BVA9507912 DOCKET NO. 93-13-868 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a heart disorder secondary to a service-connected gunshot wound (GSW) to the left chest. 2. Entitlement to an increased rating for residuals of GSW to the left chest, currently evaluated as 20 percent disabling. 3. Entitlement to an increased rating for traumatic arthritis to the sternoclavicular joint, currently evaluated as 10 percent disabling. 4. Entitlement to an increased (compensable) rating for a sternotomy with residual fibrosis to the left lung. 5. Entitlement for an increased (compensable) rating for post- traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD William H. Hickman, Associate Counsel INTRODUCTION The veteran served on active duty between May 1969 and April 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 1992 and subsequent rating decisions of the Department of Veterans Affairs (VA), Houston, Texas, Regional Office (RO). The case was previously before the Board in January 1995 at which time it was administratively remanded in order to afford the RO an opportunity to adjudicate the veteran's claims for service connection for various disorders alleged to have been caused by exposure to Agent Orange during service. These claims were adjudicated in an RO rating decision dated in February 1995. As no notice of disagreement has been received into the record with respect to these claims, they are not before the Board at this time. The case is now before the Board for appellate review. REMAND The Board notes that the most current VA orthopedic examination of record dated in November 1991 did not list the ranges of motion for the left arm. The VA Physician's guide for Disability Evaluation Examinations, 2-1 (March 1985), indicates that the extrinsic muscles of the shoulder girdle, muscle group II, control some of the movements of the arm. The orthopedic examiner on the VA examination dated in November 1991 indicated that the muscles exposed to the GSW trauma are the muscles in muscle group II. Therefore, it is necessary, in order to be able to accurately rate the residual functional impairment, if any, in veteran's muscles in muscle group II, for the Board to have before it the results of range of motion studies for the left arm. Additionally, the Board notes that the veteran at the time of the VA orthopedic examination in November 1991 had complaints with regard to his left arm and shoulder experiencing fatigability. Although the VA orthopedist reported that there was no muscular atrophy in the applicable muscle group, there was nothing on the examination to compare the endurance of the muscles affected by the GSW residuals in the veteran's left chest and shoulder area with the corresponding muscle groups on the veteran's right side. That is, comparison studies by which the veteran's complaints of fatigability could be measured. In this regard, the VA Physician's Guide for Disability Evaluations (March 1985) in section 2-2 directs that examinations concerning the evaluation of muscle functions, give an indication of the muscles capacity for prolonged use. Since the veteran is contending that his ability to perform physical work is diminished due to the left shoulders fatigability, it is necessary to evaluate the muscle group in the affected area for endurance. Additionally, the veteran is claiming that he has neurological symptoms that are part and parcel of the service-connected GSW residuals. During a VA surgical examination in November 1991 it was stated that the veteran presented with numbness of the left side of the body and left arm secondary to damage to the brachioplexus on the left side. Although on the VA neurological examination it was indicated that no sensory deficits were found, the Board notes that this examination did not include any nerve conduction studies. While such studies are not required as part of a neurological examination, inasmuch as the veteran has continuing complaints of a left side neurological deficit, and inasmuch as this symptomatology, if existent, may be intertwined with the veteran's complaints of left arm muscle fatigue, further exploration of the subject is warranted. Also, the Board notes that on the VA orthopedic examination it was reported that the veteran's left sternoclavicular joint was ankylosed and did not sublux. The veteran had complaints that this joint interfered with rotation of his cervical spine. While a disorder of the cervical spine is not part of the veteran's service-connected disabilities, such a disorder, if existent, may be inextricably intertwined with the residuals of the sternotomy precipitated by the repair of the service connected GSW residuals to the left chest. As such further investigation and development of the record is warranted as to whether the veteran has a disorder of the cervical spine attributable to the residuals of the service-connected GSW residuals. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, since additional development of the record is required the case is remanded for the following actions: 1. The RO should inquire of the veteran if he has received medical treatment at either VA or other medical facilities for the service-connected GSW residuals, cervical symptomatology, or for neurological symptomatology on his left side or arm, since November 1991. If so, the RO, after obtaining the necessary information and making the necessary arrangements, should associate with the claims folder those medical records not already of record. 2. Subsequently the veteran should be scheduled for VA examination by an orthopedist and neurologist to determine the nature and extent of the pathology present, if any, in the muscle groups of the left chest, left shoulder, and left arm; as well as the nature and extent of any pathology present in the left sternoclavicular joint and cervical spine. All necessary testing should be accomplished including nerve conduction, radiographic, MRI, and CAT studies if appropriate, and the examiners should review the results of any testing prior to the completion of their reports. It is requested that the ranges of motion for the left arm and cervical spine be recorded in degrees, and that the examiners comment on the degree of painful motion, if any, that is present. The reports of examination should include a detailed account of any pathology present in the specified areas. The examiners should offer written opinions as to the extent, if any, that pathology attributable to the veteran's service- connected disorders impairs the use of the veteran's left arm and shoulder, written opinions as to whether the residuals of sternotomy to the left sternoclavicular joint have caused impairment in the function of, or pathology to, the cervical spine, and written opinions as to whether the veteran has neurological pathology attributable to the service-connected GSW residuals. The examiners must provide complete rationale for all conclusions reached. The claims folder as well as a copy of this remand must be made available to and reviewed by the examiners prior to their examinations. 3. Following completion of the above actions, the RO should review the examination reports and determine if they are adequate for rating purposes and in compliance with this remand. If not, the reports should be returned for corrective action. 4. Subsequently, the RO should readjudicate the veteran's claims for increased ratings for the service-connected GSW residuals including the residual of traumatic arthritis to the sternoclavicular joint. Additionally, the RO should adjudicate the issues of whether the veteran should be service-connected for a separate neurological and/or cervical spine disorder(s) secondary to the service- connected GSW residuals. For any claim which remains denied, the RO should issue the veteran and his representative, a supplemental statement of the case and give them a reasonable opportunity to respond thereto. Additionally, the veteran should be given the opportunity to file a notice of disagreement as to the denial of any issue involving secondary service connection for pathology attributable to the service-connected GSW residuals and a chance to include the issues of secondary service connection for pathology attributable to the service-connected GSW residuals as part of his current appeal if it is his desire to do so. Thereafter, the case should be returned to the Board for further appellate review. The purpose of this remand is to further develop the evidence and afford the appellant due process of law. By this remand the Board intimates no opinion, either factual or legal, as to the ultimate disposition of the issues on appeal. The issues of service connection for a heart disorder secondary to the service- connected GSW residuals, and the issues of increased (compensable) ratings for service-connected PTSD and infiltrates to the lungs as a result of the residuals of a sternotomy are deferred pending completion of the actions associated with this remand. No action is required by the veteran until he receives further notice from the RO. Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).