Citation Nr: 21027220 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 17-49 118 DATE: May 5, 2021 REMANDED Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected seronegative arthritis, is remanded. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected seronegative arthritis, is remanded. Entitlement to service connection for a left hip disability, to include as secondary to service-connected seronegative arthritis, is remanded. Entitlement to an initial rating in excess of 10 percent for service-connected degenerative arthritis of the right hip (right hip disability) is remanded. Entitlement to a compensable rating for service-connected seronegative arthritis is remanded. REASONS FOR REMAND The Veteran had active military service from May 1994 to February 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2017 (seronegative arthritis, bilateral shoulder disability) and April 2017 (bilateral hip disability) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2020, the Veteran testified at a hearing. The transcript of the hearing is of record. 1. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected seronegative arthritis, is remanded. 2. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected seronegative arthritis, is remanded. In the October 2020 hearing, the Veteran claimed that his bilateral shoulder disability manifested as a result of his service-connected seronegative polyarthritis; or, in the alternative that the Veteran's bilateral shoulder pain is part of his seronegative polyarthritis. The Board notes that in a May 2017 VA treatment record the Veteran was diagnosed with right shoulder pain and in a July 2018 VA treatment record the Veteran was diagnosed with left shoulder pain. See June 2019 CAPRI. Due to the bilateral shoulder pain, the March 2017 VA examiner opined that the Veteran is limited in lifting or performing overhead activities with weights. A review of service treatment records (STRs) shows that in December 1995 the Veteran complained of right shoulder pain. See April 2016 STR Medical. In a May 1996 STR, the Veteran complained of pain in the shoulders. In a July 1996 STR, the Veteran exhibited upper extreme bilateral arthralgia from the wrist to the shoulder. See June 2008 Medical Treatment Record Government Facility. In a September 1996 STR, the Veteran endorsed having sore shoulder joints. On examination, the Veteran exhibited bilateral acromioclavicular (AC) joint tenderness with limited range of motion. A review of the post-service medical records shows that the Veteran was afforded a VA examination in March 2017. In the March 2017 VA examination, the examiner did not provide a diagnosis for the Veteran's bilateral shoulder pain. However, the examiner noted that the Veteran reported bilateral shoulder pain. On examination, the Veteran exhibited normal range of motion. However, the examiner determined that repeated lifting or performing overhead activities with weights will aggravate the Veteran's shoulder pain. The examiner opined that the Veteran's current symptoms are most likely suggestive of overuse syndrome with repeated weight training and are less likely to be related to his seronegative polyarthritis which has been stable with no evidence of further treatment or evaluation over the years since 1997. In the October 2020 hearing, the Veteran clarified that his bilateral shoulder disability manifested and/or was aggravated as a result of his service-connected seronegative polyarthritis; or, in the alternative that the Veteran's seronegative polyarthritis spread to his bilateral shoulder pain. Based on the foregoing, the Board finds that a remand is warranted. 3. Entitlement to service connection for a left hip disability, to include as secondary to service-connected seronegative arthritis, is remanded. The Board notes that in an April 2019 VA treatment record the Veteran complained of chronic pain in his bilateral hips. See June 2019 CAPRI. Due to his bilateral hip pain, the Veteran is unable to sit for prolonged period of time. See April 2017 C&P Exam. A review of the STRs shows that in September 1996 the Veteran complained of hip pain. See April 2016 STR Medical. On examination, the Veteran exhibited a full range of motion of the hips. The Veteran was afforded a VA examination in April 2017 wherein the Veteran recalled having pain with walking and running in service especially when he had to carry his protective gear. The Veteran stated that he does not remember any specific injury during active duty but recalled that his right hip pain was aggravated by doing activities like long marches while carrying his 100-pound gear. The Veteran reported that he did not seek any care for any of his pain as he was just living with it. Initially, the examiner diagnosed the Veteran with degenerative arthritis of the bilateral hip, but at the end of the examination the examiner concluded that there was no diagnosis for the left hip pain. The examiner opined that based on the review of the records provided from rheumatologist on repeated occasions, "there is no etiological evidence to provider next this connection to his bilateral hip condition which ... in [his] opinion a gradual progressive degeneration over the years to his seronegative polyarthritis." The Board finds that a remand is necessary as the April 2017 medical opinion is incomplete. It is unclear whether the examiner opined that the Veteran's left hip pain was aggravated by the progressive degeneration of the Veteran's seronegative polyarthritis or whether the Veteran's left hip pain is part of the Veteran's seronegative polyarthritis. Additionally, during the October 2020 hearing, the Veteran clarified that his left hip disability manifested and/or was aggravated as a result of his service-connected seronegative polyarthritis; or, in the alternative that the Veteran's seronegative polyarthritis spread to his left hip. Based on the foregoing, the Board finds that a remand is warranted. 4. Entitlement to an initial rating in excess of 10 percent for service-connected right hip disability is remanded. 5. Entitlement to a compensable rating for service-connected seronegative arthritis is remanded. In the October 2020 hearing, the Veteran attested that his right hip disability and seronegative polyarthritis worsened since his last VA examination. Specifically, the Veteran stated that his conditions are worse especially during the cold weather. The Veteran reported that it takes him longer than 15 to 30 minutes to get stretched out and loosened up. The Veteran was unsure whether the range of motion of his affected joints worsened but testified that his hands and his joints are tighter particularly during the cold weather. As the Veteran claimed worsening of his service-connected disabilities, the Board finds that a remand is warranted. The matters are REMANDED for the following action: 1. Obtain all outstanding VA and private medical records, to include any from MedCenter One or Sanford Health, and associate them with the claims file. 2. Thereafter, arrange for a VA examination from an appropriately qualified examiner to determine the nature and etiology of any bilateral shoulder disability and left hip disability. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. A record of the review of the claims file should be documented in the examination report. All indicated diagnostic tests should also be completed. Bilateral shoulder disability (a) The examiner must determine whether it is at least as likely as not (50 percent probability or more) the Veteran's bilateral shoulder pain is part and/or manifestation of his service-connected seronegative polyarthritis. (b) If the Veteran's bilateral shoulder pain is a separate impairment from and/or is not a manifestation of his service-connected seronegative polyarthritis, then for each diagnosed bilateral shoulder disability (or for any shoulder pain that causes functional impairment), provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the bilateral shoulder disability had its onset in service or is otherwise etiologically related to service. If no diagnosis is rendered for the Veteran's bilateral shoulder disability, the examiner must determine whether the Veteran's bilateral shoulder pain causes functional impairment. The examiner must consider the service treatment records wherein a December 1995 STR the Veteran complained of right shoulder pain. See April 2016 STR Medical. In a May 1996 STR, the Veteran complained of pain in the shoulders. In a July 1996 STR, the Veteran exhibited upper extreme bilateral arthralgia from the wrist to the shoulder. In a September 1996 STR, the Veteran endorsed having sore shoulders joints. On examination, the Veteran exhibited bilateral AC joint tenderness with limited range of motion. (c) For each identified bilateral shoulder disability, state whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran's bilateral shoulder disability was (a) caused by or (b) has been aggravated (worsened beyond the natural progress of the disorder) by his service-connected seronegative polyarthritis. The examiner is reminded that the standard does not require that worsening be permanent worsening. If aggravation is found, identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. Left hip disability (a) The examiner must determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's left hip pain is part of and/or a manifestation of his service-connected seronegative polyarthritis. (b) If the Veteran's left hip pain is a separate impairment from his service-connected seronegative polyarthritis, then for each diagnosed left hip disability (or left hip pain that causes functional impairment), provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the left hip disability had its onset in service or is otherwise etiologically related to service. The examiner must address the service treatment records wherein a September 1996 STR the Veteran complained of hip pain. See April 2016 STR Medical. (c) For each identified left hip disability, state whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran's left hip disability was (a) caused by or (b) has been aggravated (worsened beyond the natural progress of the disorder) by his service-connected seronegative polyarthritis. The examiner is reminded that the standard does not require that worsening be permanent worsening. If aggravation is found, identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. After the development in #1 is completed, schedule the Veteran for a VA examination to evaluate the current severity of his seronegative polyarthritis and right hip disability. (Continued on the next page) All pertinent pathology found on examination should be noted in the report of the evaluation. Any testing deemed necessary should be performed. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, 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.