Citation Nr: 18157962 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 11-05 710 DATE: December 13, 2018 REMANDED ISSUE Entitlement to service connection for a right lower extremity disorder as secondary to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active military service from September 1961 to August 1964. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in April 2010 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2015, the Board remanded the issue on appeal for additional development and, in February 2017, denied it. The Veteran appealed the Board’s decision only to the extent that it denied service connection on a secondary basis to the United States Court of Appeals for Veterans Claims (Court). Consequently, in April 2018, the Court issued a Memorandum Decision that affirmed the Board’s February 2017 decision to the extent that it denied service connection on a direct basis, and set aside the decision to the extent that it denied service connection on a secondary basis. As such, the matter now returns for further appellate review. The Board notes that, following the issuance of the December 2015 supplemental statement of the case pertinent to the Veteran’s the instant claim, additional evidence, to include updated VA and private treatment records, has been associated with the record. While the Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such evidence, the AOJ will have an opportunity to consider it in the readjudication of the claim on remand. Entitlement to service connection for a right lower extremity disorder as secondary to service-connected disabilities. The Veteran contends that he has right knee and hip disorders secondary to his service-connected lumbar spine disability and radiculopathy of the right lower extremity. In the April 2018 Memorandum Decision, the Court found that the Board provided insufficient reasons and bases for favoring a negative December 2015 VA opinion over the positive opinions of record. As an initial matter, the Board notes that there is no dispute that the Veteran has a right knee disorder, diagnosed as arthritis and a history of medial meniscus tearing. However, the Court found that the Board accepted the December 2015 VA examiner’s conclusion that there was no disability associated with the right hip without weighing the conflicting evidence suggesting the presence of an arthritic condition in the hip. In this regard, the December 2015 VA examiner found that, based on the record, “there is no diagnosis of a right hip condition.” In this regard, X-rays taken such month revealed no acute findings. However, as noted by the Court, in an October 2010 letter, the Veteran’s private chiropractor, Dr. W.M., indicated that X-rays showed osteoarthritis of the right hip and, in June 2012, reiterated that there were degenerative changes to the right hip. A private April 2016 MRI interpreted by a chiropractor showed degenerative hip joint disease on the right with mild joint effusion. However, an MRI conducted the previous month by VA and interpreted by a radiologist showed no significant degenerative changes. Furthermore, regardless of whether a right hip disorder has been clinically diagnosed, the record reflects that the Veteran had pain and reduced range of hip motion following repetition at an October 2012 VA examination Consequently, there remains a question as to whether the Veteran has a right hip disability as contemplated by VA regulations. With regard to the etiology of the Veteran’s right knee disorder, the Court noted that numerous theories of entitlement had been raised and, while the Board discounted a number of them, it failed to address the theory of sciatic compression by the piriformis muscle raised in Dr. W.M.’s April 2016 opinion. In this regard, he indicated that the Veteran had pain down his right leg for many years and was suffering from sciatica. Dr. W.M. stated that the pain down his leg was most likely a result of the impingement of the L5 nerve root and ganglion, and the piriformis was found to be hypertonic on the right. In this regard, it was noted that the piriformis crossed the sciatic nerve as it exits the pelvis. Dr. W.M. concluded that the Veteran’s leg pain was probably from a combination of impingement from the spinal level and pressure from the piriformis muscle. Finally, the Court found that the December 2015 VA examiner’s opinion raised a question as to whether the Veteran had inflammation of the sciatic nerve. Specifically, he stated that such was not present; however, the Court found that it was unclear as to whether or how the tests of record were sufficient to establish the absence of sciatic inflammation or whether further tests were available that would address the matter. Furthermore, it was noted that, while the December 2015 VA examiner stated that the Veteran’s arthritis at L5 would not cause inflammation of the sciatic nerve, 38 C.F.R. § 4.59 states that sciatic neuritis is not uncommonly caused by arthritis of the spine and the Veteran is currently in receipt of a 20 percent rating for moderate incomplete paralysis of the right sciatic nerve. Moreover, while the December 2015 VA examiner indicated that the Veteran always had full motor, normal muscle tone, no inelasticity and no muscle atrophy, he did not address Dr. W.M.’s examination findings of hypertonicity in various paraspinal muscles since at least 2009. Therefore, the Board finds that a remand is necessary to afford the Veteran a new examination that addresses whether he has a right hip disability as contemplated by VA regulations and considers Dr. W.M.’s April 2016 theory of entitlement, to include whether he had inflammation of the sciatic nerve at any time during the appeal period. The matter is REMANDED for the following action: Afford the Veteran an appropriate VA examination to determine the nature and etiology of his claimed right lower extremity disorders. The record, to include a complete copy of this remand and the Court’s decision, must be made available to the examiner, and all indicated tests and studies, to include any testing that would demonstrate inflammation of the right sciatic nerve, should be accomplished. Thereafter, the examiner should address the following inquires: (A) Identify any current disability of the right hip that has been present shortly before, at the time of, or during the pendency of the January 2010 claim (even if currently asymptomatic or resolved) Specifically, the examiner is requested to reconcile the March 2016 VA MRI showing no acute findings and the April 2016 private MRI showing degenerative hip joint disease on the right with mild joint effusion. If no diagnosis pertinent to the right hip is rendered, please offer an opinion as to whether the Veteran’s right hip symptomatology, to include pain and reduced range of hip motion following repetition, as noted at an October 2012 VA examination, results in functional impairment of earning capacity, i.e., is considered a disability for VA purposes. (B) The examiner should determine if the Veteran has sciatic nerve inflammation, to include shortly before, at the time of, or during the pendency of the January 2010 claim (even if currently asymptomatic or resolved). The examiner should consider and discuss 38 C.F.R. § 4.59, which indicates that sciatic neuritis inflammation is not uncommonly caused by arthritis of the spine, the fact that the Veteran is service-connected for moderate incomplete paralysis of the right sciatic nerve, and Dr. W.M.’s examination findings of hypertonicity in various paraspinal muscles since at least 2009. If the examiner finds that there is no inflammation of the sciatic nerve, he or she should indicate what testing supports such a determination. (C) The examiner should determine if the Veteran has sciatic compression by the piriformis muscle, to include shortly before, at the time of, or during the pendency of the January 2010 claim (even if currently asymptomatic or resolved). The examiner should consider and discuss Dr. W.M.’s April 2016 opinion that the Veteran’s leg pain was probably from a combination of impingement from the spinal level and pressure from the piriformis muscle. (D) After addressing the foregoing, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s right hip and/or right knee disability is caused or aggravated by his service-connected lumbar strain with degenerative changes, degenerative disc disease, and spondylosis, and/or radiculopathy of the right lower extremity, to include as a result of sciatic compression by the piriformis muscle. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline. A rationale should be provided for any opinion offered. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brennae L. Brooks, Associate Counsel