Citation Nr: 22018910 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 18-18 792A DATE: March 30, 2022 REMANDED Entitlement to an evaluation in excess of 30 percent for right shoulder capsulitis regional pain syndrome is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from September 1987 to July 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In the May 2015 rating decision, the RO denied a higher than 30 percent evaluation for right shoulder capsulitis including right upper extremity complex regional pain syndrome. The Veteran appealed for a higher evaluation. The Veteran testified before the undersigned Veterans Law Judge at a November 2021 Virtual hearing. A transcript of this hearing is of record. 1. Entitlement to an evaluation in excess of 30 percent for right shoulder capsulitis regional pain syndrome is remanded. The Veteran's last VA examination for his service-connected right shoulder capsulitis regional pain syndrome was in February 2018, more than four years ago. Further, at the November 2021 Board hearing, the Veteran testified that his right shoulder symptoms had worsened over the past four to five years. He described how he had right hand swelling and numbness, which made it difficult to hold and grasp items. He also said that he had been provided a compression sleeve for his right arm that he wore on a daily basis. He said that he had limited range of motion in his right shoulder, and that he had to use his left arm to compensate for the restrictions of his right shoulder. VA is required to afford the Veteran a contemporaneous VA examination to assess the current nature, extent, and severity of his service-connected disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also 38 C.F.R. § 3.326(a). As the Veteran's service-connected right shoulder capsulitis regional pain syndrome may have worsened since his last VA examination, a remand is required to determine the current severity of his service-connected disability. Moreover, the Board finds that the February 2018 VA examination is inadequate for rating purposes. The February 2018 VA examiner provided opinions which did not comply with the requirements of Sharp v. Shulkin, 29 Vet. App. 26 (2017) (holding that an opinion for whether the Veteran had additional functional loss during flare-ups or after repeated use over time for a musculoskeletal disability could not be provided without speculating was inadequate). Accordingly, a remand is required to obtain a new VA examination for the Veteran's right shoulder capsulitis regional pain syndrome that complies with Sharp. The matter is REMANDED for the following actions: 1. Obtain all outstanding treatment records for the Veteran's right shoulder capsulitis regional pain syndrome that are not currently of record, to include treatment records from the Veteran's private primary care physician in Anderson, South Carolina. 2. Schedule the Veteran for a VA examination by an appropriately qualified clinician (M.D.) to determine the current severity of his service-connected right shoulder capsulitis regional pain syndrome. The examiner should 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 also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of his right shoulder symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment 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. The examiner should comment on the extent of any functional impairment caused by the Veteran's service-connected right shoulder capsulitis regional pain syndrome, to include in an occupational setting and in performing ordinary, daily activities. All findings should be fully documented in the examination report. 3. Thereafter, review the requested VA medical examination and opinion report to ensure responsiveness and compliance with the directives of this remand; implement corrective procedures as needed. Compliance with the Board's remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). 4. After ensuring the above development has been completed, readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, send the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. Then, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Journet Shaw, 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.