Citation Nr: 21001569 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 18-05 051 DATE: January 11, 2021 REMANDED Entitlement to service connection for a left elbow condition is remanded. Entitlement to service connection for a right elbow condition is remanded. REASONS FOR REMAND The Veteran served honorably on active duty in the United States Army from September 2004 to May 2016. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board. In May 2020, after determining that the Veteran’s July 2019 VA examination was inadequate because the examiner based negative findings on a lack of contemporaneous treatment records and without addressing the Veteran’s lay statements, the Board remanded the issue of entitlement to service connection for a right elbow and a left elbow disability for further development, to include a new VA examination. This development is now complete, and these matters are now before the Board for appellate review. 1. Entitlement to service connection for a left elbow condition 2. Entitlement to service connection for a right elbow condition The Veteran contends his right and left elbow conditions are related to his active service. Specifically, he asserts these conditions are the result of a fall in service, or alternatively due to lifting equipment boxes. See July 2019 VA Examination at 6; June 2016 VA Examination at 1. The Veteran most recently appeared for a VA examination in September 2020. The examiner stated that the Veteran did not currently have a left elbow disability or a right elbow disability. See Sept. 2020 VA Examination at 15. In making this determination, the examiner opined there was no pathology indicating a current disability based on the lack of pain, tenderness, and normal muscle strength on examination, as well as a lack of abnormalities found on imaging tests. See id. While the examiner noted abnormal range of motion, the examiner opined this occurred because the Veteran resisted participating in the exam, and as such, the abnormal range of motion did not indicate a current disability. See id. at 8. Unfortunately, the Board finds the September 2020 examination inadequate for adjudication purposes. In this regard, the examiner failed to consider that the Veteran had been previously diagnosed with a bilateral elbow strain. See July 2019 VA Examination at 5. She further failed to consider the Veteran’s lay reports of pain and functional impairment, specifically that he experiences reduced mobility, difficulty getting dressed, difficulty with daily tasks, and diminished grip strength. See Sept. 2020 VA Examination at 7. While pain alone does not constitute a disability warranting service connection, pain causing functional impairment affecting earning capacity is considered a current disability. See 38 C.F.R. §§ 3.102, 3.303; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); Wait v. Wilkie, No. 18-4349. Accordingly, the claims must be remanded in order to obtain an adequate examination and opinion. See 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). The matters are REMANDED for the following action: 1. Obtain any updated VA treatment records pertaining to the Veteran and associate them with the file. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed left elbow and right elbow disabilities. The examiner must review pertinent documents in the claims file in conjunction with the examination. This must be noted in the examination report. All tests and studies deemed necessary by the examiner should be performed. a) The examiner is asked to provide a diagnosis for any bilateral elbow conditions that have existed during the pendency of the claim. If an underlying diagnosis cannot be provided, the examiner is asked to determine whether the Veteran’s elbow pain causes functional impairment. In providing this opinion, the examiner must consider (1) the July 2019 VA examination showing a diagnosis of bilateral elbow strain; and (2) the Veteran’s lay reports of pain and functional impairment, specifically that he experiences reduced mobility, difficulty getting dressed, difficulty with daily tasks, and diminished grip strength. See Sept. 2020 VA Examination at 7. b) The examiner should then opine as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s current bilateral elbow conditions (or pain and functional impairment) had its onset in service or is otherwise etiologically related to active service. In providing this opinion, the examiner must address the Veteran’s assertion that his condition may be due to lifting equipment boxes in service or an injury in service. The examiner must also consider service treatment records documenting a history of bilateral elbow pain for three years that began during strength training in service. See April 2016 STR p. 1. The examiner is advised the Veteran is competent to report his symptoms and history, and such reports must be considered. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. Rationale for all requested opinions must be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board O. Gomez, Law Clerk 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.