Citation Nr: 21004382 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 14-35 348A DATE: January 27, 2021 REMANDED The claim of entitlement to service connection for sciatica is remanded. REASONS FOR REMAND The Veteran had active service from February 1986 to May 1986 and from March 1988 to January 1995. His claim comes before the Board of Veterans’ Appeals (Board) on appeal of an August 2011 Department of Veterans Affairs (VA) rating decision. The Veteran testified in support of this claim during a June 2014 hearing before a Decision Review Officer at the Agency of Original Jurisdiction (AOJ). In December 2018, the Board denied this claim. The Veteran then appealed the Board's decision to the United States Court Of Appeals For Veterans Claims (Court). In September 2019, based on a Joint Motion For Partial Remand (joint motion), the Court remanded this matter to the Board for action consistent with the terms of the joint motion. Entitlement to service connection for sciatica The Veteran is currently service connected for a back disability characterized as thoracic strain with scoliosis, scoliosis of the lumbar spine and spondylosis. He seeks service connection for sciatica on either a direct basis, as initially manifesting in service or related to an in-service slip-and-fall accident, or secondary basis, as related to the service-connected back disability. He has testified that he developed sciatica within a year or two of developing feet, back and right knee problems. He described the sciatica as pins and needles, numbness and aching pain that radiates to his lower extremities, occasionally necessitating prescription pain medication. During the hearing, he submitted multiple documents that reportedly show he was first treated for sciatica in service. Service treatment records establish that, as claimed, during service, the Veteran slipped and fell on ice and developed back, foot and knee problems. After discharge from service, the Veteran began reporting leg complaints, and medical professionals noted a functionally short left leg and neurological abnormalities, primarily in the Veteran’s feet and calves. In April 1996, one diagnosed sciatica. Since then, the Veteran has expressed similar complaints, including originating from his back, and medical professionals have diagnosed sciatica, albeit rarely. Although the record is clear that the Veteran has had neurological abnormalities since discharge, the record conflicts regarding whether sciatica is a valid diagnosis. In a September 2020 opinion, a VA examiner addressed this matter, concluding that the Veteran has no indication of sciatica. This opinion is inadequate to decide this claim. First, it is based on a 2019 VA examination report, rather than a complete review of all critical documents (including those referenced by the Board in its June 2020 Remand). Second, in then assuming sciatica is a valid diagnosis, the examiner ruled out a relationship between that condition and the Veteran’s service-connected back disability on the basis that sciatica is unrelated to the thoracic spine and caused by nerve root irritation in the lumbar spine. This opinion ignores the fact that the Veteran’s service-connected back disability is characterized to include both the thoracic and lumbar segments of the spine. Given these facts, this opinion is not probative, and another is needed. In addition, a copy of the April 16, 1996 document the Veteran submitted during his hearing, which, as asserted, includes a finding of sciatica, is illegible in certain parts, requiring that it be recopied and associated with the record. Also, the handwriting in this document very obviously changes midway through a sentence, necessitating a review of the original, including for the purpose of verifying its veracity. The matter is REMANDED for the following action: 1. Recopy the original April 16, 1996 medical document the Veteran submitted during his hearing (now located in Caseflow under January 18, 2000 submission) and associate it with the record. Review the handwriting changes evident mid-way through the document, mid-sentence, and indicate in writing in the record whether the original document appears altered. 2. Thereafter, transfer this case to the VA examiner who reviewed the Veteran’s file in September 2020 for an addendum opinion. The examiner should review all pertinent evidence of record, including: (a) the Veteran’s service treatment records showing an in-service fall onto ice, reports of and treatment for foot, leg and back problems, including a functional short leg, and a discharge due to disabilities (knee, thoracic spine, feet, hypertension, Gilbert’s syndrome and a benign essential tremor); (b) the April 16, 1996 document noting sciatica; (c) a November 1998 medical record, in which the Veteran first described his leg pain as radiating (to left flank); (d) an August 1999 VA feet examination report reflecting the Veteran’s complaints of pain in his feet and fatigue in his feet and legs, findings of hypertonicity of the anterior muscle groups, tonic contractions, and positive clonus and Babinski tests, and the examiner’s opinion that the findings pointed to an upper motor neuron pathology of unknown origin; (e) a December 1999 VA spine examination report, in which the Veteran reported tenderness, spasm and a pulling sensation on a straight leg raise test; (f) an April 2000 letter from DL, D.P.M., indicating that he had seen the Veteran for, in part, significant pain in both legs and found, in pertinent part, severe diminishment of the anterior muscles of both legs; (g) July 2002 VA joints and feet examination reports, in which the Veteran reported numbness of the lower extremities and pain going to his upper and lower extremities, and the examiner diagnosed, in part, paresthesias of the left lower extremity; (h) an August 2002 normal EMG report reflecting the Veteran’s reports of weakness and numbness in the legs and non-radiating back pain since 1994; (i) a March 2003 VA joints examination report reflecting complaints of foot numbness; (j) treatment records dated from 2010 to 2011, which reflect the Veteran’s regular reports of low back pain and radiculopathy on the right and left, but no diagnosis of sciatica; (k) records from the Social Security Administration, which include complaints of “sciatic pain”, findings of numbness and weakness in the lower extremities and a July 2011 doctor’s report confirming low back pain with sciatica; (l) October 2011, August 2014, July 2016 and April 2019 VA examination reports, in which examiners found no evidence of sciatica or radiculopathy; (m) a July 2013 private treatment record diagnosing sciatica; and (n) the examiner’s inadequate September 2020 opinion. Referring to this evidence, the examiner should opine whether the sciatica diagnoses of record since 2011 are valid, or whether various medical professionals misdiagnosed this condition. Whether the sciatica was intermittent or persistent is irrelevant. The question is whether, at any point during the claims process (since 2011), the Veteran was validly diagnosed with sciatica. If so, the examiner should opine whether the sciatica initially manifested during or within a year of service or is at least as likely as not (50 percent or greater probability) related to service, including the fall on the ice and/or resulting injuries. If not, the examiner should opine whether the Veteran’s sciatica is proximately due to, the result of, or aggravated by, his service-connected thoracic strain with scoliosis, scoliosis of the lumbar spine and spondylosis. The examiner should provide clear rationale for the opinion. 3. The Agency of Original Jurisdiction should ensure the examiner has corrected the deficiencies described above before returning this case to the Board. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. N. 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.