Citation Nr: 18156144 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 17-29 291 DATE: December 7, 2018 REMANDED Entitlement to a higher evaluation for status post acromioclavicular separation of the right shoulder with degenerative joint disease and status post resection, currently evaluated as 20 percent is remanded. Entitlement to a compensable evaluation for residual right shoulder scar is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for retinopathy with visual field defects as secondary to diabetes mellitus, is remanded. Entitlement to service connection for erectile dysfunction, as secondary to diabetes mellitus, is remanded. Entitlement to service connection for peripheral neuropathy of the left upper extremity, as secondary to diabetes mellitus, is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity, as secondary to diabetes mellitus, is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity, as secondary to diabetes mellitus, is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity, as secondary to diabetes mellitus, is remanded. Entitlement to service connection for chronic venous insufficiency, claimed as peripheral artery disease of the bilateral upper extremity, to include as secondary to diabetes mellitus, is remanded. Entitlement to service connection for chronic venous insufficiency, claimed as peripheral artery disease of the bilateral lower extremity, to include as secondary to diabetes mellitus is remanded. Entitlement to service connection for right leg right patella tendon residuals of pain is remanded. Entitlement to service connection for right knee tendon condition is remanded. REASONS FOR REMAND The claims of entitlement to a higher evaluation for status post acromioclavicular separation of the right shoulder with degenerative joint disease and status post resection, and entitlement to a compensable evaluation for residual right shoulder scar are remanded. The last VA examination of the Veteran’s right shoulder was in May 2014. In estimating the Veteran’s pain on use or during flare-ups, the examiner indicated that a medical opinion could not be rendered without undue speculation. No explanation was provided which explained why an opinion could not be provided. The May 2014 VA examiner’s opinion is incomplete. The report does not indicate 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). Further, direct observation of functional impairment during a flare-up is not a prerequisite to offering an opinion. A new medical opinion is therefore necessary. Additionally, according to VA treatment records, the Veteran underwent a right shoulder arthroscopy and a rotator cuff debridement in August 2018. As the current severity of the Veteran’s right shoulder disabilities is unclear, a new examination is warranted. The claim of entitlement to service connection for diabetes mellitus is remanded. The Veteran’s service treatment records are negative for any diagnosis of diabetes mellitus. A November 1988 emergency care and treatment note indicated that the Veteran was not feeling well, but still did a run for physical therapy. He was noted to have developed chest pains and leg cramps. He was noted to have walked in with assistance and was noted to have elevated glucose levels. A June 1991 laboratory urinalysis profile noted that the Veteran’s urine was negative for ketones, but that his glucose was “2+ H;” “H” was noted in the key to mean “abnormal high.” A November 1992 history and physical noted the Veteran had reported to the emergency room with 440 blood sugar. The physical was being conducted for workup and treatment of new onset diabetes mellitus and unstable angina. The Veteran’s history of the condition was noted to have onset on November 19, 1992, where the Veteran noticed left arm numbness, followed by short-lived left anterior internal chest wall pain, with lightheadedness and mild dyspnea, and nausea, with some diaphoresis. A diagnosis of new onset diabetes mellitus was noted, probably mature onset diabetes of the young (type I). A May 2014 VA examination confirmed a diagnosis of diabetes mellitus, type 1, insulin-requiring. The VA examiner noted review of the claims file, and noted that there was no objective evidence of onset of diabetes during or within two years of military service, and noted a random/non-fasting glucose of 118 during the November 1988 evaluation and treatment for heat cramps after prolonged running. The VA examiner noted the reading was well within that expected to occur in a non-diabetic patient in such a clinical situation. The VA examiner noted that there were multiple other glucose values within normal limits during service, to include the value of 92 mg/dL on separation in October 1990. The VA examiner opined that the Veteran’s diabetes mellitus type 1 was not incurred in, caused by, or a result of military service, to include a November 1988 finding of mildly elevated glucose level during evaluation and treatment for heat cramps. The Veteran submitted the above-mentioned November 1992 medical record after the VA examination occurred. His representative contends that his condition was diagnosed within two years of his separation from active service, contrary to the findings of the April 2017 statement of the case (SOC). However, as noted in the June 2017 supplemental statement of the case (SSOC), diabetes is a chronic disease listed under 38 C.F.R. § 3.309(a), which must have become manifest to a degree of 10 percent or more within one year of active duty for presumptive service connection. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a). A grant cannot be issued on the basis of a diagnosis of diabetes mellitus within two years of separation alone. However, further development is warranted. Specifically, the VA examiner did not express any opinion regarding the 1992 date of onset and was under the impression that the Veteran’s diabetes did not manifest with two years of his separation (which was in December 1990). Also, the VA examiner did not note or provide any commentary on the June 1991 urinalysis results. Once VA undertakes the effort to provide an examination when developing a service-connection claim, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). Remand for a new VA examination is required under the circumstances. The claims of entitlement to service connection for retinopathy, erectile dysfunction, and peripheral neuropathy of the bilateral lower and upper extremities, as secondary to diabetes mellitus are remanded. The Veteran is seeking service connection for retinopathy, erectile dysfunction, and peripheral neuropathy of the bilateral upper and lower extremities, as secondary to his diabetes mellitus. These issues are inextricably intertwined with his claim for diabetes mellitus that the Board is remanding for additional development. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending adjudication. The claims of entitlement to service connection for right leg right patella tendon residuals of pain, and right knee tendon condition are remanded. On a July 1981 entrance examination, a May 1981 automobile accident (prior to service) was noted as having caused a fracture in the Veteran’s right leg and having injured his right shoulder. The right leg fracture was noted to be resolved. Although the Veteran was ultimately discharged from active-service due to the worsening of his shoulder condition, his leg fracture is not noted at any point as having become symptomatic during active service. The Veteran’s service treatment records are silent for any right leg patella tendon or right knee condition. Although the Veteran reported cramps in his legs, he did not report any tendon or knee problems. His October 1990 separation examination noted his lower extremities were normal. The Veteran was afforded a VA examination of the knee and lower leg in May 2014. The Veteran reported that in Panama, he felt a twinge and saw a bruise on his right calf, and the next week the right lower leg was painful and swollen. He reported a doctor told him he had torn the patellar tendon. He recalled being hospitalized for two weeks with his leg elevated as the doctors initially believed it was a blood clot, but that no clot was found. He reported that his knee remained sore. The VA examination noted having performed a full file review and an examination of the Veteran, but the examiner did not confirm any patella tendon issue; the examiner noted only the diagnosis of remote fracture of the right fibula, with no residuals, which occurred in May 1981 per review of the records. The VA examiner noted no functional loss, full range of motion, full strength, no pain on palpation. The VA examiner noted that there was no patella tendon condition or any right knee tendon condition that could be confirmed on examination. Remand of this claim for further development is required. The Veteran contended that he was hospitalized for two weeks while on active duty due to complaints including his knees or legs. However, these records are not associated with the claims file, and it does not appear that a specific request has been made to obtain them to date. In-patient hospitalization records are typically maintained separately from the general service treatment records, and exhaustive efforts to secure these records must be made prior to the adjudication of this claim. 38 C.F.R. § 3.159(c)(2). The claims of entitlement to service connection for peripheral artery disease of the bilateral upper extremities and bilateral lower extremities are remanded. The Veteran filed a claim for peripheral artery disease (PAD) in February 2013, contending such was secondary to his diabetes mellitus. The Veteran was referred in February 2013 by his physician to a cardiologist due to high risk symptoms of PAD. A May 2013 note from a Dr. R.W. indicated that although the Veteran did have frequent areas of folliculitis and sores on his lower extremities they are not related to arterial disease and the Veteran had mild chronic venous insufficiency. A May 2014 VA examination was conducted, which noted a full file review, and noted that PAD was not found or diagnosed. The VA examiner did note that although there is evidence of bilateral chronic venous insufficiency (CVI), the condition was not present during or within 18 months of active duty, and was not incurred in or caused by complaint that occurred while in service between 1981 to 1990 to include treatment for heat cramps and pain/numbness in his leg that occurred in November 1988. The VA examiner noted that medical literature does not support such events as cause for CVI. Due to the outstanding in-service hospitalization records which the Veteran described being hospitalized with his leg elevated, and the fact that this claim may be for a condition related to diabetes mellitus, which is being remanded, consideration of these claims must be deferred. The matters are REMANDED for the following action: 1. Contact the appropriate federal records repository, or repositories, to conduct an exhaustive search for the Veteran’s service hospitalization records; specifically, records of hospitalization from Gorgas Hospital, Panama in or around October 1990. Associate the records with the file. 2. After the completion of the above and any additional development deemed necessary by the Agency of Original Jurisdiction (AOJ), schedule the Veteran for: (a.) an appropriate examination to determine the severity of his status post acromioclavicular separation of the right shoulder with degenerative joint disease and status post resection. (b.) an appropriate examination to determine the severity of the residual right shoulder scar. (c.) an appropriate examination to determine if the Veteran’s diabetes mellitus is related to active service. In addition to noting the specifics discussed on prior examination, the examiner’s attention is drawn to the urinalysis of June 1991 showing abnormal high glucose levels and the diagnosis from November 1992 that was associated with the file in 2017. After reviewing the claims file and performing all indicated tests, the examiner is to state whether it is at least as likely as not that the Veteran’s diabetes mellitus had its onset during active service or within the one-year period after active service, or is otherwise related to the Veteran’s active service. If the VA examiner reaches the conclusion that the Veteran’s diabetes mellitus is related to active service or had its onset within a year thereof, the VA examiner is requested to opine whether any of the remaining disabilities on appeal are at least as likely as not related to diabetes mellitus. M. Donohue Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD King, Timothy (BVA)