Citation Nr: 1308623 Decision Date: 03/14/13 Archive Date: 03/25/13 DOCKET NO. 11-07 331 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to an initial compensable evaluation for a right groin strain. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served on active duty from March 1983 to February 1987. This matter comes to the Board of Veterans' Appeals (Board) from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran was afforded a Travel Board hearing in March 2012. A transcript of the testimony offered at this hearing has been associated with the record. 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 In furtherance of substantiating his claim, the Veteran was last afforded a VA examination in October 2011. A review of the examination documents that it was conducted using VA's Disability Benefits Questionnaire (DBQ) for evaluating Muscle Injuries. Also, an addendum was entered by the examiner in December 2011, identifying the muscle group and characterizing the extent of the injury. VA's duty to assist includes providing an adequate examination when such an examination is indicated. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Once VA provides an examination, it must be adequate or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An examination is adequate if it "takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." Barr, 21 Vet. App. at 311 (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). An examination must be based upon consideration of the Veteran's prior medical history and examinations. Stefl, 21 Vet. App. at 123. Neither the DBQ nor the addendum thereto address any range of motion in the Veteran's right hip. Notably, the December 2011 addendum identified that muscle group XV was affected and that this muscle group controlled adduction of the hip. Accordingly, the examination report is inadequate and must be returned. 38 C.F.R. § 4.2. Upon remand, the Veteran should be afforded a VA examination by a male examiner, if possible, as he has expressed feeling uncomfortable when examined in the groin by a female. See March 2012 Board hearing transcript. Along these lines, the Board notes that the RO has evaluated the Veteran's right groin strain under 38 C.F.R. § 4.73, Diagnostic Code 5313, which addresses muscle injuries to Muscle Group XV, which involves adduction of the hip. This diagnostic code typically involves examination of the residuals of gunshot or shell fragment wounds incurred in service, i.e., for the rating of residual muscle damage from such wounds. Although this diagnostic code may indeed be the most favorable one to apply in this case, as no diagnostic code squarely addresses a groin strain, upon remand the RO is advised to consider the applicability of 38 C.F.R. § 4.71a, Diagnostic Codes 5250-5255, which provide for evaluation of musculoskeletal disability of the hip and thigh. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). The Veteran is advised that it is his duty to report for the scheduled examination, cooperate with the examiner, and attempt all testing required in order to get an adequate picture of the severity of his disability. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination, addressing both the DBQ for Muscle Injuries and the DBQ for Hip and Thigh Conditions, to include a complete physical examination, in order to determine the current severity of his service-connected right groin strain. Any tests deemed necessary should be conducted, and all clinical findings should be reported in detail. The complete claims folder must be provided to the examiner for review in conjunction with the examination and the examiner should note in the examination report that the claims file was reviewed. Attention is invited to the Veteran's credible testimony before the Board in March 2012, as to how the disability affects him on a daily basis. The examination report should specifically state the degree of disability present in the Veteran's right hip and groin, his current range of motion of the hip, including where pain begins, as well as identify any objective evidence of pain. The examiner should also discuss how the Veteran's disability impacts his daily activities of living. If possible, schedule the Veteran for a VA examination to be conducted by a male examiner. The extent of any weakened movement and excess fatigability on use should be described. To the extent possible, the functional impairment due to weakened movement and excess fatigability on use should be assessed in terms of additional degrees of limitation of motion. Range of motion studies should be conducted using a goniometer and the use thereof should be noted in the examination report. Any and all opinions must be accompanied by a complete rationale. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 2. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claim, to include consideration of the rating criteria pertaining to the hip and thigh in 38 C.F.R. § 4.71a, Diagnostic Codes 5250-5255. If action remains adverse to the Veteran, provide the him and his representative a Supplemental Statement of the Case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters 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). _________________________________________________ BETHANY L. BUCK 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).