Citation Nr: 18146302 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-28 319 DATE: October 31, 2018 ORDER Entitlement to a 10 percent initial evaluation for right hip strain with limitation of flexion is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a 10 percent initial evaluation for right knee patellofemoral pain syndrome is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for prolactinoma/pituitary bleeding is remanded. Entitlement to service connection for headaches is remanded. FINDINGS OF FACT 1. The preponderance of the evidence weighs in favor of a finding that the Veteran’s right hip strain has been painful, but that it has not been characterized by or resulted in ankylosis, limitation of extension to 5 degrees, limitation of flexion to 45 degrees or less, impairment of thigh, flail joint or impairment of femur. 2. The preponderance of the evidence weighs in favor of a finding that the Veteran’s right knee patellofemoral pain syndrome has been painful, but that it has not been characterized by or resulted in ankylosis, recurrent subluxation or lateral instability, meniscal conditions, limitation of flexion to 60 degrees or less or limitation of extension to 5 degrees or more, impairment of the tibia or fibula or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 10 percent disability evaluation for right hip strain with limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.59, 4.71a, Diagnostic Codes (DCs) 5250-5255. 2. The criteria for entitlement to a 10 percent disability evaluation for right knee patellofemoral pain syndrome have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.59, 4.71a, DCs 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2004 to July 2008. Increased Rating The Veteran claims entitlement to increased ratings for her service-connected right hip strain and right knee patellofemoral pain syndrome. The Board notes at the outset that, as discussed below, in the “Reasons for Remand” section, the Veteran indicated that she received medical treatment in relation to her claimed prolactinoma, pituitary bleeding and headaches at the La Jolla, CA VA medical center (VAMC). However, she did not indicate that she received any treatment for her right hip or right knee conditions there. Accordingly, the Board finds that in that regard, the Department of Veterans Affairs has fulfilled its duty to assist the Veteran in relation to the right hip and right knee claims decided below, and a remand to acquire her treatment records from the La Jolla VAMC is not necessary prior to the Board’s adjudication of those claims. See 38 C.F.R. § 3.159(c)(2)(i). Thus, the Board has proceeded to decide those claims herein, as follows. 1. Entitlement to an increased initial evaluation of right hip strain with limitation of flexion, currently 0 percent disabling Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When a claimant is assigned an initial disability rating or when a higher disability rating is granted during the direct appeal of the decision below, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, “pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system.” Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, actually painful joints are entitled to at least the minimum compensable rating for the joint. Also, functional loss due to pain must be supported by pathology and shown through objective observation. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). Here, the Veteran’s right hip strain is currently evaluated as 0 percent disabling (i.e., noncompensable) under DCs 5251, 5252 and 5253. DCs 5251-5253 provide that compensable evaluations (i.e., disability evaluations greater than 0 percent disabling) are warranted where there is limitation of extension of the thigh to 5 degrees, limitation of flexion of the thigh to 30 degrees or less, limitation of abduction of the thigh causing loss of motion beyond 10 degrees, limitation of adduction of the thigh preventing the crossing of legs, or limitation of rotation of the thigh preventing toe-out of the affected leg more than 15 degrees. 38 C.F.R. § 4.71a, DC 5251-5253. Normal range of motion of the hip is listed as 125 degrees of flexion and 45 degrees of abduction. 38 C.F.R. § 4.71a, Plate II. Also of note, compensable evaluations may be warranted for ankylosis of the hip under DC 5250, flail joint of the hip under DC 5254, and impairment of the femur under DC 5255. The Board finds that the most pertinent evidence related to this claim is comprised of the Veteran’s statements, her VA treatment records, and the report of a February 2014 VA examination. The Veteran claims that she has pain in her right hip. See, e.g., VA Form 21-0958, Notice of Disagreement received in February 2015. The VA treatment records show that the Veteran has complained of bilateral hip pain during the period on appeal; however, those records do not suggest that her right hip strain has been characterized by or resulted in ankylosis, limitation of extension to 5 degrees, limitation of flexion to 45 degrees or less, impairment of the thigh, flail joint or impairment of the femur. The February 2014 VA examination report shows that the examiner explicitly opined that the Veteran’s right hip strain has not been characterized by or resulted in any such conditions. To the extent that the Veteran claims that it is characterized by or has resulted in such symptoms, the Board finds that she is not competent to opine on such matters. Those issues are medically complex, as such diagnoses and determinations require certain medical education, training, experience and/or other credentials that the Veteran has not been shown to possess. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Considering the above, the Board finds that the preponderance of the evidence weighs in favor of a finding that the Veteran is not entitled to an increased evaluation under the provisions of any of the relevant diagnostic codes, as discussed above. See 38 C.F.R. § 4.71a, DC 5250-5255. However, because the Veteran does claim that her hip is painful, including but not limited to on movement, and because her VA treatment records do support that contention, the Board finds that she is entitled to a 10 percent (though not higher) disability evaluation pursuant to the provisions of 38 C.F.R. § 4.59, which reflects that “actually painful” joints are entitled to at least the minimum compensable rating, here 10 percent. 2. Entitlement to an increased initial evaluation of right knee patellofemoral pain syndrome, currently 0 percent disabling The laws and regulations set forth above also apply to the Veteran’s claim of entitlement to an increased initial evaluation of right knee patellofemoral pain syndrome, with the exception of the regulations detailing the hip-related diagnostic codes. The diagnostic codes implicated in the consideration of this issue (i.e., the issue of entitlement to an increased initial rating for right knee patellofemoral pain syndrome) include DCs 5256-5263. DCs 5256-5263 provide that compensable disability evaluations may be warranted for ankylosis of the knee, recurrent subluxation or lateral instability of the knee, dislocated semilunar cartilage or the symptomatic removal of semilunar cartilage (i.e., meniscal conditions), limitation of flexion of the knee to 45 degrees or less or limitation of extension of the knee to 10 degrees or more, nonunion or malunion of the tibia and fibula (i.e., impairment of the tibia and fibula) and for genu recurvatum. The Board finds that the most pertinent evidence related to this claim is also comprised of the Veteran’s statements, her VA treatment records and the report of a February 2014 VA examination. The Veteran claims that she experiences a great deal of pain in her right knee. See, e.g., VA Form 21-0958, Notice of Disagreement received in February 2015. However, the February 2014 VA examination report indicates that her right knee patellofemoral pain syndrome has not been characterized by or resulted in ankylosis, recurrent subluxation or lateral instability, meniscal conditions, limitation of flexion to 60 degrees or less or limitation of extension to 5 degrees or more, impairment of the tibia or fibula or genu recurvatum. Her VA treatment records do not show otherwise. Again, to the extent that the Veteran claims that her right knee is characterized by or has resulted in any such conditions, the Board finds that she is not competent to opine on such matters since they are medically complex and require certain medical education, training, experience and/or other credentials that the Veteran has not been shown to possess. See Jandreau, supra. Nevertheless, because of her credible complaints of significant pain in her right knee, including on movement of the joint, the Board finds that she is entitled to a 10 percent, though not higher, disability evaluation of her right knee under 38 C.F.R. § 4.59. REASONS FOR REMAND 1. Entitlement to service connection for prolactinoma/pituitary bleeding is remanded. As mentioned above, the Veteran indicated that she received medical treatment in relation to her claimed prolactinoma, pituitary bleeding and headaches at the La Jolla, CA VAMC. However, those records are not in the claims file. The Veteran’s treatment records from the Oceanside, CA VAMC are in the claims file, and those records reference prior treatment of the Veteran at the La Jolla VAMC. Also of note is the fact that the Veteran’s VA treatment records may be found using a different last name, according to a December 2013 VA Form 21-6789, Deferred Rating Decision. Those records should be obtained prior to the Board’s adjudication of this claim. Furthermore, the Veteran’s records from the Oceanside, CA VAMC indicate that the Veteran has a past medical history which includes a pituitary adenoma. Considering this evidence, together with her claims that her prolactinoma/pituitary bleeding symptoms began during her active duty service, the Board finds that the Veteran should be afforded a VA examination for the purpose of determining the etiology and approximate date of onset for her claimed prolactinoma and pituitary bleeding. 2. Entitlement to service connection for headaches is remanded. For the reasons set forth above, this claim must also be remanded so that the La Jolla VAMC records can be obtained. Additionally, because the Veteran claims that these claimed headaches are secondary to her prolactinoma and/or pituitary bleeding, she should be afforded an examination for this claimed condition, too. Specifically, the examiner should be asked to render opinions as to whether the Veteran’s claimed headaches began during or within one year of her active duty service and whether they were caused or aggravated by her claimed prolactinoma and/or pituitary bleeding. The matters are REMANDED for the following action: 1. Make efforts to obtain the Veteran’s records from the La Jolla, California VAMC, in accordance with the duties set forth in 38 C.F.R. § 3.159(c). Note that, as discussed above, the Veteran’s records may be found under a different last name (identified on the first page of this decision.) 2. Schedule the Veteran for a VA examination by an appropriate clinician to determine the nature and etiology of any prolactinoma, pituitary bleeding and headaches. The examiner must opine whether any such conditions found are at least as likely as not (a 50 percent or greater probability) related to an in-service injury, event, or disease. The examiner should also opine on whether any prolactinoma, pituitary bleeding and/or headaches are at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Finally, the examiner should also opine on whether it is at least as likely as not that any headaches are (1) proximately due to prolactinoma and/or pituitary bleeding, or (2) aggravated beyond its natural progression by prolactinoma and/or pituitary bleeding. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Banks, Associate Counsel