Citation Nr: 18156200 Decision Date: 12/11/18 Archive Date: 12/07/18 DOCKET NO. 16-42 912 DATE: December 11, 2018 REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for low back disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for bilateral plantar fasciitis is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for an acquired psychiatric disability to include PTSD is remanded. Entitlement to an increased rating in excess of 20 percent for a right shoulder disability is remanded. Entitlement to a compensable disability rating for a deviated septum is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1982 to November 1985. 1. Entitlement to an initial increased rating in excess of 20 percent for a right shoulder disability and an initial compensable disability rating for a deviated septum is remanded. The Veteran has claimed since his last VA examination that his disabilities have worsened. The Veteran’s last VA examination, to determine the status of his disabilities, was in August 2015. As a result, and given the time that has transpired since his last examination, the Board finds that a new examination is warranted. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) Entitlement to service connection for low back disability, bilateral plantar fasciitis, sinusitis is remanded. The Board notes that no examination was provided to the Veteran on these above issues. This omission was an error. Here the Veteran has had repeated complaints of his low back, sinusitis, and plantar fasciitis. He has provided statements asserting that these disabilities began in service and are related to his active duty service. The Court has been has held that a medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds that considering the foregoing a medical examination is warranted to address the Veteran’s contention and provided a competent medical opinion on the issue of etiology 2. Entitlement to service connection for a left shoulder, bilateral knees disability is remanded. The opinion provided in the August 2015 VA examination is inadequate. Upon review, the Board notes that the VA examiner did not adequately explain why the Veteran’s statements surrounding an alleged injury in basic training could not be attributed to his current left shoulder and bilateral knee disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In Nieves-Rodriguez v. Peake the Court of Appeals for Veterans Claims (Court) held that most of the probative value of a medical opinion comes from its reasoning and the Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. Upon reviewing the August 2015 opinion, the Board finds that the opinion is insufficient to meet this standard for the reasons noted above. 4. Entitlement to service connection for an acquired psychiatric disability to include PTSD is remanded. The Board finds that an additional examination is warranted. While the August 2015 examination addressed the Veteran’s contentions of PTSD, the Board notes that the examiner did not address the Veteran’s other psychiatric diagnosis, namely adjustment disorder from a VA physician in November 21, 2014, which the Veteran continues to carry as noted in a March 2018 problem list. The Board notes that the Court has held that claims for service connection for psychiatric disorders encompass claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Moreover, the Board notes that after the August 2015 VA examination the Veteran was service connected for a traumatic brain injury (TBI) and there has been no inquiry into whether the Veteran’s acquired psychiatric disability may be secondary to his now service connected TBI. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Considering the forgoing, the Board finds that a new VA examination is warranted. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his disabilities. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. Regardless of the Veteran’s response, VA treatment records should be collected from the Salt Lake City, Utah VA Medical Center (VAMC) and all associated outpatient center and clinics. In particular, the AOJ should retrieve VA treatment records from October 2018 to present should be collected. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. If the records are unavailable, notify the Veteran in accordance with 38 C.F.R. § 3.159. 2. After the above development is accomplished, schedule the Veteran for appropriate VA examinations for his right and left shoulder, deviated septum, right and left knees, low back, bilateral plantar fasciitis, sinusitis, and psychiatric disorder. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner(s) as part of the examination. A notation to the effect that this review has taken place should be made in the evaluation report. All tests, studies, and evaluations should be performed as deemed necessary by the examiner(s), and the results of any testing must be included in the examination report. (A). An appropriate VA examiner is asked to determine the nature and severity of the Veteran’s RIGHT SHOULDER disability. Any opinion provided must be accompanied by supporting rationale. (B) An appropriate VA examiner is asked to determine the nature and severity of the Veteran’s DEVIATED SEPTUM. Any opinion provided must be accompanied by supporting rationale. (C) After considering the pertinent information in the record in its entirety, an appropriate examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that the Veteran’s LOWER BACK disability was incurred or aggravated by his active duty OR whether it is at least as likely as not i.e. 50 percent probability or greater was caused or aggravated by one of his service connected disabilities. (D) After considering the pertinent information in the record in its entirety, an appropriate examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that the Veteran’s PLANTAR FASCIITIS was incurred or aggravated by his active duty OR whether it is at least as likely as not i.e. 50 percent probability or greater was caused or aggravated by one of his service connected disabilities. (E). After considering the pertinent information in the record in its entirety, an appropriate examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that the Veteran’s SINUSITIS was incurred or aggravated by his active duty OR whether it is at least as likely as not i.e. 50 percent probability or greater was caused or aggravated by one of his service connected disabilities. (F). After considering the pertinent information in the record in its entirety, an appropriate examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that the Veteran’s LEFT SHOULDER disability was incurred or aggravated by his active duty OR whether it is at least as likely as not i.e. 50 percent probability or greater was caused or aggravated by one of his service connected disabilities. (G) After considering the pertinent information in the record in its entirety, an appropriate examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that the Veteran’s BILATERAL KNEE disabilities was incurred or aggravated by his active duty OR whether it is at least as likely as not i.e. 50 percent probability or greater was caused or aggravated by one of his service connected disabilities. (H) After considering the pertinent information in the record in its entirety, an appropriate examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that the Veteran’s acquired psychiatric disability, to include adjustment disorder, was incurred or aggravated by his active duty OR whether it is at least as likely as not i.e. 50 percent probability or greater was caused or aggravated by one of his service connected disabilities, specifically his service connected TBI. 3. Ensure that the examination report complies with this remand and the questions presented in this request. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After completing the requested actions and any additional notification and/or development deemed warranted, readjudicate the issues on appeal. If the benefit sought on appeal is not granted, the Veteran and his representative must be furnished a supplemental statement of the case and afforded the appropriate time period for response. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Acosta, Counsel