Citation Nr: 22017388 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-44 968 DATE: March 24, 2022 REMANDED Entitlement to service connection for a lumbar spine disability with sciatica and right lower extremity peripheral neuropathy is remanded. Entitlement to service connection for piriformis syndrome with sciatica and right lower extremity peripheral neuropathy is remanded. Entitlement to service connection for an orthopedic injury autoimmune reaction with sciatica and right lower extremity peripheral neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1978 to February 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was scheduled for a Board hearing in May 2019. However, the Veteran withdrew the hearing request in April 2019. In June 2019, the Board denied service connection for a right hip disability, to include as secondary to a left great toe disability. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims. In April 2020, the Court granted a Joint Motion for Remand, vacating the June 2019 Board decision that denied service connection for a right hip disability, to include as secondary to a left great toe disability, and remanding the matter for action consistent with the April 2020 Joint Motion. The parties agreed the Board provided an inadequate statement of reasons and bases for denying service connection. A claim for disability benefits can encompass more than one condition and that the scope of a claim is generally not limited to a specific diagnosis. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In June 2019, the Board denied service connection for a right hip disability, to include as secondary to a left great toe disability, because a September 2015 VA examiner concluded the Veteran's decreased range of motion and pain in the right hip were consistent with and most likely secondary to sciatic pain from a lumbar spine surgery, not from a right hip disability. The parties notes that the Board did not address whether the claim for a right hip disability encompassed sciatic pain. In a September 2020 Board remand, the Board found that the claim reasonably includes sciatic pain and remanded for a VA examination to consider service connection for right hip and sciatic pain. The RO issued a statement of the case in November 2020. The Board then issued a January 2021 decision denying service connection for a right hip disability, to include as secondary to a service-connected left great toe disability. The Veteran appealed the January 2021 Board decision to the Court. In October 2021, the Court granted a Joint Motion for Remand, vacating the January 2021 Board decision that denied service connection for a right hip disability, to include as secondary to a left great toe disability, and remanding the matter for action consistent with the October 2021 Joint Motion. The parties agreed that the Board did not address a May 2015 private opinion that discussed a possible autoimmune reaction due to orthopedic injury, and stated, "peripheral neuropathy is most like due to his orthopedic injury to the left foot he sustained in 1978, in absence of any other clear cause of peripheral neuropathy." In order to fully consider the Veteran's claim, the issue of entitlement to service connection for a right hip disability has been recharacterized to include the issues that the parties have agreed should be considered. The Veteran's contention is that right hip pain is due to peripheral neuropathy from a lumbar disability, piriformis syndrome, or an autoimmune reaction and those disabilities were caused by a service-connected left great toe disability. The Veteran has stated that he initially thought that it was hip pain, but he has come to realize that the pain in the hip is related to sciatica with peripheral neuropathy. The Veteran's claim includes the contention that peripheral neuropathy is related to a lumbar disability, piriformis syndrome, or autoimmune reaction which were caused by a service-connected left great toe disability. This claim has been advanced on the docket pursuant to 38 C.F.R. § 20.900. 1. Entitlement to service connection for a lumbar spine disability with sciatica and right lower extremity peripheral neuropathy is remanded 2. Entitlement to service connection for piriformis syndrome with sciatica and right lower extremity peripheral neuropathy is remanded 3. Entitlement to service connection for an orthopedic injury autoimmune reaction with sciatica and right lower extremity peripheral neuropathy is remanded The Veteran's claim has been recharacterized in order to fully consider those issues the parties have agreed are contained within the claim. The Veteran has been provided multiple VA hip examinations. However, those opinions have not addressed whether any diagnosed lumbar disability or orthopedic injury autoimmune reaction was caused by a service-connected left great toe disability. The September 2015 and October 2020 opinions stated that the right hip pain was associated with sciatica that is related to a lumbar disability, but did not discuss whether a lumbar spine disability was related to a left great to disability. The medical evidence demonstrates that the Veteran has been diagnosed with intervertebral disc syndrome, L4-L5 disc herniation, and right lower extremity peripheral neuropathy, as shown in a November 2012 Medical Note and a March 2013 EMG. In May 2015, a medical opinion was received which diagnosed an orthopedic injury autoimmune reaction and opined that the right lower extremity peripheral neuropathy was caused by an autoimmune reaction as a result of a service-connected left great toe injury. Additionally, medical articles were received in November 2020, regarding piriformis syndrome. The articles suggest a potential connection between a service-connected left great toe disability and piriformis syndrome with sciatic and right lower extremity neuropathy. As the Veteran's claim has not previously encompassed any of these issues, but has solely focused on the right hip, the VA hip examinations and opinions have not addressed whether any lumbar disability, piriformis syndrome, or autoimmune reaction, resulting in sciatica and right lower extremity peripheral neuropathy, were caused by a service-connected left great toe disability. At the time of the September 2015 and October 2020 VA hip examinations, sufficient evidence was of record to raise the issues of whether a lumbar spine disability or an autoimmune reaction, resulting in sciatica and right lower extremity peripheral neuropathy were caused by a service-connected left great toe disability. However, the examiners did not address those issues. Sufficient evidence is now of record to also raise the issue of whether the Veteran has a diagnosis of piriformis syndrome causing sciatica with right lower extremity neuropathy and whether that condition was caused by a service-connected left great toe disability. A medical opinion is inadequate when it does not consider all raised theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120 (2007). Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, remand is warranted for further development. The matters are REMANDED for the following action: 1. Associate with the case file any relevant outstanding VA medical records. 2. Then, schedule the Veteran for a VA examination with a medical doctor who has not previously examined the Veteran in conjunction with this claim, to obtain a medical opinion as to whether the Veteran has a diagnosis of piriformis syndrome with sciatic and right lower extremity peripheral neuropathy and the nature and etiology of a lumbar spine disability with sciatica and right lower extremity peripheral neuropathy, autoimmune reaction with sciatica and right lower extremity peripheral neuropathy, and piriformis syndrome with sciatica and right left lower extremity peripheral neuropathy. The examiner should obtain a complete, pertinent, history from the Veteran and review the claims file in conjunction with the examination, including this remand, giving particular attention to the Veteran's VA treatment records, lay assertions, and the pertinent medical evidence. Any rating, studies, or tests deemed necessary by the examiner should be accomplished and any results must be included in the examination report. The examiner must be advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and chronic nature of symptoms, must be considered, along with the other evidence of record, in formulating the requested opinions. In providing the opinions, the examiner must consider the Veteran's contention that a left great toe disability has caused the claimed disabilities due to overcompensation. The examiner must address the May 2015 private medical opinion finding that the Veteran's peripheral neuropathy was caused by an autoimmune reaction from a service-connected left great toe injury. The examiner must also address the medical articles that were received in November 2020 regarding piriformis syndrome. The examiner must provide a complete rationale for any opinion expressed. Based on the examination and review of the record, the examiner is asked to provide a response to the following: a.) Opine whether it is at least as likely as not that a diagnosis of piriformis syndrome is warranted. Reconcile that diagnosis with all other diagnoses of record. b.) Opine whether it is at least as likely as not that piriformis syndrome is related to service or any event, injury, or disease during service. c.) Opine whether it is at least as likely as not that piriformis syndrome was caused by a service-connected left great toe disability. d.) Opine whether it is at least as likely as not that piriformis syndrome has been aggravated (increased in severity beyond the natural progress of the disorder) by a service-connected left great toe disability. e.) Diagnose all lumbar spine disabilities shown by the record or found on examination. Reconcile that diagnosis with all other diagnoses of record. f.) Opine whether it is at least as likely as not that any lumbar spine disability is related to service or any event, injury, or disease during service. g.) Opine whether it is at least as likely as not that any lumbar spine disability was caused by a service-connected left great toe disability. h.) Opine whether it is at least as likely as not that any lumbar spine disability has been aggravated (increased in severity beyond the natural progress of the disorder) by a service-connected left great toe disability. i.) Diagnose all autoimmune reaction disabilities found on examination or shown in the record. Reconcile that diagnosis with all other diagnoses of record. Specifically reconcile that finding with a May 2015 private opinion that discussed a possible autoimmune reaction due to orthopedic injury, and stated, "peripheral neuropathy is most like due to his orthopedic injury to the left foot he sustained in 1978, in absence of any other clear cause of peripheral neuropathy." j.) Opine whether it is at least as likely as not that any autoimmune reaction disability is related to service or any event, injury, or disease during service. k.) Opine whether it is at least as likely as not that any autoimmune reaction disability was caused by a service-connected left great toe disability. l.) Opine whether it is at least as likely as not that any autoimmune reactions disability has been aggravated (increased in severity beyond the natural progress of the disorder) by a service-connected left great toe disability. m.) Diagnose all lower extremity neurologic disabilities found on examination or shown in the record. n.) Opine whether it is at least as likely as not that any lower extremity neurologic disability is related to service or any event, injury, or disease during service. o.) Opine whether it is at least as likely as not that any lower extremity neurologic disability was caused by a service-connected left great toe disability. Specifically reconcile that finding with a May 2015 private opinion that stated, "peripheral neuropathy is most like due to his orthopedic injury to the left foot he sustained in 1978, in absence of any other clear cause of peripheral neuropathy." p.) Opine whether it is at least as likely as not that any lower extremity neurologic disability has been aggravated (increased in severity beyond the natural progress of the disorder) by a service-connected left great toe disability. 3. After completing the requested actions, and any additional action deemed warranted, readjudicate the claims on appeal as characterized by the Board. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. The, return the case to the Board. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Temple, 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.