Citation Nr: 22016959 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 17-29 250 DATE: March 23, 2022 ORDER Entitlement to an increased rating of 30 percent, but no higher, for limitation of motion of the left shoulder from June 1, 2014, to March 3, 2015, is granted. Entitlement to an increased rating of 30 percent, but no higher, for limitation of motion of the left shoulder from May 1, 2015, to November 10, 2015, is granted. Entitlement to an increased rating of 30 percent, but no higher, for limitation of motion of the left shoulder beginning January 1, 2016, is granted. REMANDED Entitlement to service connection for a right upper extremity disability, to include pain, limitation of motion of the right shoulder, and radiculopathy/neuropathy, is remanded. FINDINGS OF FACT 1. On February 6, 2014, the Veteran submitted a claim for temporary evaluation of 100 percent [for his service-connected limitation of motion of the left shoulder] based on surgical treatment necessitating convalescence. 2. In an April 2014 rating decision, a temporary evaluation of 100 percent was assigned effective March 26, 2014, based on surgical or other treatment necessitating convalescence. An evaluation of 10 percent for the service-connected limitation of motion of the left shoulder was continued on June 1, 2014. 3. On February 23, 2015, the Veteran submitted a claim for temporary evaluation of 100 percent based on surgical treatment necessitating convalescence. 4. In an August 2015 rating decision, a temporary evaluation of 100 percent was assigned effective March 4, 2015, based on surgical or other treatment necessitating convalescence. An evaluation of 10 percent for the service-connected limitation of motion of the left shoulder was continued on May 1, 2015. 5. On November 12, 2015, the Veteran submitted a claim for temporary evaluation of 100 percent based on surgical treatment necessitating convalescence. 6. In a July 2016 rating decision, a temporary evaluation of 100 percent was assigned effective November 11, 2015, based on surgical or other treatment necessitating convalescence. An evaluation of 10 percent for the service-connected limitation of motion of the left shoulder was continued on November 1, 2016. 7. In a May 2017 rating decision, the evaluation of the service-connected limitation of motion of the left shoulder was increased to 20 percent disabling effective: June 1, 2014, to March 3, 2015, from May 1, 2015, to November 10, 2015, and from January 1, 2016. 8. The weight of the persuasive evidence shows that for the period on appeal from June 1, 2014, to March 3, 2015, the Veteran's left shoulder disability more nearly approximates left arm motion limited to 25 degrees from the side, which warrants the maximum percent rating for left [minor] shoulder. 9. The weight of the persuasive evidence shows that for the period on appeal from May 1, 2015, to November 10, 2015, the Veteran's left shoulder disability more nearly approximates left arm motion limited to 25 degrees from the side, which warrants the maximum percent rating for left [minor] shoulder. 10. From January 1, 2016, the Veteran's left shoulder disability more nearly approximates left arm motion limited to 25 degrees from the side, which warrants the maximum percent rating for left [minor] shoulder. CONCLUSIONS OF LAW 1. For the period on appeal from June 1, 2014, to March 3, 2015, the criteria for a 30 percent rating, but no higher, for limitation of motion of the left shoulder [minor] are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201. 2. For the period on appeal from May 1, 2015, to November 10, 2015, the criteria for a 30 percent rating, but no higher, for limitation of motion of the left shoulder [minor] are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201. 3. The criteria for an evaluation of 30 percent, but no higher, for limitation of motion of the left shoulder [minor] are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 2004 until his honorable discharge in October 2005. This case has a long procedural history, initially coming to the Board on appeal of a September 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office. In October 2020, the Board remanded this matter to the Agency of Original Jurisdiction to afford the Veteran additional VA examinations and medical opinions. The matter has now been returned for appellate consideration. Increased Rating The Veteran is seeking an increased disability rating for his left shoulder disability. He is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his service-connected disabilities. Layno v. Brown, 6 Vet. App. 465 (1994). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service. and their residual conditions in civilian occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). VA regulations allow for the assignment of an increased rating up to one year prior to receipt of a claim for increase, when it is factually ascertainable that an increase in the disability had occurred. 38 C.F.R. §§ 3.157, 3.400. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestations of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. When there is a question as to which of two evaluations shall be assigned the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. A claim will be denied only if the weight of the persuasive evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). In determining the appropriate evaluation for musculoskeletal disability, particular attention is focused on functional loss of use of the affected part(s). Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidence by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability, and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45 but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the U.S. Court of Appeals for Veterans Claims (Court) held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factor, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board notes here, that the Veteran was provided with VA examinations in May 2015, June 2018, and December 2021. The May 2015 VA examination is not adequate as it does not comply with the requirements of Correia and Sharp, and the June 2018 VA examination is not adequate as it does not comply with Sharp and the requirements of 38 C.F.R. § 4.59. When VA requests an examination report, it is necessary to provide an adequate one or else explain to the claimant why one cannot be provided. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds the December 2021 VA examination complies with Correia and Sharp by explaining that joint limitations with respect to the Veteran's left shoulder are as described in the VA examination. Unfortunately, the earlier failures to comply with VA's duty to assist necessarily resulted in the loss of certain evidence concerning range of motion during flare-ups, after repeated use over time, and on passive motion and in non-weight-bearing where applicable. Accordingly, the Board has considered increased ratings, and awarded them where appropriate, as a way to avoid the possibility that inadequacies in earlier examination reports could potentially prejudice the Veteran. 1. Entitlement to an increased rating of 30 percent, but no higher, for limitation of motion of the left shoulder from June 1, 2014, to March 3, 2015, is granted. 2. Entitlement to an increased rating of 30 percent, but no higher, for limitation of motion of the left shoulder from May 1, 2015, to November 10, 2015, is granted. 3. Entitlement to an increased rating of 30 percent, but no higher for limitation of motion of the left shoulder beginning January 1, 2016, is granted. On February 6, 2014, the Veteran submitted a claim for temporary evaluation of 100 percent [for his service-connected limitation of motion of the left shoulder] based on surgical treatment necessitating convalescence. As noted above, the Veteran has been granted a temporary evaluation of 100 percent effective March 26, 2014 to May 31, 2014, from March 4, 2015 to June 30, 2015, and from November 11, 2015 to December 31, 2016, based on surgical treatment necessitating convalescence. 38 C.F.R. § 4.30. Because the 100 percent rating assigned for the Veteran's service-connected left shoulder disability is the maximum rating available for this disability, a higher rating claim for a left shoulder disability for these periods is not on appeal. Currently, the Veteran has a 20 percent rating for his left shoulder disability from June 1, 2014 to March 3, 2015; from May 1, 2015 to November 10, 2015; and from January 1, 2016, under Diagnostic Code (DC) 5201. In general, disabilities of the shoulder and arm are rated under 38 C.F.R. § 4.71a, DCs 5200 through 5203. A distinction is made between major (dominant) and minor (non-dominant) musculoskeletal groups for rating purposes. 38 C.F.R. § 4.69. In this case, the record clearly indicates that the Veteran is right hand dominant. As such the left shoulder disability is rated as a minor joint. Under DC 5201 (minor), a rating of 20 percent is warranted for limitation of motion at the shoulder level (e.g., flexion to 90 degrees). A 20 percent rating is warranted for limitation of motion midway between side and shoulder level. A 30 percent rating is warranted for limitation of motion to 25 degrees from the side. 38 C.F.R. § 4.71a, DC 5201. Effective February 7, 2021, clarifying amendments were made to DC 5201. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5100(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the older criteria prior to February 7, 2021, and both the old and new criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Under the new criteria, under DC 5201 (minor), a rating of 20 percent is warranted for limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees). A rating of 20 percent is warranted for limitation of motion midway between side and shoulder level (flexion and/or abduction limited to 40 degrees). A rating of 30 percent is warranted for limitation of motion of flexion and/or abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a, DC 5201. DC 5201 does not provide separate ratings for limitations of flexion, extension, abduction, and rotation, but rather permits only a single rating for limitation of an arm. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013). For VA compensation purposes, normal range of motion of the shoulder is forward elevation (flexion) to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71a, Plate I. After review of the evidence, lay and medical, the Board finds that, for the rating periods on appeal, the criteria for a 30 percent rating, but no higher, for the left shoulder disability has been met or more nearly approximated. Throughout these periods on appeal, the left shoulder disability more nearly approximates left arm motion limited to 25 degrees from the side, with consideration of functional loss due to pain, after repeated use, and during flare-ups. In April 2014, the Veteran submitted private treatment records from Dr. W.N., of the Murfreesboro Medical Clinic. These records confirm that in February 2014 the Veteran underwent spinal cord stimulator trial for chronic pain affecting the thoracic spine, ribs and chest, back, legs, abdomen, and pelvis. On March 26, 2014, the Veteran underwent placement of permanent spinal cord stimulator leads and generator for chronic pain management. Throughout 2014, Dr. W.N., noted the Veteran would need the following restrictions: no lifting greater than 15-30 pounds, no repetitive bending, lifting, or twisting. In June 2014, Dr. C.I., of Genesys Family Medicine, stated the Veteran is suffering from permanent left sided thoracic neuropathic damage due to his surgical lobectomy in 2004. In his August 2014 correspondence, the Veteran reported chronic daily pain. Because of the spinal cord stimulator, he must avoid non-pressurized flights, scuba diving, large crowds, freezing cold, and hot weather. He is also limited with bending, twisting, pulling, pushing, reaching, standing, stretching, and standing for long periods. In July 2014, D.D., the Veteran's Manager at the Army and Air Force Exchange Service, stated the Veteran's physical ability has deteriorated and he is limited in activities such as lifting and being unable to raise his arms above his head. D.D. stated, the Veteran's physical ability to do even simple things has gotten worse. In his December 2014 correspondence, the Veteran reported suffering drastic limitations in most ranges of motion and primary functions, stating the evidence demonstrates that he is "totally disabled." In January 2015, the Veteran reported no longer receiving benefit from his spinal cord stimulator. In February 2015, Dr. W.N. sought approval for spinal cord stimulator revision. On March 4, 2015, the Veteran presented to Cool Spring Surgery Center for revision/replacement of spinal cord stimulator for chronic post thoracotomy pain, causalgia, and discogenic pain. Dr. W.N. stated the Veteran would be absent from work from March 4, 2015, until April 6, 2015. During the May 2015 VA examination the Veteran reported the following symptoms: pain, numbness and tingling of the left shoulder and arm. He reported functional loss/functional impairment of the left shoulder which he described as pain with lifting/pulling. On examination, initial range of motion testing demonstrated flexion to 140 degrees with objective evidence of pain; abduction to 140 degrees with objective evidence of pain; external rotation to 90 degrees; and internal rotation to 90 degrees. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion. The examiner remarked the Veteran's pain from the thoracotomy, coupled with the spine stimulator would interfere with any physical work requiring repetitive lifting/pulling. In October 2015, Dr. W.N. confirmed the Veteran would be undergoing a spinal cord stimulator revision on November 11, 2015, and he would need to remain out of work until December 12, 2015. In May 2018, the Veteran presented to the Tennessee Valley HCS for long-term opioid treatment for chronic pain. The Veteran's spinal cord stimulator leads malfunctioned/fractured, therefor on May 31, 2018, the Veteran underwent spinal cord stimulator removal. During the June 2018 VA examination the Veteran reported daily pain, worse since the stimulator was removed. The examiner diagnosed limitation of motion of the left shoulder secondary to scarring, status post pneumothorax and placement of thoracic spine stimulator (removed). The Veteran did not report flare-ups or functional loss/functional impairment. On examination, initial range of motion testing demonstrated flexion to 170 degrees with objective evidence of pain; abduction to 170 degrees with objective evidence of pain; external rotation to 90 degrees; and internal rotation to 90 degrees. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion. He was examined immediately after repetitive use over time. Muscle strength testing of shoulder forward flexion and abduction was normal (5/5). There was no muscle atrophy. There was no ankylosis. A rotator cuff condition was suspected. Regarding Correia, the examiner remarked there was no evidence of pain on passive range of motion testing, there was no evidence of pain when the joint is used in non-weight-bearing, and the opposing joint was undamaged. In March 2019, because of the failed spinal cord stimulator and chronic post-thoracotomy pain, the Veteran was recommended for, and began receiving Ketamine infusion therapy. In accordance with the September 2021 Board remand, the Veteran was afforded a VA examination in December 2021. During the examination, the Veteran stated his left shoulder pain and numbness has worsened. His current treatment plan included nerve ablations, Lyrica, Xtampza ER, and Oxycodone IR. He reported flare-ups of the left shoulder occurring several times a month; precipitated by using his arm to work at, and above, shoulder level; they are alleviated by pain medication; at a severity level of 8 of 10. He reported functional loss or functional impairment as being unable to lift more than 20 pounds and lost precision due to tremor in his left hand. On examination, initial active range of motion testing demonstrated flexion to 80 degrees, abduction to 100 degrees, internal rotation to 40 degrees, and external rotation to 40 degrees, with objective evidence of pain on motion. The examiner stated pain and fatigability significantly limit functional ability with at least three repetitions and repeated use over time. Range of motion testing demonstrated flexion to 70 degrees, abduction to 90 degrees internal rotation to 40 degrees, and external rotation to 30 degrees. Although the Veteran was not examined during a flare-up, the examiner stated pain, fatigability, and lack of endurance significantly limit function ability with flare-ups. The examiner described the functional loss in terms of range of motion as flexion to 60 degrees, abduction to 70 degrees, internal rotation to 30 degrees, and external rotation to 30 degrees. There was no muscle atrophy. There was no ankylosis. A rotator cuff condition was suspected, and Hawkins' impingement test, empty can test, external rotation/infraspinatus strength test, crank apprehension and relocation test, and cross-body adduction test were positive. The examiner remarked, "passive range of motion testing was medically contraindicated as it may cause the Veteran severe pain or the risk of further injury. It is not medically advisable to conduct passive range of motion testing because Veteran had significant pain on active range of motion." Given the totality of the evidence when considering the Veteran's competent and credible reports of limited left shoulder motion and pain, combined with his consistent reports of flare-ups, the Board finds a 30 percent rating, but no higher is warranted. In reviewing the evidence, the Board has considered functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40; DeLuca, 8 Vet. App. 202. The Board has also considered the effects of less movement than normal, weakened movement, fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45. The Board accepts the Veteran's competent and credible assertions that his left shoulder is painful and as described, he has additional loss of motion and pain during flare-ups. The May 2015 VA examination provides objective evidence of pain, numbness, and tingling of the left shoulder and arm with functional loss/functional impairment. The examiner remarked the Veteran's pain from the thoracotomy, coupled with the spine stimulator would interfere with any physical work requiring repetitive lifting/pulling. The June 2018 examiner diagnosed limitation of motion of the left shoulder secondary to scarring, status post pneumothorax and placement of thoracic spine stimulator (removed); a rotator cuff condition was suspected. The December 2021 examiner noted the Veteran's reports of flare-ups to a severe level, lasting a variable duration, precipitated by use of the arm at, or above, shoulder level, and alleviated by pain medication and rest. Given this, and resolving all doubt in favor of the Veteran, the weight of the persuasive evidence demonstrates limited left arm motion that more nearly approximates left arm motion limited to 25 degrees from the side, which warrants the maximum percent rating for left [minor] shoulder. While range of motion testing over the appeal typically did not, by itself, approximate motion limited to 25 degrees from the side, the Veteran clearly suffers from severe symptoms as a result of his left shoulder disability. The overall disability, with consideration of pain, weakness, and other factors, then more nearly approximates limitation of motion to 25 degrees from the side. Regarding other diagnostic codes, a higher rating under the other applicable diagnostic codes is also not warranted. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). To that end, the Board finds that DCs 5200 and 5203 are not applicable. For example, he has not been shown to have unfavorable ankylosis of scapulohumeral articulation with abduction limited to 25 degrees from the side, DC 5200; or fibrous union of the humerus. DC 5202. The Board acknowledges the Veteran's assertions that his service-connected left shoulder disability warrants a higher evaluation. In determining the actual degree of disability however, contemporaneous medical records and an objective examination by a health professional are more probative of the degree of the Veteran's impairment. This particularly so where the rating criteria require analysis of the clinically significant symptoms and objectively measurable criteria. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In sum, the weight of the persuasive evidence establishes that the Veteran's service-connected left shoulder disability was manifested by left arm motion limited to 25 degrees from the side. To the extent that the Veteran seeks an even higher rating, the approximate balance of the evidence is against the claim. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.71a; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). Thus, entitlement to a 30 percent rating, but no higher, from June 1, 2014 to March 3, 2015, from May 1, 2015 to November 10, 2015, and beginning June 1, 2016, is granted. REASONS FOR REMAND Entitlement to service connection for a right upper extremity disability, to include pain, limitation of motion of the right shoulder, and radiculopathy/neuropathy, is remanded. The claim for "peripheral neuropathy right upper extremity" may encompass claims for any disability that may reasonable be encompassed by several factors, including the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or that the Secretary of VA obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Board has taken an expansive view of the Veteran's claim for service connection for "nerve damage", "peripheral neuropathy", and "nerve paralysis" pursuant to Clemons, and recharacterized the issue as shown on the cover page of this decision. The Veteran contends his right upper extremity disability was caused by service. In the alternative he contends his right upper extremity disability is secondary to his service-connected disabilities. The record reflects the Veteran was afforded a VA examination with opinion concerning his claim in December 2021, however the Board finds the examination is inadequate. As to the direct-service-medical opinion, the examiner opined it is less likely as not that the Veteran's right upper extremity peripheral neuropathy is caused by or related to service. As rationale, the examiner stated a review of the service treatment records (STRs) did not show any complains, diagnosis, or treatment for such complaint related to an injury during service. However, review of the Veteran's STRs shows the Veteran was referred for physical therapy from March 2005 to May 2005: "patient with history lung reduction surg secondary to bleb formation with chronic post shoulder and upper back pain." As to the secondary-service-connection opinion, the examiner opined the Veteran's right upper extremity peripheral neuropathy is less likely than not proximately due to or the result of the service-connected chronic thoracic back pain as the nerve roots leading to the right upper extremity peripheral neuropathy are located in the cervical spine. Furthermore, it is impossible to determine if the left upper extremity peripheral neuropathy aggravated the right upper extremity peripheral neuropathy. As rationale, the examiner stated, "all arenas concerning etiology of right upper extremity peripheral neuropathy have not been exhausted which would make such an opinion possible." The Board cannot make a fully informed decision on the issue of entitlement to service connection because the medical opinion is inadequate for decision-making purposes. Therefore, a remand for a VA examination with opinion, which addresses all the relevant evidence of record with adequate supporting rationale, is necessary prior to rendering a decision on the appeal. Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, an examination with opinion should be conducted. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should afford the Veteran an opportunity to submit or identify any outstanding pertinent evidence not already associated with the claims file. The AOJ should then attempt to obtain those records if the appropriate authorization is provided. 2. After completion of the above, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of any currently diagnosed right upper extremity disability, to include pain, limitation of motion of the right shoulder, and radiculopathy/neuropathy. The entire claims file and a copy of this Remand must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should address the following: (a.) Identify/diagnose any right upper extremity disorder, to include pain, limitation of motion of the right shoulder, and radiculopathy/neuropathy, that presently exists or that has existed during the appeal period. With respect to any right upper extremity disorder the examiner should provide the following opinion: 1. Whether it is as likely as not (an approximate balance of negative and positive evidence) that the disability(ies) had its onset in or is otherwise related to his military service. The examiner's attention is drawn to the Veteran's in-service March 2005 to May 2005 physical therapy records and the June 2005 Medical Evaluation Board. 2. Whether the disability is proximately due to the Veteran's service connected disabilities: (i) bullous lesion left lung, status post pneumothorax with residual dyspnea and chest pain; (ii) thoracotomy scar associated with bullous lesion left lung, status post pneumothorax with residual dyspnea and chest pain; (iii) scars of the anterior and posterior trunk status post thoracotomy associated with bullous lesion left lung, status post pneumothorax with residual dyspnea and chest pain; (iv) limitation of motion of the left shoulder secondary to scarring, status post pneumothorax and placement of thoracic spine stimulator; (v) peripheral neuropathy left upper extremity associated with thoracotomy scar; (vi) chronic thoracic back pain. 3. Whether the disability has been aggravated (worsened beyond its natural progression) by the Veteran's (above listed) service-connected disabilities. Please note that separate opinions addressing causation and aggravation are needed. (Continued on the next page) Please address the Veteran's lay statements regarding onset of symptomatology and any continuity of symptomatology since onset and/or since discharge from service. 3. A complete rationale must be provided. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. Steve Ginski Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Grace Johnk, 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.