Citation Nr: 21070440 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-42 020 DATE: November 24, 2021 REMANDED Entitlement to service connection for a right shoulder injury is remanded. Entitlement to service connection for left leg sciatic nerve condition is remanded. Entitlement to service connection for migraines is remanded. Entitlement to service connection for pelvic pain is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2005 to May 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision. The Veteran did not request a Board hearing. 1. Entitlement to service connection for a right shoulder injury is remanded. The Veteran contends that her right shoulder injury is due to an injury occurring from a fall during service. A December 2010 STR notes the Veteran had right shoulder pain status post dislocation. She was seen again in January 2011 due to concerns for her right shoulder and right shoulder discomfort. A May 2012 private treatment record notes the Veteran fell back and pulled her right shoulder while loading an 80-pound robot in October 2010. It is noted the Veteran has at least a four-to-five-year history of tightness and spasms in her right upper back and shoulder. The Veteran was afforded a VA examination in September 2013. The examiner noted the Veteran did not have a right shoulder diagnosis. There was no loss of range of motion and no functional loss or impairment. The August 2015 VA examination noted the Veteran had a diagnosis of right shoulder strain. The Veteran reported she injured her right shoulder in October 2010 while in Afghanistan and unloading a piece of robotic equipment. Upon VA examination in August 2016, the examiner noted the Veteran had limited range of motion due to fibromyalgia bilaterally. The Veteran was unable to lift her arms without weakness and pain. There is loss of range of motion. The Board cannot make a fully informed decision on the issue of entitlement to service connection for a right shoulder injury because no VA examiner has opined whether the Veteran's right shoulder strain is due to her injury in service. Therefore, remand is necessary. 2. Entitlement to service connection for left leg sciatic nerve condition is remanded. The Veteran contends her left leg sciatic nerve condition first manifested around 2006 during a military physical test. A March 2012 private treatment record notes the Veteran had lower back pain with radiculopathy down both legs. The September 2013 VA examination report noted the Veteran does not have any radicular pain or any other signs or symptoms due to radiculopathy. A September 2014 private treatment record states the Veteran has migratory nerve pains. Medical Evaluation Board proceedings from March 2014 note the Veteran experienced generalized nerve pain. The August 2016 VA examination report noted the Veteran had no radiculopathy. A February 2017 VA treatment record notes the Veteran has involvement of the sciatic nerve, on the right side. The Veteran noted her spasms started in approximately 2006 during a physical fitness test. The Board cannot make a fully informed decision on the issue of entitlement to service connection for a left leg sciatic nerve condition because no VA examiner has opined whether the Veteran's sciatic nerve involvement is due to her claimed injury in service. Therefore, remand is necessary. 3. Entitlement to service connection for migraines is remanded. The Veteran contends that her migraines first manifested during service due to exposure to a blast. See August 2017 VA Form 9. A September 2011 post-deployment health re-assessment notes the Veteran experienced bad headaches. The Veteran noted she experienced a blast or explosion during her deployment. A November 2011 STR notes the Veteran experienced "paralyzing" headaches. Private treatment records from November 2012 and February 2013 note an impression of migraine headaches. In July 2013, a VA treatment record notes the Veteran was prescribed medication for her headaches. In a November 2013 private treatment record, the Veteran notes she fell off of a truck and hit her head with loss of consciousness for a few seconds. The January 2017 VA examination report notes a diagnosis of migraine and a history of headaches after deployment and exposure to an IED. The Board cannot make a fully informed decision on the issue of entitlement to service connection for migraines because no VA examiner has opined whether the Veteran's migraines are due to her headaches and exposure to an IED in service. Therefore, remand is necessary. 4. Entitlement to service connection for pelvic pain is remanded. The Veteran contends her pelvic pain is due to falls and injuries during service. See September 2015 Private Treatment records. A November 2009 STR notes the Veteran experienced pelvic pain for two weeks. A December 2009 STR notes the Veteran experienced pelvic pain. October 2015 and November 2015 private treatment records note an assessment of right side sacroiliitis. Sacroiliitis is inflammation of the sacroiliac joint or region. Merriam-Webster's Medical Dictionary (merriam-webster.com/medical, accessed October 28, 2021). The sacrum is the part of the spinal column that is directly connected with or forms a part of the pelvis. Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed October 28, 2021). The February 2017 VA examination report noted no diagnosis of a pelvic condition. The Board cannot make a fully informed decision on the issue of entitlement to service connection for pelvic pain because no VA examiner has opined whether the Veteran's pelvic pain is due to her pelvic pain in service. Therefore, remand is necessary. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of a right shoulder condition. The entire file must be made available to the examiner designated to examine the appellant, and the report of examination should include discussion of the Veteran's documented history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner must opine whether it is at least as likely as not the Veteran's right shoulder condition is related to an in-service injury, event, or disease, to include a fall in October 2010. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of a left leg sciatic nerve condition. The entire file must be made available to the examiner designated to examine the appellant, and the report of examination should include discussion of the Veteran's documented history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner must opine whether it is at least as likely as not the Veteran's left leg sciatic nerve condition is related to an in-service injury, event, or disease, to include claimed spasms during service, OR caused by or aggravated by the service connected low back disability. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of migraines. The entire file must be made available to the examiner designated to examine the appellant, and the report of examination should include discussion of the Veteran's documented history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner must opine whether it is at least as likely as not the Veteran's migraines are related to an in-service injury, event, or disease, to include headaches and exposure to an IED during service. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of a pelvic condition, to include sacroiliitis. The entire file must be made available to the examiner designated to examine the appellant, and the report of examination should include discussion of the Veteran's documented history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner must opine whether it is at least as likely as not the Veteran's claimed pelvic condition, to include sacroiliitis is related to an in-service injury, event, or disease, to include pelvic pain during service. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alexia E. Palacios-Peters, Associate 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.