Citation Nr: 18150296 Decision Date: 11/15/18 Archive Date: 11/14/18 DOCKET NO. 16-39 527 DATE: November 15, 2018 REMANDED Entitlement to service connection for tonsillitis is remanded. Entitlement to service connection for left shoulder disability is remanded. Entitlement to a disability rating higher than 20 percent for urinary incontinence is remanded. Entitlement to a disability rating higher than 10 percent for thoracolumbar strain is remanded. Entitlement to a disability rating higher than 0 percent for headaches is remanded. Entitlement to a disability rating higher than 0 percent for right knee disability is remanded. Entitlement to a disability rating higher than 0 percent for right foot hallux valgus is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1987 to May 2013. This appeal is before the Board of Veterans’ Appeals (Board) from December 2013 and February 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The issues the Veteran appealed to the Board previously included service connection for hypertension and a disability rating higher than the 10 percent rating that was initially assigned for her depression. Her April 2014 notice of disagreement explicitly sought a 30 percent rating for depression. In a July 2016 rating decision, the RO granted service connection for hypertension and increased the initial rating for depression from 10 to 30 percent. Therefore, neither of those issues remains on appeal before the Board as they have both been granted in full. 1. Service connection for tonsillitis The Board is remanding this issue for additional medical review, examination, and opinion. The Veteran contends that frequent, recurrent tonsillitis began during service and continued after service. Her service medical records reflect treatment on numerous occasions for tonsillitis and for sore throat and strep throat. Chronic tonsillitis was noted as late as November 2012, a few months before her separation from service. In March 2013, before separation from service, she initiated an informal claim for service connection for multiple conditions, including tonsillitis. On examination in July 2013, about two months after separation from service, she again reported chronic tonsillitis. Her claims file was not provided to the examiner to review. The examiner noted that she had allergic rhinitis, but did not indicate whether she had chronic or recurrent tonsillitis. The Board is remanding the claim for a new VA examination, with review of the claims file, and opinion as to the likelihood that any post-service chronic or recurrent tonsillitis is a continuation of or otherwise related to the tonsillitis noted during service. 2. Service connection for left shoulder disability The Board is remanding this issue for additional medical review, examination, and opinion. The Veteran contends that left shoulder injury in service, including in a motor vehicle accident (MVA) in 1993, produces ongoing left shoulder problems. Her service medical records show that the MVA in September 1993 was followed by treatment for sternum fracture, collapsed lung, right patella fracture, and left shoulder pain. After another MVA, in August 2005, she reported neck and back pain. In March 2013, before separation from service, she sought service connection for problems in her left and right shoulders. On VA examination in July 2013, the examiner did not receive her claims file for review. Her left shoulder had full ranges of motion, but there was pain on abduction. The examiner did not answer a question as to whether there was any disorder of the left and/or right acromioclavicular (AC) joints. The Board is remanding the claim for a new VA examination, with review of the claims file, findings as to the existence and nature of any current condition left shoulder disorders, and opinion as to the likelihood of a relationship between any current disorder and the injury and symptoms noted during service. 3. Disability rating for urinary incontinence The Board is remanding this issue for a current medical examination. In a December 2013 rating decision, the RO granted service connection for the Veteran’s urinary incontinence. The RO made service connection effective in June 2013, immediately following the Veteran’s separation from service, and assigned a 0 percent disability rating. The Veteran appealed that rating. In a July 2016 rating decision, the RO increased the initial rating to 20 percent. The Veteran continued her appeal, seeking a rating higher than 20 percent. In a substantive appeal submitted in August 2016, she contended that the disorder was worse. In the 2016 rating decision, the RO considered records of a VA examination in July 2013 and VA treatment in 2016. The treatment records discussed in the rating decision do not appear to be associated with the Veteran’s claims file. The Board is remanding the rating issue to obtain her VA treatment records, and to provide a new VA examination to afford more current findings. 4. Disability rating for thoracolumbar strain The Board is remanding this issue for a medical examination to obtain complete and current information. The Veteran appealed the initial 10 percent rating assigned for her back disability, described by the RO as thoracolumbar strain. Since the most recent VA examination of her back, in May 2015, she has asserted that her back disorder is worse. The Board is remanding the claim for a new VA examination to obtain current findings. In addition, in Correia v McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that, in accordance with 38 C.F.R. § 4.59, VA examinations of painful joints should include testing of joints for pain on both active and passive motion, and with and without weightbearing, and should include recording of the range of motion of any opposite undamaged joint. The new examination should include such findings. VA regulations and Court decisions also indicate that evaluation of joint disorders must include consideration of impairment of function due to such factors as pain on motion, weakened motion, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). The new examination should also address those considerations. 5. Disability rating for headaches The Board is remanding this issue for a current medical examination. The Veteran appealed the initial 0 percent rating assigned for her headaches. The most recent VA examination addressing her headaches was in July 2013. Since then, in August 2016, she contended that her headaches were worse. The new examination should provide current findings. 6. Disability rating for right knee disability The Board is remanding this issue for a current medical examination. The Veteran appealed the initial 0 percent rating assigned for her right knee disability. The most recent VA examination addressing her knees was in May 2015. Since then, in August 2016, she contended that her right knee disability was worse. The new examination should provide current findings. The examination should also address the considerations discussed in Correia and Deluca, supra. As the considerations for rating painful joints apply to the disabilities of both her back and her right knee, it would be practical to address both disabilities in the same examination. 7. Disability rating for right foot hallux valgus The Board is remanding this issue for a current medical examination. The Veteran appealed the initial 0 percent disability rating assigned for her right foot hallux valgus. The most recent VA examination addressing her feet was in July 2013. Since then, in August 2016, she contended that the right foot disorder was worse. The new examination should provide current findings. The matters are REMANDED for the following action: 1. Obtain records of all VA outpatient and inpatient treatment of the Veteran from June 2013 through the present. Associate those records with her claims file. 2. Schedule the Veteran for a VA examination to address the nature and likely history of any disorder manifested by chronic or recurrent tonsillitis. Provide the expanded claims file to the examiner. Ask the examiner to thoroughly review the claims file, including the service medical records. Ask the examiner to examine the Veteran. Ask the examiner to indicate whether records and/or examination findings indicate that the Veteran has chronic or recurrent tonsillitis. Ask the examiner, for any chronic or recurrent tonsillitis found, to provide an opinion as to whether it is at least as likely as not (at least a 50 percent likelihood) that the post-service tonsillitis is a continuation of or otherwise related to the tonsillitis noted in service. Ask the examiner to explain the conclusions and opinions. 3. Schedule the Veteran for a VA examination to address the nature and likely history of any current disorders of the left shoulder. Provide the expanded claims file to the examiner. Ask the examiner to review the claims file and examine the Veteran. Ask the examiner to provide diagnoses for any current disorders of the Veteran’s left shoulder. Ask the examiner, for each current left shoulder disorder, to provide an opinion as to whether it is at least as likely as not (at least a 50 percent likelihood) that the disorder is causally related to injury in the 1993 motor vehicle accident or other events in service. Ask the examiner to explain the conclusions and opinions. 4. Schedule the Veteran for a VA examination to determine the current manifestations of her urinary incontinence. Provide the expanded claims file to the examiner. Ask the examiner to review the claims file. Ask the examiner to obtain from the Veteran history and current circumstances regarding her urinary incontinence, specifically including how many times per day absorbent materials have to be changed. Ask the examiner to only perform a physical examination if deemed relevant, that is, if physical findings would help to show the current extent and effects of the incontinence. 5. Schedule the Veteran for a VA examination to address the current manifestations of her back disorders, including thoracolumbar strain, and disorders of her right knee, including patella fracture. Provide the expanded claims file to the examiner for review. Ask the examiner to review the claims file and examine the Veteran. Ask the examiner to conduct all necessary tests of the function and functional impairment of her back and her right knee, specifically including findings as to whether there is pain on active and passive ranges of motion, and on ranges of motion with and without weightbearing. Ask the examiner to report, for comparison purposes, the ranges of motion of the left knee. Ask the examiner to provide findings as to whether the right knee has instability, effusion, or locking, or requires a brace. Ask the examiner to report, with respect to the back and the right knee, whether there is functional impairment due to pain, weakness, fatigability, or incoordination, or with repeated use or flare-ups. Ask the examiner to describe any functional impairment from such factors as equivalent to degrees of additional loss of motion, if feasible. 6. Schedule the Veteran for a VA examination to address the current manifestations, severity, and effects of her headaches. Provide the expanded claims file to the examiner for review. Ask the examiner to review the claims file, examine the Veteran, and obtain detailed history regarding her headaches. Ask the examiner to specifically note whether the Veteran reports any prostrating headache attacks, and if so, the reported frequency of such attacks over the preceding several months. Ask the examiner to state the extent, if any, to which the Veteran’s headaches affect her capacity for occupational tasks and consistent job attendance. 7. Schedule the Veteran for a VA examination to address the current manifestation for her right foot hallux valgus. Provide the expanded claims file to the examiner for review. Ask the examiner to review the claims file, obtain current history from the Veteran, and examine her. Ask the examiner to note whether the Veteran has had surgery to address the hallux valgus, and if so, whether the metatarsal head was resected. Ask the examiner to report the current symptoms and manifestations of the hallux valgus, including any effects on functioning, such as on standing and walking. Ask the examiner to provide opinions as to whether the hallux valgus is severe, and whether it produces functional impairment equivalent to amputation of the great toe. 8. Thereafter, review the expanded claims file and review the remanded claims. If any of those claims is not granted to the Veteran’s satisfaction, issue a supplemental statement of the case and afford the Veteran and her representative an opportunity to respond. Thereafter, return the case to the Board for appellate review, if otherwise in order. J. GALLAGHER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. J. Kunz, Counsel