertinent private treatment records to the extent possible. 3. Schedule an examination to assess the nature and severity of the left shoulder and back disabilities. After reviewing the electronic claims file, interviewing the Veteran, and examining him, the examiner should answer the following questions: Left shoulder (minor extremity) Is left arm flexion and/or abduction limited to 25 degrees from the Veteran's side? Back Is forward flexion of the thoracolumbar spine 30 degrees or less? In answering questions related to range of motion, detail loss of motion during flare ups, after repeated use over time, during active and passive motion, and while weight bearing and nonweight bearing (if possible). In the October 2017 and November 2018 VA reports of record, the examiners stated that limitation after repeated use over time was "neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time." Elicit from the Veteran details regarding any such limitations associated with repeated use over time, and estimate if possible the range of motion of the left shoulder and thoracolumbar spine during such periods. (Continued on the next page) The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher McEntee 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.