Citation Nr: 18149605 Decision Date: 11/13/18 Archive Date: 11/09/18 DOCKET NO. 16-32 173 DATE: November 13, 2018 REMANDED Entitlement to service connection for low back disability is remanded. Entitlement to service connection for left knee disability is remanded. Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for left shoulder disability is remanded. Entitlement to service connection for right hamstring disability is remanded. Entitlement to a compensable rating for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from February 2008 to April 2012. This matter is before the Board of Veterans’ Appeals (Board) on appeal of an August 2013 rating decision of the Oakland, California, Regional Office (RO) of the Department of Veterans Affairs (VA). 1. Entitlement to service connection for low back disability is remanded. 2. Entitlement to service connection for left knee disability is remanded. 3. Entitlement to service connection for right knee disability is remanded. 4. Entitlement to service connection for left shoulder disability is remanded. 5. Entitlement to service connection for right hamstring disability is remanded. The Veteran’s service treatment records (STRs) reflect treatment for low back, knee disorder, left arm, and right hamstring tendonitis. The Veteran appeared for a VA examination in July 2013. Regarding low back, bilateral knee, left shoulder and right hamstring, the VA examiner found no current disabilities for the claimed disorders By May 2016 Substantive Appeal, the Veteran stated that he continued to experience pain and weakness in the low back, knees, and left shoulder and described functional impairment. He also stated that in June 2012 an ultrasound as to the knee was conducted at the VA Central California Health Care System. Remand is required to associate updated treatment records with the claims file for the purposes of establishing the existence of a present disability, to include records from the VA Central California Health Care System, as identified by the Veteran. Further, the Veteran in his May 2018 Appellate Brief noted that his belief that his pain constitutes disability under Saunders v. Wilkie, 886 F.3d 1356, 1363-64 (Fed. Cir. 2018), which clarified that pain alone can be a disability if it amounts to functional impairment. A VA examiner’s opinion is requested, to determine if the Veteran has a low back, knee, left shoulder/arm, and right hamstring disability relating to service, to include an assessment of functional impairment. 6. Entitlement to a compensable rating for tension headaches is remanded. By May 2016 Substantive Appeal and May 2018 Appellate Brief, the Veteran reported worsening of his tension headache disability. The Court has held that a veteran is entitled to a new VA examination where there is evidence that the disability has worsened since the last VA examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). As well, VA’s duty to assist includes providing a new medical examination when the available evidence is too old for an adequate evaluation of the current condition. Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that VA should have ordered a contemporaneous examination of the veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). The matters are REMANDED for the following action: 1. Obtain all outstanding VA clinical records and give the Veteran the opportunity to identify any private treatment records for association with the claims file. All records/responses received must be associated with the claims file. 2. Then, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any low back, bilateral knee, left shoulder and arm, and right hamstring diagnosis and pain. (a.) Please state all current diagnoses as to the Veteran’s low back, bilateral knee, left shoulder and arm, and/or right hamstring. (b.) Please opine whether it is at least as likely the diagnoses and/or reported pain as to the low back, bilateral knee, left shoulder and arm, and/or right hamstring are as likely as not related to an in-service injury, event, or disease, including the Veteran’s reported in-service injury, that he fell from a truck in 2011. (c.) Please detail the functional impairment suffered by the Veteran as a result of his low back, bilateral knee, left shoulder and arm, and/or right hamstring, to include the impact on his employability. (d.) If the Veteran reports flare-ups, please detail the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of the flares. 3. Schedule the Veteran for an examination of the current severity of his service-connected tension headaches. The examiner must also 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 the service-connected tension headache disability alone and discuss the effect of the Veteran’s tension headache disability on any occupational functioning and activities of daily living. If it is not possible to provide 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). 4. After the above is complete, readjudicate the Veteran’s claims. If a complete grant of the benefits requested is not granted, issue a supplemental statement of the case (SSOC) to the Veteran and his representative to afford them the opportunity to respond before the case is returned to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. M. Georgiev