Citation Nr: 18144143 Decision Date: 10/24/18 Archive Date: 10/23/18 DOCKET NO. 15-09 180 DATE: October 24, 2018 REMANDED Entitlement to service connection for left foot plantar fasciitis is remanded. Entitlement to service connection for mitral valve prolapse (originally claimed as a heart murmur) is remanded. Entitlement to service connection for left knee strain is remanded. Entitlement to an increased initial evaluation in excess of 10 percent prior to May 31, 2012 and from August 1, 2012 to November 4, 2014 and in excess of 20 percent prior to November 10, 2016 and from March 1, 2017 to present for service-connected degenerative joint disease of the lumbosacral spine. Entitlement to an increased initial evaluation in excess of 10 percent for left wrist strain. Entitlement to an increased initial evaluation in excess of 10 percent for right knee chondromalacia patella. Entitlement to an increased initial evaluation in excess of 10 percent for blepharitis with Salzmann’s nodular degeneration. REASONS FOR REMAND The Veteran had active service from May 1977 to May 1981; from September 1, 2005, to September 15, 2005; and from April 2009 to April 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Blepharitis, Heart, Bilateral Knees, and Left Wrist It is noted that the Veteran was last provided with VA examinations regarding increased severity for her blepharitis, right knee, and left wrist as well as and etiology examination regarding left knee in November 2017 and an etiology examination regarding her heart in June 2017. Additionally, there have been VA outpatient treatment records detailing treatment for each of these conditions dated from October 2016 to present since the last supplemental statement of the case (SSOC). However, there is no indication that such has been reviewed by the RO in the first instance, as there have been no subsequent rating decisions or SSOC discussing such. The Board recognizes that, although the Veteran’s substantive appeal was received after February 2, 2013, (in March 2015), the automatic waiver provision does not apply because this additional evidence was obtained by VA and was not submitted by the Veteran. See Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 to provide that if new evidence is submitted with or after a substantive appeal received on or after February 2, 2013, then it is subject to initial review by the Board unless the Veteran explicitly requests agency of original jurisdiction (AOJ) consideration). As noted above, this provision only applies to evidence submitted by the Veteran. Therefore, the issues must be remanded to allow for AOJ consideration of the additional evidence received from the last SSOC in October 2016. 2. Lumbar Spine The Board observes that a recent precedential opinion that may impact this case was issued by the Court. In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. In this case, the examination forms used in the administration of the Veteran’s prior VA examinations (her last being administered in October 2016) appears to have used a format that did not contain any discussion of these presentations as appear to have been contemplated by the holding in Correia. Accordingly, the Veteran should be afforded a new VA examination for the lumbar spine to comply with this case. Additionally, this remand will also afford the RO the opportunity to ask the clinician who conducts the VA examination requested above to apply a decision issued by the Court, Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court noted that the VA’s Clinician’s Guide specifically advises examiners to try to procure information necessary to render an opinion regarding flares from Veterans. The Court in Sharp found that the examination in question in that case to be inadequate because the examiner, although acknowledging that the appellant was not then suffering from a flare of any of her conditions, failed to ascertain adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding her flares by alternative means. Id. The prior VA examinations discussed above did not reflect the considerations required by Sharp, and the instructions to the examiner below will request such consideration. 3. Plantar Fasciitis The Veteran contends that she suffers from left foot plantar fasciitis that is the result of military service. In this regard, she has provided that she first began experiencing this condition after prolonged walking during her duties in Kuwait in 2010. The RO previously provided the Veteran with a VA examination for this condition in June 2010. Upon a review of the record, subjective interview, and objective testing, the VA examiner diagnosed the Veteran with left foot plantar fasciitis and heel spurring. However, the VA examiner did not provide an opinion regarding etiology and there have been no indications of such opinion in the Veteran’s outpatient treatment records. Thus, the Board finds that the June 2010 VA examination report is incomplete, as it does not provide an opinion regarding a nexus for the Veteran’s current disability to her complaints of in-service onset. Hence, additional medical guidance is required in order to decide this claim. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Accordingly, the Veteran’s claims file should be returned to the June 2010 VA examiner so that an addendum etiology opinion may be provided. A complete rationale for any opinion rendered must be provided. Additionally, as this case must be remanded for the foregoing reasons, any recent VA records should also be obtained. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (c) (2017); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The matters are REMANDED for the following action: 1. Appropriate efforts must be made to obtain all available VA treatment records that have not already been associated with the record. 2. The RO should review the June 2017 and November 2017 VA examinations as well as VA outpatient treatment records received since October 2016 for the Veteran’s blepharitis, heart, bilateral knees, and left wrist in the first instance. 3. Thereafter, schedule the Veteran for appropriate VA examinations to evaluate the service-connected degenerative joint disease of the thoracolumbar spine. The electronic record should be made available to the examiner. All appropriate tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should conduct range of motion testing of the lumbar spine (expressed in degrees) in active motion, passive motion, weight-bearing and nonweight-bearing. The examiner should note the point at which pain begins in the range of motion. The examiner should also render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination associated with the lumbar spine. If pain on motion is observed, the examiner should indicate the point at which pain begins. In addition, the examiner should indicate whether, and to what extent, the Veteran experiences likely functional loss of the lumbar sprain due to pain and/or any of the other symptoms noted above during repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. The examiner should also describe the functional limitations resulting from the lumbar spine, to include during flare-ups. If flare-ups are not shown during the examination, the examiner should conduct efforts to obtain adequate information regarding the impairment resulting from flare-ups by alternative means, to include statements as to any such impairment by the Veteran herself. Any opinions expressed in the report should be fully explained. 4. Return the Veteran’s record to the VA examiner who conducted the June 2010 VA examination. If that examiner is no longer available, then to another appropriate examiner. Any necessary testing should be completed and the examiner should discuss the current severity of the Veteran’s disability, to include any functional limitations or effects on occupation or activities of daily living. The examiner should provide an opinion as to whether it is it at least as likely as not (a 50 percent or greater probability) that any currently diagnosed left foot disability (to include left foot plantar fasciitis and heel spurring) had its onset in service, or was caused by any incident that occurred during service, including the Veteran’s account of prolonged walking while stationed in Kuwait in 2010. Any opinions expressed in the report should be fully explained. 5. After completing the above actions, the claim should be re-adjudicated. If it remains denied, a SSOC should be provided to the Veteran and her representative. After the Veteran and her representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. J. CONNOLLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Dodd, Counsel