Citation Nr: 18148159 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 17-64 864 DATE: November 6, 2018 REMANDED Entitlement to a rating in excess of 20 percent for a right shoulder strain is remanded. Entitlement to a compensable rating for a right hip strain with piriformis syndrome (right hip disability) with limited flexion is remanded. Entitlement to a compensable rating for a right hip disability with thigh impairment is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, depression, and bipolar disorder, is remanded. REASONS FOR REMAND The Veteran had active service from February 2010 to June 2012. She also had prior service in the Army Reserves. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran’s PTSD claim has been expanded to include the additional documented psychiatric disorders of anxiety, depression, and bipolar disorder, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to a rating in excess of 20 percent for a right shoulder strain is remanded. 2. Entitlement to a compensable rating for a right hip disability with limited flexion is remanded. 3. Entitlement to a compensable rating for a right hip disability with right thigh impairment is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety, depression, and bipolar disorder, is remanded. The evidence indicates there may be outstanding relevant VA treatment records. VA treatment records from September 21, 2017 indicate that the Veteran was referred for physical therapy for right hip pain and was instructed to return for follow up appointment in March 2018. VA treatment records subsequent September 22, 2017 have not been associated with the claims file. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issues on appeal. A remand is required to allow VA to obtain them. The claims file indicates that the Veteran applied for VA vocational rehabilitation in March 2018. To date, the Veteran’s vocational rehabilitation folder has not been associated with the record. Accordingly, on remand the Veteran’s complete VA vocational rehabilitation counseling folder, to include all evaluations and narrative reports, should be obtained. While the record contains a contemporaneous VA examination regarding the Veteran’s right shoulder, the examination is internally inconsistent. While the examiner stated that pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability during flare-ups, in describing that additional limitation in terms of range of motion, the examiner merely recited the range of motion findings that were obtained during initial range of motion testing. As the examiner’s opinion appears internally inconsistent and is not accompanied by any rationale resolving that inconsistency, another VA examination is warranted. Concerning the Veteran’s claim for PTSD, there is no indication in the record that the Veteran has reported sufficient information to corroborate her in-service stressors. The Board notes that the RO requested that the Veteran submit a completed VA Form 21-0871 or 0781a. In a March 2017 report of information, she stated that she submitted the required forms. Nevertheless, those forms have not been associated with the record. Therefore, giving the Veteran the benefit of the doubt, the Veteran should be provided another opportunity to submit the requested information regarding her in-service stressors. If the requested information is received, the RO should complete the necessary steps to verify the reported stressor(s). Additionally, as the Veteran’s service treatment records indicate that she was treated for stress related insomnia, she should be afforded a VA examination to determine if she has a current acquired psychiatric disorder which is related to service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated her for her claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Obtain and associate the Veteran’s complete VA vocational rehabilitation counseling folder, to include all evaluations and narrative reports. If the records are not available, the claims file should be annotated to reflect such and the Veteran notified of such. 3. Request that the Veteran provide information regarding her claimed stressors in connection with her PTSD claim, to include completing a VA Form 21-0871a. Then, if the Veteran provides sufficient information to conduct a meaningful search, contact all appropriate sources and request that research be conducted to verify such stressors. All efforts to perform the search must be documented and associated with the claims file. If the information provided by the Veteran lacks sufficient specificity to be verified, the AOJ should make a formal finding to that effect. 4. After the above is completed to the extent possible, schedule the Veteran for an examination of the current severity of her right shoulder strain. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to right shoulder strain alone and discuss the effect of the Veteran’s right shoulder strain on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Schedule the Veteran for a VA PTSD examination. The claims file should be reviewed by the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders present and then respond to the questions presented: (a.) If the Veteran is diagnosed with PTSD, the examiner should indicate the stressor(s) upon which the diagnosis is based. (b.) If the Veteran is not diagnosed PTSD, the examiner should specifically indicate so and explain why she does not meet the diagnostic criteria for PTSD. (c.) For each diagnosed psychiatric condition other than PTSD, to include the documented diagnoses of anxiety, depression, and bipolar disorder, state whether it is at least as likely as not that the conditions arose during service or are otherwise related to the Veteran’s military service. In so opining, the examiner should address the Veteran’s documented in-service assault and her in-service treatment for stress related insomnia and an adjustment disorder. (Continued on the next page)   A rationale for all opinions expressed should be provided J. A. Anderson Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Saudiee Brown, Associate Counsel