Citation Nr: 18157912 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 15-13 001 DATE: December 13, 2018 REMANDED Entitlement to an initial compensable rating for right hamstring strain is remanded. REASONS FOR REMAND The Veteran served in the United States Navy from January 2010 to November 2011. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran has withdrawn her appeal for an increased rating for her service connected GERD in a Form 9 submitted in April 2015. Entitlement to an increased initial rating for right hamstring strain is remanded. The Veteran has been provided three VA examinations regarding her right hamstring disability. The first, in July 2011, noted that the Veteran suffered from pain, pain with exercise, and a tender hamstring. This VA examination also included range of motion (ROM) testing which indicated normal range of motion. In July 2013, the Veteran was provided a second VA examination. This examination focused on the muscle injury and did not include any ROM testing. The examiner found that the Veteran suffered from a non-penetrating muscle injury with no related scarring. The examiner also found that there was no effect on muscle substance or function. However, the examiner did note that the Veteran suffers from occasional fatigue and pain as a result of the muscle injury and that these symptoms impact work by limiting prolonged standing, walking, and running. The last VA examination occurred in January 2015. Similar to the July 2013 examination, this examination did not include any ROM testing. This examination report noted consistent lowered threshold of fatigue, and consistent fatigue and pain. Again, this examiner found that the disability impaired working ability because of limitations surrounding prolonged standing, walking, and running. The record also contains treatment records that indicate that the Veteran suffers from severe leg pain but the cause of the underlying pain is unclear. Additionally, the Veteran provided her own statements surrounding the symptoms associated with her hamstring disability in her Form 9, received in April 2015. The Veteran indicated that she suffers from a large amount of pain whenever using leg, limited range of motion, and muscle fatigue. This statement indicates that the Veteran’s condition may have worsened in severity since the last VA examination and also supports consideration of the condition under a different diagnostic code (DC) that may better reflect the reduced ROM experienced by the Veteran. She had similar contentions in her December 2012 notice of disagreement. In particular, she contended that because of her pain and limited range of motion, this disability should be warranted at least a 10 percent rating. The Veteran’s hamstring disability is currently assigned DC 5313. This diagnostic code focuses on muscle injuries impacting the thigh. However, rating under DC 5313 requires the Board to focus partially on the characteristics of the initial injury sustained to the region of the body. For instance, the rating criteria incorporate discussion of the type of projectile causing the injury. In this case, the Veteran suffered a non-penetrating injury to her hamstring. Such an injury is not clearly captured by the criteria under DC 5313. Therefore, the Board finds that an additional VA examination is necessary to evaluate both the current severity of the Veteran’s condition and to conduct range of motion testing for the lower extremities that may allow for the Veteran to be rated under a different diagnostic code. The matter is REMANDED for the following actions: 1. Contact the appropriate sources and obtain any treatment records not currently associated with the file. 2. After associating any treatment records with the claims file, arrange for the Veteran’s record to be forwarded to an appropriate medical provider for an in-person examination regarding the current level of severity of her right hamstring strain and associated symptomatology. The examiner is to provide a comprehensive rationale for an opinion offered. The examiner must consider lay reports from the Veteran along with pertinent medical evidence, including medical literature submitted by her. The examiner’s report is to address the Veteran’s range of motion for her lower extremities. 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. 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). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Watkins, Attorney Advisor