Citation Nr: 22018576 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 16-59 624 DATE: March 29, 2022 REMANDED Entitlement to an evaluation in excess of 20 percent for lumbosacral disc disease is remanded. Entitlement to an evaluation in excess of 20 percent for right shoulder traumatic bursitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1967 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Here, the RO granted service connection for lumbosacral disc disease at 20 percent disabling, effective November 14, 2011, and right shoulder traumatic bursitis at 10 percent disabling, effective November 14, 2011. In October 2016, the Veteran's right shoulder traumatic bursitis was increased to an initial disability rating of 20 percent, effective November 14, 2011. This matter was previously before the Board in September 2019 and last in July 2021, when it was remanded for further development. 1. Entitlement to an evaluation in excess of 20 percent for lumbosacral disc disease is remanded. 2. Entitlement to an evaluation in excess of 20 percent for right shoulder traumatic bursitis is remanded. Pursuant to July 2021 Board remand instructions, the Veteran was afforded VA back and shoulder examinations in November 2021. Review of the record reveals that the Veteran underwent VA back examination in March 2019; however, the examinations do not comply with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (the examiner should "estimate the functional loss that would occur during flares."). The November 2021 VA examination reports both relate that the Veteran denied flare-ups but also reflect that he essentially identified and described flare-ups while discussing his current symptoms. Specifically, the shoulder examination reflects the Veteran's reports of worsening sharp throbbing pain, limited motion, tenderness, stiffness, reduced grip and inability to lift heavy items, weight bare or brush teeth. The Veteran noted he requires help with daily activities and is unable to put his shirt on from the pain and stiffness resulting from those movements. It was also reported that the Veteran had additional limitation of motion after repetitive use testing, was positive on all rotator cuff condition tests, and pain was noted on palpation. It was further noted that pain was productive of functional loss. The VA examination of the back similarly reflects the Veteran's reports that he is unable to sit, stand or walk for more than a couple of minutes, and has worsening sharp shooting back pain with limited motion radiating into the lower limbs. The Veteran additionally reported his back pain is so severe that he falls to the floor, resulting in an ER visit, cannot grocery shop, nor can he groom or use the toilet and shower without assistance at times. Guarding and muscle spasms were noted on examination. The Board notes that in its July 2021 remand instructions, it was underlined that the Veteran reported flare ups at all his prior VA back and shoulder examinations. Furthermore, remand instructions indicated that even if there were no flare ups reported during the examination, the examiner should still estimate any additional functional loss during flare-ups. Finally, Board instructions also indicated that the examiner was to provide a retrospective opinion as to the estimated range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing for the prior VA examinations conducted during the appeal period. This was not done. See Stegall v. West, 11 Vet. App. 268, 271 (1998) Thus, a remand is required for an addendum opinion that is complaint with Sharp and Stegall. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Updated VA and private treatment records should be associated with the record. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA and private treatment records pertinent to the Veteran's shoulder and back disabilities. 2. Thereafter, schedule the Veteran for examinations with an appropriate clinician(s) to assess the severity level of his lumbosacral disc disease and right shoulder traumatic bursitis. The examiner(s) is asked to assess the severity level of the Veteran's lumbosacral disc disease and right shoulder traumatic bursitis: a) In compliance with the Court in Correia, the examiner must test for pain and record the range of motion for the lumbosacral disc disease and right shoulder traumatic bursitis in active motion, passive motion, weight-bearing, and nonweight-bearing conditions and, if possible, with the range of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, or is not medically appropriate, then the examiner should provide a clear explanation as to why the testing was not conducted. b) The examiner must also express an opinion as to whether there would be additional functional impairment on repeated use over time or during flare-ups. The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range-of-motion loss, if possible. If the Veteran indicates that he is not currently experiencing a flare-up at the time of the examination, the examiner should still estimate any additional functional loss during flare-ups or on repeated use, based on the Veteran's description of his flares' severity, frequency, duration, and/or functional loss manifestations. c) The examiner must provide a retrospective opinion as to the estimated range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing for the prior VA examinations conducted during the appeal period. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, they should clearly explain so in the report. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). The examiner must also address all prior VA examinations of record as well as the Veteran's competent lay statements as to the severity of his disabilities. (Continued on next page) A complete rationale for all opinions is required. J. LEE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Comninos, Georgio 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.