Citation Nr: 20032945 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 18-49 728 DATE: May 12, 2020 REMANDED Service connection for sacroiliitis is remanded. Service connection for left lower extremity varicose veins is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1986 to June 2016. This matter comes before the Board of Veterans’ Appeals (Board) from two rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). 1. Service connection for sacroiliitis is remanded. The Veteran believes that service connection for sacroiliitis is warranted. See Form 9. The Veteran underwent a July 2016 VA examination for sacroiliitis. The examination found no objective evidence of sacroiliitis and that no diagnosis was warranted. See August 2016 C&P Exam. The Board finds the July 2016 VA examination inadequate because it did not consider all the relevant evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, among other evidence, medical records from March 2016 show a diagnosis of sacroiliitis, an assessment of sacroiliitis, a sacroiliac injection resulting in immediate pain improvement, and postural faults with gait abnormalities due to SIJ inflammation/dysfunction. It was noted that the Veteran had been informed by other providers that there were no identified SIJ structural abnormalities even though the Veteran complained of pain that interrupted her concentration. The pain occurred almost daily. Medical records from February 2016 show that the Veteran had had right sacroiliac joint pain that radiated into the buttock for about one year, an assessment of sacroiliitis, and that there was tenderness on palpation of the sacroiliac joint. Medical records from April 2016 show a diagnosis of sacroiliitis. See July 2016 Medical Treatment Record. Medical records from June 2016 show provider comments of osteoarthritis/sacroiliitis status post hip injection. Medical records from July 2016 show a diagnostic history of sacroiliitis. See August 2016 STR. The examination also did not take into consideration that the Veteran had a medical background and may have been competent to diagnose the condition. See DD-214. The Board notes the Veteran’s contention that not all of the evidence was reviewed. See Form 9. Therefore, a remand is needed for a new VA examination. 2. Service connection for left lower extremity varicose veins is remanded. The Veteran believes that service connection for left lower extremity varicose veins is warranted. See Form 9. The Veteran underwent a July 2016 VA examination for left lower extremity varicose veins. The examination found that there was insufficient evidence to support left lower extremity varicose veins and no diagnosis was warranted. The examination also detailed information about the Veteran’s right lower extremity radio frequency ablation. The examination stated that all of the information about the right lower extremity radio frequency ablation came from the Veteran. The examination gave essentially no information about the left lower extremity. See August 2016 C&P Exam. The Board finds the July 2016 VA examination inadequate because it did not consider all the relevant evidence of record. See Nieves-Rodriguez, 22 Vet. App. at 295. Specifically, among other evidence, the examination did not consider the Veteran’s report that she had left lower extremity varicose veins and was treated for the condition during service. See NOD; July 2016 Fully Developed Claim. The Board notes that a Veteran with no medical expertise would be competent to provide a diagnosis of varicose veins. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In this case, the Veteran has the added benefit of having medical expertise. See July 2016 Medical Treatment Record. The examination also did not consider medical records from 2016 showing varicose veins and complaints of painful varicose veins for the last several years, among other medical evidence that does not specify whether it refers to the left lower extremity, right lower extremity, or to both lower extremities. Medical records also discuss the Veteran’s right lower extremity radio frequency ablation. See August 2016 STR. It also does not appear that the examination solicited any information from the Veteran concerning the left lower extremity. The Board notes the Veteran’s contention that not all of the evidence was reviewed. See Form 9. Therefore, a remand is needed for a new VA examination. The matter is REMANDED for the following action: 1. Update VA and private treatment records. 2. Schedule an appropriate VA examination for the sacroiliitis condition. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following: (A) Identify any and all disabilities associated with the Veteran’s sacroiliac joints at any point during the pendency of the appeal (i.e. since July 2016), even if they are currently asymptomatic or have resolved during the pendency of the appeal. If the examiner cannot identify a sacroiliac joint disability, the examiner shall determine whether the pain the Veteran has experienced in relation to her sacroiliac joints at any point during the pendency of the appeal results/resulted in a functional loss or impairment to the Veteran.   (B) If the examiner determines that the Veteran has/had a sacroiliac joint disability or that the Veteran’s sacroiliac joint pain results/resulted in a functional loss or impairment, the examiner shall then determine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s sacroiliac joint pain/disability is related to service, to include environmental exposures during Gulf War service in Southwest Asia. (C) If the examiner determines that the Veteran has/had a sacroiliac joint disability or that the Veteran’s sacroiliac joint pain results/resulted in a functional loss or impairment, the examiner shall then determine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s sacroiliac joint pain/disability is/was caused by any or all of the Veteran’s service-connected disabilities. (D) If the examiner determines that the Veteran has/had a sacroiliac joint disability or that the Veteran’s sacroiliac joint pain results/resulted in a functional loss or impairment, the examiner shall then determine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s sacroiliac joint pain/disability is/was aggravated beyond its natural progression by any or all of the Veteran’s service-connected disabilities. State whether there is a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue.   The Veteran is service-connected for bilateral pes planus with degenerative arthritis; right shoulder AC joint osteoarthritis, bursitis, and degenerative arthritis; overactive bladder; left upper extremity radiculopathy; right knee degenerative arthritis and chondromalacia; left knee meniscal tear with degenerative arthritis and chondromalacia; spine degenerative arthritis, intervertebral disc syndrome, spinal stenosis, and osteopenia; left eye narrow angle glaucoma, bilateral dry eye, and bilateral probable posterior vitreous detachment with photopsia; tinnitus; seborrheic dermatitis; hypothyroidism; bilateral lower extremity radiculopathy; cervical spine degenerative arthritis; bilateral hip bursitis; bilateral hallux valgus; costochondritis; chronic maxillary sinusitis; allergic rhinitis; hypertension; status post greater saphenous vein, radiofrequency ablation; gastroesophageal reflux disease; and headache syndrome/intermittent tension. See August 2017 Rating Decision – Codesheet. (E) Is it at least as likely as not (a 50 percent or greater probability) that any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities) caused or aggravated the Veteran’s obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue.   (F) If yes, is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated the Veteran’s sacroiliac joint pain/disability including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (G) Is it at least as likely as not (a 50 percent or greater probability) that any sacroiliac joint arthritis manifested to a compensable degree within one year following service? In addition to the other relevant evidence of record, the examiner is asked to consider the following: (1) The Veteran’s report that she was treated for sacroiliitis while on active duty. See NOD. (2) Service records showing that the Veteran served in Afghanistan and Iraq. See September 2016 DD-214. (3) Medical records from June 2016 showing osteoarthritis/sacroiliitis status post hip injection, osteoarthritis and sacroiliitis, and that the Veteran received a right SI joint injection. See August 2016 STR. (4) Medical records from July 2016 showing a diagnostic history of sacroiliitis. Medical records from February, March, and April 2016 showed a diagnosis of sacroiliitis, tenderness on palpation of the sacroiliac joint, right sacroiliac joint pain, an assessment of sacroiliitis, and pain in the SIJ region with TTP along the SIJ region. Id. (5) Medical records from May 2016 showing a diagnosis of sacroiliitis and SIJ inflammation/dysfunction. Id. (6) Medical records from March 2016 showing a diagnostic history of sacroiliitis. See July 2016 Medical Treatment Record. (7) Medical records from April 2016 showing that the Veteran presented with lower back pain, limited range of motion, postural faults with gait abnormality due to SIJ inflammation/dysfunction from pelvic obliquity. Id. (8) Medical records from March 2016 showing the Veteran’s complaint of SIJ pain and axial lower back pain. Per other providers, the Veteran understood that she had no identified SIJ structural abnormalities, but stated that pain interrupted her concentration and that she would like a fuller evaluation and treatment. The Veteran had been prescribed NSAIDS, which helped. Physical therapy provoked pain. Pain occurred almost daily and it felt like a deep irritation or inflammation that worsened with continued activity. There was pain in the right buttock over the SIJ which radiated to the low buttocks for minutes to hours. The pain was sharp, stabbing, and surprising. Excessive ambulation, stretching, and prolonged sitting correlated with its onset. Id. (9) Medical records from March 2016 showing an assessment of sacroiliitis. The Veteran had had 18 months of axial low back pain and one year of sharp posterior hip pain. Id. (10) Medical records from February 2016 showing that the Veteran was an orthopedic hand surgeon and one year prior, developed right sacroiliac pain that radiated into the buttock. See July 2016 Medical Treatment Record. (11) Medical records from May 2016 showing problems with obesity. Id. (12) Any and all other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran’s documented history and assertions. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community or the limits of the examiner’s medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 3. Schedule an appropriate VA examination for the left lower extremity varicose vein condition. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following:   (A) Identify any and all disabilities associated with the Veteran’s left lower extremity veins at any point during the pendency of the appeal (i.e. since July 2016), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (B) For each disability identified, the examiner shall determine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s left lower extremity vein disability is related to service, to include environmental exposures during Gulf War service in Southwest Asia. (C) For each disability identified, the examiner shall determine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s left lower extremity vein disability is/was caused by any or all of the Veteran’s service-connected disabilities. (D) For each disability identified, the examiner shall determine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s left lower extremity vein disability is/was aggravated beyond its natural progression by any or all of the Veteran’s service-connected disabilities. State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. The Veteran is service-connected for bilateral pes planus with degenerative arthritis; right shoulder AC joint osteoarthritis, bursitis, and degenerative arthritis;   overactive bladder; left upper extremity radiculopathy; right knee degenerative arthritis and chondromalacia; left knee meniscal tear with degenerative arthritis and chondromalacia; spine degenerative arthritis, intervertebral disc syndrome, spinal stenosis, and osteopenia; left eye narrow angle glaucoma, bilateral dry eye, and bilateral probable posterior vitreous detachment with photopsia; tinnitus; seborrheic dermatitis; hypothyroidism; bilateral lower extremity radiculopathy; cervical spine degenerative arthritis; bilateral hip bursitis; bilateral hallux valgus; costochondritis; chronic maxillary sinusitis; allergic rhinitis; hypertension; status post greater saphenous vein, radiofrequency ablation; gastroesophageal reflux disease; and headache syndrome/intermittent tension. See August 2017 Rating Decision – Codesheet. (E) Is it at least as likely as not (a 50 percent or greater probability) that any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities) caused or aggravated the Veteran’s obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (F) If yes, is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated the Veteran’s left lower extremity vein disability including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. In addition to the other relevant evidence of record, the examiner is asked to consider the following: (1) The Veteran’s report that she was treated for left lower extremity varicose veins while on active duty. See NOD. (2) Service records showing that the Veteran served in Afghanistan and Iraq. See September 2016 DD-214. (3) Medical records from June 2016 showing varicose veins and painful varicose veins for the last several years without reference to location. See August 2016 STR; July 2016 Medical Treatment Record. (4) Any and all other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran’s documented history and assertions. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community or the limits of the examiner’s medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 4. Readjudicate the issues on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Dougan The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.