Citation Nr: 21075651 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 17-50 732 DATE: December 21, 2021 REMANDED Entitlement to service connection for right wrist carpal tunnel syndrome is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to a compensable initial rating for a right shoulder disability is remanded. Entitlement to a rating in excess of 10 percent for a left shoulder disability is remanded. Entitlement to a compensable initial rating for a right knee disability is remanded. Entitlement to a compensable initial rating for a left knee strain with shin splints is remanded. Entitlement to a compensable initial rating for a right ankle strain status post fracture is remanded. Entitlement to an initial rating in excess of 10 percent for insomnia disorder with traumatic brain injury (TBI), to include whether a separate rating for TBI is warranted, is remanded. REASONS FOR REMAND The Veteran had active service from October 1988 to March 1989, May 1989 to December 1995, August 1998 to March 2000, January 2003 to November 2003, November 2006 to May 2015, to include service in Southwest Asia from August 1990 to March 1991. The Veteran was awarded a Bronze Star with "V" device, Combat Infantryman Badge, Combat Medical Badge, Free Fall Parachutist Badge (Jumpmaster), and Kuwait Liberation Medal among other decorations. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for right wrist carpal tunnel syndrome is remanded. 2. Entitlement to service connection for a right hip disability is remanded. 3. Entitlement to a compensable initial rating for a right shoulder disability is remanded. 4. Entitlement to a rating in excess of 10 percent for a left shoulder disability is remanded. 5. Entitlement to a compensable initial rating for a right knee disability is remanded. 6. Entitlement to a compensable initial rating for a left knee strain with shin splints is remanded. 7. Entitlement to a compensable initial rating for a right ankle strain status post fracture is remanded. 8. Entitlement to an initial rating in excess of 10 percent for insomnia disorder with TBI, to include whether a separate rating for TBI is warranted, is remanded. The evidence indicates there may be outstanding relevant VA treatment records. On his February 2015 VA Form 21-526EZ, the Veteran reported that he received treatment at the Chicago VA Medical Center (VAMC) as early as 1996. The record does not contain any records from the Chicago / Jesse Brown VAMC, or any records dated prior to May 15, 2002. As such records are relevant to the service connection claims, a remand to obtain the outstanding records is required. Regarding the Veteran's carpal tunnel claim, he was provided a VA examination in March 2015. While the examiner indicated there was no diagnosis because there was no pathology, the examiner did not document the Veteran's reported neurological symptoms, perform any special tests, such as Phalen's sign and Tinel's sign, or perform an electromyography (EMG). Moreover, as the Veteran had service in the Persian Gulf, the examiner should have opined whether the Veteran's right wrist neurological symptoms represent an undiagnosed illness consistent with service in the Persian Gulf. Accordingly, further examination is warranted. Regarding the Veteran's right hip claim, the March 2015 VA examination report and August 2017 addendum opinion noted that the Veteran had right hip pain with movement and reported being diagnosed with early arthritis. Nevertheless, the examiner, without performing any imaging studies or providing a rationale indicated that the Veteran did not have any hip and/or thigh condition because his hip pain was "most likely referred pain from the back." Accordingly, further examination is warranted. The Veteran's last VA examinations for his right ankle, knees, and shoulders were in March 2015. As noted in the notice of disagreement and June 2020 informal hearing presentation, the Veteran has requested a remand for additional examinations because the examination reports do not comply with the requirements set forth in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). None of the examination reports provided range of motion findings for passive motion, in weight-bearing, and non-weight-bearing. Id. Additionally, the ankle examination report does not comply with the requirements set forth in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Specifically, while the ankle examination report indicated that an opinion regarding flare-ups could not be provided without resort to speculation, the sole rationale was that the Veteran was not presently having a flare-up. Accordingly, a remand for a Correia and Sharp compliant examination is warranted. Regarding the Veteran's increased rating claim for insomnia with TBI, his last VA examinations were in March 2015. At that time, the only reported symptoms were chronic sleep impairment, mild memory loss, and irritability. In his October 2016 notice of disagreement, the Veteran reported that his symptoms now included anxiety, depressed mood, panic attacks, and suspiciousness. In light of the Veteran's assertion of additional symptoms, he should be afforded VA mental disorder and TBI examinations to assess the nature and severity of his service-connected insomnia disorder with TBI. Finally, additional records were associated with the claims file subsequent to the subsequent to the September 2017 Statement of Case and prior to the appeal being transferred to the Board. As the records were relevant to the Veteran's insomnia disorder with TBI, such records must be reviewed on remand. 38 C.F.R. §§ 19.31(b)(2), 19.37, (2020). The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain all VA treatment records dated prior to May 15, 2002 and any updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. After records development is completed, the Veteran should be afforded a VA examination to determine the nature of any carpal tunnel syndrome and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests, including an EMG and/or nerve conduction study, should be conducted and the results reported. If such testing is not necessary, the examiner should explain why. Following review of the claims file and examination of the Veteran, the examiner should: (a.) Identify any disability manifested by right wrist neurological symptoms and state whether it is at least as likely as not (50 percent probability or greater) that any current neurological disability of the right wrist arose during service or is otherwise related to service. The examiner shoulder address the November 15, 2019 vocational rehabilitation counseling record noting that the Veteran had right wrist carpel tunnel syndrome. (b.) If there is no diagnosis to account for the Veteran's right wrist neurological symptoms, the examiner should indicate whether there are objective indications of disability and whether such indications represent an undiagnosed illness consistent with service in the Persian Gulf. A rationale for all opinions expressed should be provided. 3. After records development is completed, the Veteran should be afforded a VA hip examination to determine the nature of any right hip disability and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests, including x-rays, should be conducted and the results reported. If such testing is not necessary, the examiner should explain why. Following review of the claims file and examination of the Veteran, the examiner should: (a.) Identify any disability manifested by right hip pain and provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any right hip arose disability arose during service or is otherwise related to service, including his in-service parachuting duties and January 15, 2011, January 25, 2011, October 22, 2013, and February 3, 2015 reports of right hip pain and assessment with "possible early onset of arthritis." (b.) If there is no diagnosis to account for the Veteran's right hip symptoms, the examiner should indicate whether there are objective indications of disability and whether such indications represent an undiagnosed illness consistent with service in the Persian Gulf. The examiner should address the January 6, 2017 record from FirstHealth noting osteoarthritis of hip on the Veteran's active problem list. A rationale for all opinions expressed should be provided. 4. After the above record development is completed to the extent possible, schedule the Veteran for a VA shoulder examination to determine the current nature and severity of his service-connected right and left shoulder disabilities. The claims file should be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. Range of motion testing should be undertaken, and should be tested actively and passively, in weight bearing, and after repetitive use. (a.) For each range of motion testing conducted, the examiner must state where in the range of motion the Veteran reports that he begins to experience pain. If the examiner is unable to conduct any of the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (b.) The examiner should also state whether there is likely to be additional range of motion loss due to flare-ups and due to pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. In doing so, the examiner should elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record, including the Veteran's lay information. (c.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, 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). 5. After the above record development is completed to the extent possible, schedule the Veteran for a VA knee examination to determine the current nature and severity of his service-connected right and left knee disabilities. The claims file should be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. Range of motion testing should be undertaken, and should be tested actively and passively, in weight bearing, and after repetitive use. (a.) For each range of motion testing conducted, the examiner must state where in the range of motion the Veteran reports that he begins to experience pain. If the examiner is unable to conduct any of the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (b.) The examiner should also state whether there is likely to be additional range of motion loss due to flare-ups and due to pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. In doing so, the examiner should elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record, including the Veteran's lay information. (c.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, 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). 6. After the above record development is completed to the extent possible, schedule the Veteran for a VA right ankle examination to determine the current nature and severity of his service-connected right ankle disability. The claims file should be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. Range of motion testing should be undertaken, and should be tested actively and passively, in weight bearing, and after repetitive use. (a.) For each range of motion testing conducted, the examiner must state where in the range of motion the Veteran reports that he begins to experience pain. If the examiner is unable to conduct any of the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (b.) The examiner should also state whether there is likely to be additional range of motion loss due to flare-ups and due to pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. In doing so, the examiner should elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record, including the Veteran's lay information. (c.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, 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). 7. After records development is completed, schedule the Veteran for VA mental disorder and TBI examinations to determine the current severity of his insomnia disorder with TBI. The claims file should be reviewed by the examiner. All necessary tests should be performed, and the results reported. All symptomatology associated with the insomnia disorder with TBI should be reported. For any other mental disorder or sleep disorder identified during the examination, the examiner should state whether those diagnoses are a progression of his service-connected insomnia disorder with TBI. In so opining, the examiner should address the Veteran's assertions regarding his posttraumatic stress disorder and restless leg syndrome. A rationale for all opinions expressed should be provided. 8. If the claims remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Anderson 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.