Citation Nr: 22018793 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 13-10 243 DATE: March 30, 2022 REMANDED Entitlement to a compensable disability rating prior to November 29, 2012, and in excess of 20 percent thereafter for right acromioclavicular joint osteoarthritis, status post distal clavicle resection with dislocation is remanded. Entitlement to a disability rating in excess of 20 percent prior to July 15, 2019, and after November 1, 2019, for right acromioclavicular joint osteoarthritis, status post distal clavicle resection is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1989 until November 1991. In August 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. This appeal was last before the Board in November 2021 when it was remanded for further development. Unfortunately, for the reasons described below, there has not been substantial compliance with the Board's prior remand directives and another remand is now required. Stegall v. West, 11Vet. App. 268 (1998). Entitlement to a compensable disability rating prior to November 29, 2012, and in excess of 20 percent thereafter for right acromioclavicular joint osteoarthritis, status post distal clavicle resection with dislocation is remanded. Entitlement to a disability rating in excess of 20 percent prior to July 15, 2019, and after November 1, 2019, for right acromioclavicular joint osteoarthritis, status post distal clavicle resection is remanded. The claims must be remanded again because the December 2021 VA medical examination is inadequate. The Veteran's right shoulder disability is separately compensated for two aspects: limitation of motion and dislocation. The examination report is internally inconsistent and does not report range of motion findings in the left, undamaged joint. The examiner is further inadequate as to the severity of the manifestations of the dislocation aspect of the right shoulder disability. The examiner noted under the Veteran's report that he has right shoulder symptoms including pain 7/10 dull with movement and weight in the morning radiating to the neck, pain 8/10 dull with movement, and pain 9/10 sharp with movement and weight-bearing. However, under the initial range of motion section of the examination, the examiner stated there was no evidence of pain in active or passive motion or with weight-bearing. Additionally, the examiner noted that no functional loss or impairment is reported in the left shoulder, but it does not appear range of motion or other testing was performed on the left shoulder. Although the examiner indicated the left shoulder is damaged in the range of motion testing section of the examination, it appears the examiner mistakenly checked the box under left shoulder as the box for right shoulder remains uncompleted. 38 C.F.R. § 4.59 requires that the range of motion for the opposite, undamaged joint be reported, if possible. Because of the internal inconsistencies contained in the December 2021 examination report as well as the failure of the examiner to report range of motion findings for the left shoulder, the Board finds the examination inadequate for adjudication and non-probative. See Correia v. McDonald, 28 Vet. App. 158 (2016). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right acromioclavicular joint osteoarthritis, status post distal clavicle resection. The examiner must complete the corresponding VA disability benefits questionnaire (DBQ), provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should attempt to provide a RETROSPECTIVE OPINION, utilizing the medical records and lay history, and opine as to the severity of the (i) right shoulder range of motion and (ii) severity of the dislocation aspect of the disability from 2012 to the present. Any impairment, and any additional impairment due to repetitive use over time or flare-ups, should be assessed in terms of limitation to motion, if possible. IF THE EXAMINER IS UNABLE TO RENDER SUCH AN OPINION, THE EXAMINER SHOULD SPECIFICALLY STATE WHY AND PROVIDE A RATIONALE FOR THE DETERMINATION. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing and report the range of motion of the opposite, undamaged joint, if possible. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must 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). All provided opinions must be supported by complete rationale. 2. After completion of the above, review the completed examination to ensure that it comports with this remand and is otherwise adequate for adjudication. Specifically, verify that complete range of motion findings are provided; if not, obtain an addendum prior to readjudication of the claim. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.D. Collins, 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.