Citation Nr: 21065101 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 18-52 806 DATE: October 25, 2021 REMANDED Entitlement to an initial compensable rating for left hip strain prior to September 8, 2020, and a rating in excess of 20 percent thereafter is remanded. Entitlement to service connection for bilateral plantar fasciitis is remanded. Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for right lower extremity sciatica to include as secondary to service connected status-post lumbar surgery is remanded. Entitlement to service connection for left lower extremity sciatica to include as secondary to service connected status-post lumbar surgery is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from July 1994 to July 2014. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Atlanta, Georgia. Jurisdiction of this appeal is currently with the RO in Philadelphia, Pennsylvania. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ) of the Board in May 2021. A transcript of the hearing has been associated with the claims file. In addition, in a February 2021 rating decision, the Agency of Original Jurisdiction (AOJ) granted a separate rating for left hip strain with limitation of abduction, adduction, and rotation, and assigned a noncompensable rating; and service connection for a separate rating for left hip strain with limitation of flexion, and assigned a noncompensable rating; both assigned an effective date of September 8, 2020. To date, the Veteran has not submitted a notice of disagreement with this decision. Additionally, the February 2021 rating decision constitutes an initial decision within the Appeals Modernization Act (AMA) system. Therefore, as this decision represents a full grant of the benefits sought with respect to this claim for service connection for left hip strain with limitation of abduction, adduction, and rotation and flexion, such issues are not currently before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). In the same February 2021 rating decision, the AOJ granted staged ratings for the Veteran's service-connected left hip strain, currently on appeal before the Board, and assigned a 10 percent rating effective September 8, 2020. Thus, the Board will only consider the issue of an increased initial rating for left hip strain as characterized on the cover page of this decision. Increased Rating Left Hip Strain The Veteran was most recently afforded an examination for left hip strain in January 2021. At his May 2021 Board hearing, the Veteran testified that his left hip strain had worsened since his most recent VA examination. Specifically, the Veteran felt his pain had worsened, interfered with interactions with his daughter, and required him to lie down at least once a day. Additionally, he testified that he had additional limited range of motion, weakness, and catching. Moreover, the Veteran testified that he received treatment from the Portsmouth Naval Hospital for his disabilities. Such records have not yet been associated with the claims file and should be obtained upon remand. As the above evidence indicates a possible worsening of that the Veteran's left hip strain since his last VA examination, an additional examination should be afforded to gauge the current level of severity of his disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Service Connection Claims Bilateral Plantar Fasciitis, Right Shoulder Disorder, and Bilateral Lower Extremity Sciatica The Veteran seeks entitlement to service connection for bilateral plantar fasciitis, a right shoulder disorder, and bilateral lower extremity sciatica. Specifically, the Veteran asserts that his symptoms manifested during active service and have continued since and that his bilateral lower extremity sciatica is secondary to his service-connected status-post lumbar surgery. Initially, the Board notes that service connection is currently in effect for status post lumbar surgery (also claimed as lumbar microdiskectomy, lumbar back pain, and lumbar herniated nucleus pulposus). With regard to his bilateral plantar fasciitis and bilateral lower extremity sciatic, the Board notes that service treatment records indicate the Veteran complained of foot pain and bilateral lower leg pain during active service. See Service Treatment Record, March 10, 2014. With regard to his right shoulder disorder, the Board notes that service treatment records indicate the Veteran complained of bilateral shoulder pain during active service. See Service Treatment Record, February 24, 2014. The Veteran was afforded VA examinations for foot conditions and his right shoulder in March 2015. At those times, the VA examiners found the Veteran did not have current diagnoses as related to his bilateral feet and right shoulder. However, the Veteran reported pain in his feet and right shoulder, flare-ups of the feet and right shoulder, and described functional loss in his bilateral feet and right shoulder. Moreover, the Veteran testified at his May 2021 Board hearing that he continued to experience functional loss as due to his bilateral feet and right shoulder symptoms. The Veteran has not yet been afforded VA examinations as to his bilateral lower extremity sciatica. The Board finds the March 2015 VA examination reports incomplete to decide the claim. In this regard, the examiners failed to adequately address the Veteran's lay statements and contentions regarding pain resulting in functional loss and/or functional impairment of his bilateral feet and right shoulder. Rather, the examiner merely concluded there was no diagnoses and did not provide an etiology opinion as to the Veteran's claims. The Board notes the decision in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), holding that pain manifesting in functional loss constitutes a disability for VA purposes. Finally, as noted above, the Veteran testified that he received treatment from the Portsmouth Naval Hospital for his disabilities. Such records have not yet been associated with the claims file and should be obtained upon remand. In light of the foregoing, the Board concludes that the Veteran should be afforded VA examinations to determine the nature and etiology of the claimed bilateral plantar fasciitis, right shoulder disorder, and bilateral lower extremity sciatica. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. The RO should be sure to obtain any and all treatment records for the Veteran from Portsmouth Naval Hospital, and associate them with the claims file. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected left hip strain. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran's service-connected left hip strain. A rationale for any opinion offered should be provided. 3. Following the receipt of outstanding records, schedule the Veteran with an appropriate clinician(s) for a VA examination(s) to determine the etiology of his claimed bilateral plantar fasciitis, right shoulder disorder, and bilateral lower extremity sciatica. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies and tests should be conducted. The need for physical examination is left to the discretion of the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following question: (A) Is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral plantar fasciitis had its onset during any period of service, or is otherwise related to such period of service, to include the physical rigors of active service? The examiner must address the Veteran's complaints of, and treatment for, bilateral foot pain in March 2014. (B) Is at least as likely as not (50 percent or greater probability) that the Veteran's right shoulder disorder had its onset during any period of service, or is otherwise related to such period of service, to include the physical rigors of active service? The examiner must address the Veteran's complaints of, and treatment for, bilateral shoulder pain in February 2014. (C) Is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral lower extremity sciatica had its onset during any period of service, or is otherwise related to such period of service, to include the physical rigors of active service? The examiner must address the Veteran's complaints of, and treatment for, bilateral leg pain in March 2014. (D) Is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral lower extremity sciatica was caused by or aggravated by his service connected status-post lumbar surgery? A RATIONALE FOR ALL OPINIONS EXPRESSED SHOULD BE PROVIDED. The examiner must reconcile any conflicting medical evidence of record. A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, Counsel 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.