Citation Nr: 21013735 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-45 158 DATE: March 10, 2021 REMANDED Entitlement to a compensable initial evaluation for right shoulder strain is remanded. Entitlement to a compensable initial evaluation for left shoulder strain is remanded. Entitlement to a compensable initial evaluation for left elbow strain is remanded. Entitlement to a compensable initial evaluation for right elbow strain is remanded. Entitlement to a compensable initial evaluation for allergic rhinitis is remanded. Service connection for a left hand thumb disability is remanded. Service connection for a right hand thumb disability is remanded. Service connection for a left hand middle finger disability is remanded. Service connection for a right hand middle finger disability is remanded. Service connection for a left hand index finger disability is remanded. Service connection for a right hand index finger disability is remanded. Service connection for a left hand ring finger disability is remanded. Service connection for a right hand ring finger disability is remanded. Service connection for a left hand little finger disability is remanded. Service connection for a right hand little finger disability is remanded. Service connection for a left wrist disability is remanded. Service connection for a right wrist disability is remanded. Service connection for a left knee disability is remanded. Service connection for a right knee disability is remanded. Service connection for left leg shin splints is remanded. Service connection for right leg shin splints is remanded. Service connection for left ankle disability is remanded. Service connection for a right ankle disability is remanded. Service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2011 to November 2015. The Veteran testified before the undersigned Veterans Law Judge in November 2019. A transcript of the hearing is in the Veteran's eFolder. 1. Compensable initial evaluation for right shoulder strain is remanded. 2. Compensable initial evaluation for left shoulder strain is remanded. 3. Compensable initial evaluation for left elbow strain is remanded. 4. Compensable initial evaluation for right elbow strain is remanded. 5. Compensable initial evaluation for allergic rhinitis is remanded. 6. Service connection for a right hand index finger disability is remanded. 7. Service connection for a left hand thumb disability is remanded. 8. Service connection for a right hand thumb disability is remanded. 9. Service connection for a left hand middle finger disability is remanded. 10. Service connection for a right hand middle finger disability is remanded. 11. Service connection for a left hand index finger disability is remanded. 12. Service connection for a right hand ring finger disability is remanded. 13. Service connection for a left hand little finger disability is remanded. 14. Service connection for a right hand little finger disability is remanded. 15. Service connection for a left hand ring finger disability is remanded. 16. Service connection for a left wrist disability is remanded. 17. Service connection for a right wrist disability is remanded. 18. Service connection for a left knee disability is remanded. 19. Service connection for left leg shin splints is remanded. 20. Service connection for right leg shin splints is remanded. 21. Service connection for left ankle disability is remanded. 22. Service connection for a right ankle disability is remanded. 23. Service connection for a right knee disability is remanded. 24. Service connection for bilateral hearing loss is remanded. Each issue on appeal is remanded to obtain VA treatment records. A July 2016 statement of the case identifies and refers to medical records from the Atlanta VA Medical Center (VAMC) dated from February 2, 2016 through June 23, 2016. The Veteran's eFolder does not contain any VA treatment records. In addition, during the hearing, the Veteran stated that he only received VA medical treatment or non-VA care through VA’s Veteran’s Choice program. The non-VA care included treatment for his shoulders and knees at Advanced Physical Therapy in Rockmart, Georgia, in 2017 and 2018; ongoing chiropractic treatment for his shoulders at the Harbin Clinic in Rome, Georgia, beginning in July 2019; and an MRI for his neck (the results of which the Board notes could reasonably be expected to contain relevant shoulder findings) at the Cartersville Medical Center. The Veteran's eFolder does not contain any records of the non-VA treatment. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issues on appeal. A remand is required to allow VA to obtain them. In addition, in a claim for disability compensation, VA will make efforts to obtain records of examination or treatment at non-VA facilities authorized by VA. See 38 C.F.R. § 3.159 (c)(3) The Board recognizes that the Veteran stated during the hearing that he did not have current diagnoses for his service connection claims. However, in Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018), the Federal Circuit held that pain alone, in the absence of a diagnosed condition, may constitute a disability if it results in functional impairment of earning capacity. Thus, outstanding records of VA and non-VA treatment authorized by VA may be relevant to the Veteran's service connection claims even without containing any current diagnoses. The issues on appeal of entitlement to initial compensable evaluations are remanded for a VA examination to obtain current findings. During the hearing, the Veteran provided detailed testimony that his service-connected right and left shoulder disabilities, right and left elbow disabilities and allergic rhinitis have increased in severity since he was last examined by VA in December 2015. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of these disabilities. The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran’s eFolder/virtual file copies of all VA treatment records (no VA treatment records are currently in the virtual file), to include treatment records from the VAMC Atlanta from February to June 2016, noted in the Statement of the Case, as well as any additional VA treatment records. 2. After obtaining any necessary authorization from the Veteran, please obtain and associate with the Veteran’s virtual file all non-VA treatment records relevant to any conditions on appeal, including records of treatment authorized by VA or conducted by a community care provider through the VA Choice program, to include: (a.) treatment for his shoulders and knees at Advanced Physical Therapy in Rockmart, Georgia, in 2017 and 2018; and (b.) ongoing chiropractic treatment for his shoulders at the Harbin Clinic in Rome, Georgia, beginning in July 2019; and (c.) an MRI for his neck (the results of which the Board notes could reasonably be expected to contain relevant shoulder findings) at the Cartersville Medical Center. 3. After the above development has been completed, schedule the Veteran for examination by an appropriate clinician to determine the current severity of his service-connected right and left shoulder disabilities, right and left elbow disabilities and allergic rhinitis. The clinician should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran’s disabilities under the rating criteria. With respect to the Veteran’s right and left shoulder disabilities and right and left elbow disabilities, the clinician must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the clinician 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 clinician (does not have the knowledge or training). Similarly, with respect to the Veteran’s right and left shoulder disabilities and right and left elbow disabilities, the clinician must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the clinician should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the clinician 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 clinician (does not have the knowledge or training). A complete rationale must be provided for any opinion expressed. 4. Undertake any further development indicated by the additional VA and on-VA treatment records obtained pursuant to this remand, to include VA examination(s) for any service connection claim(s) if necessary. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Davitian, 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.