Citation Nr: 20060992 Decision Date: 09/16/20 Archive Date: 09/16/20 DOCKET NO. 17-48 057 DATE: September 16, 2020 REMANDED Entitlement to service connection for a sciatic nerve or sacroiliac joint disorder, to include as secondary to service-connected bilateral foot impairment from bipedal lymphangiogram, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1976 to July 1993. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the case for further development in November 2018. The case has since been returned to the Board for appellate review. Upon review, the Board finds that additional development is needed prior to adjudication of the claim. The Veteran has contended that he has sciatic hip joint pain caused by a bi-pedal lymphangiogram performed in service. See September 2017 VA Form 9. He is currently service-connected for bilateral foot impairment from a bi-pedal lymphangiogram. Specifically, he has asserted that his sciatic problems began around 2002 or 2003 and are due to his service-connected disability that causes him to limp, which in turn has caused hip and sacroiliac joint pain. See id; see also July 2015 notice of disagreement (NOD). The Veteran was afforded a VA examination for peripheral neuropathy in February 2016. The VA examiner did not diagnose the Veteran with peripheral neuropathy, a sciatic nerve disorder, or radiculopathy. However, the examiner did not address the Veteran’s medical records pertaining to treatment for sacroiliac joint pain, including medication and injections or the diagnoses of sacroiliac joint disease and neuropathy status post bi-pedal lymphangiogram, mild scoliosis, endplate changes and possible facet arthropathy, and rudimentary disc with questionable facets in March 2012. The Veteran was subsequently provided another VA examination in November 2019. The examiner noted that the he is currently service-connected for bilateral foot impairment from a bipedal lymphangiogram and chronic lower back pain and that he has a new diagnosis of bilateral foot neuropathy. She indicated that a MRI of the lumbar spine and sacrum were negative with no nerve root impingement or damage in 2009 and 2010. She also stated that there are no medical records documenting a diagnosis of a sciatic nerve or sacroiliac joint disorder; therefore, she could not provide an opinion regarding aggravation. Moreover, she stated that bilateral foot impairment would not cause a sciatic nerve or sacroiliac joint condition, as the two conditions are not medically or anatomically related. She commented that the Veteran's foot impairment is directly related to a lymphangiogram completed in 1991, which had no association with a lower back condition at the time of the procedure. Nevertheless, the Board notes that the November 2019 VA examiner did not address the specific treatment records as requested in the prior remand. Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Moreover, the VA examiner did provide an etiology opinion regarding the diagnosis of peripheral neuropathy. Therefore, the Board finds that an additional VA examination and medical opinion are needed. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his sciatic nerve, sacroiliac joint, and peripheral neuropathy. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any sciatic nerve or sacroiliac joint disorder or peripheral neuropathy of the lower extremities that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay statements. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should identify any current sciatic nerve disorder or sacroiliac joint disorder or peripheral neuropathy of the lower extremities. In so doing, he or she should consider the previous diagnoses of sacroiliac joint disease, as well as all diagnostic imaging results. Specifically, the examiner should refer to the April 2006 and September 2010 diagnoses of sacroiliac joint disease, the March 2012 diagnoses of neuropathy status-post bi-pedal lymphangiogram, mild scoliosis, endplate changes, possible facet arthropathy, and rudimentary disc, the February 2006 x-ray showing minimal degenerative changes to the lumbar spine, the June 2010 MRI, and August 2010 MRI. The examiner should also consider the August 2007 VA treatment record noting that the Veteran was tender to pressure over the right sacroiliac joint with limited flexibility in the low back and hamstring muscle, a March 2006 VA treatment record documenting sacroiliac joint pain that was worse with prolonged standing), and March 2012 private medical record indicating that he has a sharp burning sensation when on his feet. For each diagnosis identified or any pain resulting in functional impairment, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service, to include any symptomatology therein. See e.g. June 1978 x-rays (sacral S-1); March 1992 letter noting that the Veteran had some trauma to the small sensory nerves and ended up with a little bit of a dystrophic component. The examiner should also opine as to whether it is at least as likely as not that any current disorder was either caused by or aggravated by the Veteran’s service-connected bilateral foot impairment from bipedal lymphangiogram and chronic low back pain. In rendering his or her opinions, the examiner should address both the causation and aggravation questions. In other words, even if the Veteran’s service-connected disabilities did not cause a current disorder, the examiner should still address whether the service-connected disabilities aggravate the current disorder. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should complete any further development that may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Kuczynski 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.