Citation Nr: 22017461 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 18-33 675 DATE: March 25, 2022 REMANDED Entitlement to a rating in excess of 20 percent for left shoulder rotator cuff tear is remanded. Entitlement to service connection for left foot metatarsalgia is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2004 to September 2012. This case comes before the Board of Veterans' Appeals (Board) April 2017 and May 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. In October 2021, the Veteran presented sworn testimony during a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's claims file. Entitlement to a rating in excess of 20 percent for left shoulder rotator cuff tear The Veteran's last examination for his left shoulder was in March 2017. However, at the October 2021 Board hearing, the Veteran testified that his disability had worsened since then. Specifically, he indicated that there had been increased weakness and his range of motion decreased after activity. Therefore, this claim must be remanded for a new VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity); Caffrey v. Brown, 6 Vet. App. 377, 381 (1995). Entitlement to service connection for left foot metatarsalgia The Veteran received a VA examination in January 2019. The examiner noted a reported crush injury while in service, but opined that the condition was less likely than not caused by service, as service records did not support any incident or evidence of forefoot pain or consistent symptoms. The Board notes that a medical opinion based solely on the absence of documentation in the record is inadequate and that a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). The matters are REMANDED for the following action: 1. Schedule the Veteran for VA examinations in order to determine the current severity of his service-connected left shoulder rotator cuff tear. The claims file must be made available to and be reviewed by the examiner. All tests deemed necessary should be conducted, and the results reported in detail. Full range of motion testing must also be performed. The left leg must be tested in both active and passive motion, in weight-bearing and nonweight-bearing, and, if possible, with the range of the opposite undamaged left shoulder. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also request that the Veteran identify the extent of his functional loss during flare-ups and, if possible, offer range of motion estimates based on that information. If the examiner is unable to provide an opinion on the impact of flare-ups on the Veteran's range of motion, he/she should indicate whether this inability is due to lack of knowledge among the medical community or based on the lack of procurable information. 2. Schedule the Veteran for an to determine the current severity and etiology of left foot metatarsalgia. The VA examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that left foot metatarsalgia is due to an event or incident of the Veteran's period of active service, to include a reported incident where a barbell fell on top of his foot. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Daniels, 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.