Citation Nr: 1306338 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 10-16 879 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an evaluation in excess of 10 percent for residuals, status-post stress fracture of the pelvis. ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1989 to March 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In the Veteran's April 2010 substantive appeal (VA Form 9), she requested to appear at a hearing before the Board by videoconference from the RO. In a subsequent April 2010 written submission, the Veteran requested withdrawal of her hearing request. The Veteran has not requested a new hearing since that time. As such, the Board acknowledges the Veteran's hearing request as withdrawn. 38 C.F.R. § 20.702(e) (2012). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Board finds that further development is necessary prior to final adjudication of the Veteran's claim. Historically, the Veteran sustained an injury during basic training that resulted in a stress fracture to the right side of her pelvis, also identified in the service treatment records as a pubic stress fracture. In a June 1990 rating decision, the Veteran was granted service connection for this injury and assigned a noncompensable rating effective March 17, 1990 under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5255 for residuals analogous to impairment of the femur. Hyphenated diagnostic codes including a diagnostic code ending in the digits "99" are used when there is no specifically applicable diagnostic code and the disability is rated by analogy. 38 C.F.R. § 4.27. The Veteran filed a claim for an increased disability rating in August 2008. In the May 2009 rating decision currently on appeal, the Veteran was granted an increased rating to 10 percent effective August 15, 2008 under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5236 for residuals analogous to sacroiliac injury and weakness. Ratings under Diagnostic Code 5236 are generally determined using the spine rating criteria with consideration of painful motion of joints under 38 C.F.R. § 4.59. The Board notes that residuals of a pelvic fracture must be rated with consideration of the regulation related to pelvic bones. This regulation provides that the variability of residuals following pelvic bone fractures necessitates rating on specific residuals, faulty posture, limitation of motion, muscle injury, painful motion of the lumbar spine, manifested by muscle spasm, mild to moderate sciatic neuritis, peripheral nerve injury, or limitation of hip motion. 38 C.F.R. § 4.67. The Veteran has reported chronic, aching pain in her pelvic area and a related right-side limp due to favoring the right leg that pulls her back muscles. While the pain has varied in severity, she has reported that it has been present since the original injury in service. During the October 2008 VA pelvic bone examination, there was pain in the mid-lower pelvic area below the pubis bone, an antalgic gait, and physical limitations on walking and standing. During the spine examination, there was a stooped posture with an antalgic gait favoring the right side and objective evidence of pain on active range of motion. Flexing the hips against resistance to check muscle strength caused pain in the right lower back and pelvis. The examiner diagnosed low back strain and found that it was not due to the fracture of the pelvis, as the pelvis was completely normal on x-ray and would not cause any biomechanical stress on the lower back. VA treatment records from December 2008 to April 2012 (located only in the Virtual VA paperless claims processing system (Virtual VA)) show intermittent reports of pain and some notations of an antalgic gait. In a March 2009 written submission from the Veteran's former private physician, he opined the Veteran's chronic pain following healing of the actual fracture was most likely ligamentous or tendinous pain, possibly periosteal pain from the covering of the bone secondary to her posttraumatic stress. A May 2009 Virtual VA treatment record shows that forward flexion was no more than 60 degrees with reproduction of pelvic pain. Palpation of the back was most tender over the right sacroiliac joint projection, and the straight leg raising test produced right groin pain. In her June 2009 notice of disagreement, the Veteran indicated that her symptoms continued to become more severe with each day. During the September 2012 VA hip and thigh examination, right hip flexion was 125 degrees or greater, with pain on motion beginning at 100 degrees. The examiner noted that the Veteran had no hip disorder associated with any sacroiliac disorder; anatomically, the two areas are unrelated. The Board is mindful that the Veteran filed a claim for service connection for a low back disorder, to include as secondary to the service-connected pelvis disability which was denied by the RO in the May 2009 rating decision, based in significant part on the findings in the October 2008 VA examination. However, in this case, the evidence of record suggests that the Veteran's low back symptomatology may be related to her pelvic disability, or alternatively, such that it cannot be distinguished from the symptomatology related to the residuals of the pelvic fracture. Moreover, although the October 2008 and September 2012 VA examinations appear to identify or rule out some aspects of the residuals of the pelvic fracture, the record reflects that all such residuals have not been clearly identified. In light of the above considerations, the Board finds that a complete examination and resulting medical opinion addressing the current severity of the Veteran's pelvis disability, to include specifically identifying the residuals of the pelvic fracture is needed to have sufficient medical evidence to decide the Veteran's claim. 38 C.F.R. § 3.159 (c)(4) (VA's duty to assist includes obtaining a medical examination or opinion where necessary to decide the claim.). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination by a physician to determine the current severity of the Veteran's service-connected pelvis disability, to include identifying the residuals of the pelvic fracture. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements, as well as any relevant treatment records in Virtual VA not otherwise associated with the claims file. The examiner should identify any current residuals of the pelvic fracture on examination, to include the following: faulty posture, limitation of motion, muscle injury, painful motion of the lumbar spine, manifested by muscle spasm, mild to moderate sciatic neuritis, peripheral nerve injury, or limitation of hip motion (38 C.F.R. § 4.67). To the extent possible, the examiner should distinguish between symptoms associated with the service-connected residuals of the pelvic fracture and any symptoms associated with a nonservice-connected disorder. If the examiner is unable to distinguish the symptomatology, the examiner should so state in the report. The supporting rationale for all opinions expressed must be provided. If the required opinion cannot be provided, the examiner should explain why the opinion cannot be provided. 2. If upon completion of the above action any benefit sought remains denied, the case should be returned to the Board after compliance with requisite appellate procedures. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2012).