07-26 615, 07-26 615

Veteran served on active duty from December 1965 to September 1967 and appealed a VA RO October 2006 rating decision denying higher disability ratings for left shoulder residuals.
The Board previously remanded the appeal in October 2015 and the Veteran received a VA shoulder exam in December 2015 reporting increased symptoms.
The Board found the December 2015 examination did not fully comply with the requirements established in Correia for musculoskeletal exams under 38 C.F.R. § 4.59.
The Board remanded the claim for a new shoulder examination that includes active and passive range of motion testing, weight-bearing and non–weight-bearing measures, comparison to the contralateral shoulder, and explicit findings on weakened movement, fatigability, incoordination, and pain-related limitation.
The examiner must address functional loss during flare-ups and repeated use (per Mitchell), quantify additional ROM loss from pain if feasible, or explain why quantification is not feasible.
After obtaining outstanding VA treatment records and completing the compliant exam, the AOJ must adjudicate and, if unfavorable, issue a supplemental statement of the case and allow response.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Initial rating >20% before 11/29/2010 and >10% thereafter for left shoulder residuals	Veteran contends shoulder disability warrants higher rating based on increased symptoms and functional loss	VA contends current record/rating supported; existing exam insufficient under applicable standards	Remand: claim not decided on merits; new exam and records requested to permit proper adjudication
Adequacy of December 2015 VA shoulder exam	Veteran argues exam fails to document required ROM and functional loss details	VA/RO relied on exam but must comply with Correia and Mitchell requirements	Remand: exam inadequate; new exam must include active/passive ROM, weight-bearing/nonweight-bearing, contralateral comparison, and flare-up quantification or explanation
Requirement to address flare-ups and repeated use impact	Veteran asserts flare-ups produce additional functional loss and ROM loss	VA lacked sufficient opinion quantifying ROM loss from flare-ups	Remand: clinician must opine on ROM loss during flare-ups/repeated use and, if feasible, state degrees of additional ROM loss or explain inability to do so
Duty to obtain outstanding records	Veteran may have additional VA treatment records relevant to severity	VA must attempt to obtain and associate any outstanding records or document negative results	Remand: AOJ ordered to identify and obtain outstanding VA records and associate them with the claims file

Correia v. McDonald, 28 Vet. App. 158 (VA musculoskeletal exams must test active and passive motion, weight-bearing and nonweight-bearing, and compare to contralateral joint when possible)
Mitchell v. Shinseki, 25 Vet. App. 32 (examiner must address ROM loss due to pain and functional loss during flare-ups)
Kutscherousky v. West, 12 Vet. App. 369 (appellant may submit additional evidence and argument after remand)