Citation Nr: 22017518 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 17-46 664 DATE: March 25, 2022 REMANDED The issue of an increased rating greater than 10 percent, for a right lower extremity condition, to include runner's dystonia, is remanded. REASONS FOR REMAND The Veteran had active service from July 1982 to September 1987; from March 2004 to March 2007; and from December 2008 to April 2009. The appeal will be remanded for VA neurological and orthopedic examinations. The issue of an increased rating for a right lower extremity condition, to include runner's dystonia, is remanded. This matter is REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: This is a remand for the Regional Office (RO) to provide the Veteran with a VA neurological examination to determine the severity of her service-connected right lower extremity runner's dystonia. During the October 2021 Board hearing, the Veteran testified that her service-connected right lower extremity had worsened since the last VA examination in 2017. During her October 2021 hearing, the Veteran also testified that her non-VA physician was attempting to schedule her for testing by the Mayo Clinic. The RO should determine if that testing has been done and obtain copies of the test results. THE REMAND DIRECTIVES FOLLOW. 2. Obtain any outstanding VA and non-VA medical records and associate them with the claims file. These include any test results from the Mayo Clinic, and any additional records from the Veteran's non-VA treating physician, Chand-Kim Mousumi. 3. In November 2021, the Veteran submitted a compact disc (CD) containing a video showing her while walking. The RO MUST ensure that this video is available for review, prior to scheduling the Veteran for VA examinations, and the video MUST be provided to the VA examiners. 4. Schedule the Veteran for VA NEUROLOGICAL examination by a NEUROLOGIST to determine the current severity of her right lower extremity runner's dystonia. All evidence and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. If necessary to respond to the inquiries below, the NEUROLOGIST should coordinate with any other specialists to include ORTHOPEDISTS or others. The examiner MUST respond to the following: (a.) The examiner MUST provide a comprehensive analysis of the Veteran's disability picture involving her service-connected right lower extremity dystonia. This includes information about the severity, frequency, and duration of any flareups, and functional loss during flareups. The examiner should provide an estimate of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. This includes but is not limited to: Abnormal gait of the right and left lower extremity through weight shifting and if identified, their effect and functional loss; Involuntary and uncontrolled circumduction of the leg; Involuntary toe clawing or extending; Knee hyperextension and if identified, its effect and functional loss; Abnormal foot movement, to include weight shifting resulting in ankle supination or inversion and if identified, its effect and functional loss; Inability or difficulty in forward propulsion, and; The need or advisability for any assistive devices In providing the requested opinions, the examiners MUST review the photographs and video of the Veteran walking, referenced below. The examiner must review the entire record in conjunction with rendering the requested opinions. In addition to any records that are generated because of this Remand, the VA examiner's attention is drawn to the following: * A March 2005 STR shows that the Veteran underwent an MRI of the brain with contrast to assess multiple episodes of abnormal neurologic symptoms and to evaluate for multiple sclerosis. The report shows the following impression: 1) four small foci of subcortical T2 and flair hyperintensity, which are nonspecific, but would be atypical for multiple sclerosis complicated migraine or small vessel ischemia was noted as the more likely etiology; and 2) no evidence of abnormal signal within the cervical spine. * A March 2005 STR shows that the Veteran reported her concern with continued right foot drop and gait disturbance of the right lower extremity. * A July 2006 STR shows a diagnosis of left leg spasticity/gait disturbance. The examiner stated "[t]he nature of [the conditions] remains elusive." * An April 2007 private cervical MRI. * In a May 2007 letter, a private neurologist, stated that the Veteran has seen many neurologists for an undiagnosed neurological disorder, and that the Veteran's condition is progressively worsening. The neurologist recommended that the Veteran needs to be evaluated by "super-specialists" in movement disorders and disorders of the spinal cord. * In July 2007, a neurologist concluded that the Veteran's gait disturbance is unlikely to be dystonia or paroxysmal dyskinesia. * A September 2007 private treatment record shows that the Veteran was evaluated for neurological problems, to include abnormal gait and altered mental status. * A January 2008 private medical record shows that a review of the Veteran's neurological system revealed imbalance, clumsiness, and poor concentration without confusion. The assessment was neuropathy/polyneuropathy associated with a neuromuscular disorder of unknown cause and etiology. * A September 2008 private treatment record shows that the Veteran presented with a limp of the right lower extremity; she was evaluated for an abnormality of the right lower extremity. Upon objective evaluation, the examiner noted the following: tender facets at L5/S1 and right SI joint of the posterior sacrum, right; and tenderness along the right piriformis. The assessment was right SI joint dysfunction. * A May 2009 private assessment shows that the examiner stated "I wonder whether [the Veteran's symptoms] may represent a gait disorder or perhaps a task-specific dystonia. * An October 2009 private x-ray report shows that the Veteran was evaluated for acetabular femoral impingement. A history of bilateral hip pain and dysfunction was noted. The examiner noted the following impression: 1) a small bony bump/excrescence at the junction of the right femoral head and neck, and 2) mild calcification of the medial inferior joint capsules of the iliofemoral joints bilaterally, which was noted as probably normal for the Veteran's age. * A November 2009 private treatment record shows an assessment of hip pain, and abnormal gait affected by a right leg limp and limited extension of the right hip. * A January 2010 private neurological examination shows normal results without peripheral neuropathy, or radiculopathy, and normal muscle strength. Symptoms of tightness and stiffness of the right lower extremity while ambulating was noted, as well as a history of muscle spasm when running. The examiner noted that the Veteran's symptoms are consistent with a diagnosis of runner's dystonia and stated that the Veteran's functional impairment is due to right foot plantar flexion when running and during ambulation. * A July 2010 private physical therapy evaluation shows moderate tightness in the bilateral hip adductor and iliopsoas, mild tightness in the right hip flexor, and slight restriction in the bilateral hip flexor. * A September 2010 private medical record showing that the Veteran's runner's dystonia with foot drop when running is responding well to myofascial release and deep tissue massage without any medication. However, the examiner noted the Veteran's continued difficulty with changing from a sitting to a standing position, and with walking. The examiner also noted that the Veteran's muscle stiffness worsens with prolonged immobilization. The condition was noted to improve when the Veteran is active. * A July 2011 private neurological examination shows an impression of kinesigenic dystonia. * Treatment records indicate possible diagnoses of myalgia and myositis. * During the June 2012 VA peripheral nerve conditions examination, the examiner provided a positive nexus opinion regarding the Veteran's runner's dystonia. However, the examiner stated that this opinion is tentative, noting that he did not have the Veteran's claims file, that he does not have expertise in this area, and suggested that the Veteran be afforded a specialist examination by a neurologist. In the July 2012 VA addendum opinion, the examiner noted that the claims file was reviewed, and affirmed the prior diagnosis and nexus opinion, stating that a specialist examination was no longer needed. * An undated private treatment record shows, of the right posterior, tight muscles, and adhesions at the sacral and hip joint, with hamstrings lacking tone; and of the right anterior, very compressed quadricep, tightness at the leg to trunk attachment with almost inflexible psoas, and compression on the lateral side of the lower leg. * A January 2014 VA treatment record shows normal gait over short distances, decreased knee flexion over longer distances, more so on the right, and stiffened gait with mild circumduction of the right leg. * During the September 2014 VA central nervous system examination, the examiner noted a diagnosis of a central nervous system movement disorder, specifically dystonia, noted as previously thought to be runner's dystonia, with symptoms of tightness of the bilateral lower extremity muscles and gait disturbance. The examiner recommended a neurological specialty examination. * A November 2016 VA treatment record shows that the Veteran underwent surgery related to a diagnosis of right popliteal artery entrapment syndrome. * During the June 2017 VA central nervous system examination, the examiner noted a diagnosis of a central nervous system movement disorder, specifically dystonia, noted as probable paroxysmal kinesigenic. The examiner noted symptoms of tightness of the bilateral lower extremity muscles and gait disturbance. The examiner recommended a neurological specialty examination. * In an August 2017 statement, the Veteran reported that she is unable to bend her right knee when walking, resulting in abnormal gait which causes her feet, hips, and shoulders to function improperly due to overcompensation. She also reported difficulty with descending stairs. * An October 2017 letter from Dr. J.H.L., MD, states that the Veteran has been evaluated at the Austin VA outpatient neurology clinic for paroxysmal kinesigenic dystonia since 2004. * An August 2018 VA treatment record shows that the Veteran has a long history of abnormal gait with abnormal movement of the right hip. She reported that she has to "swing" the right hip out and forward to ambulate, and that her right foot falls off to the side, which makes forward propulsion difficult. * An August 2018 VA x-ray report shows bilateral hip arthritis and gait dysfunction from tightness and tension throughout the bilateral leg. * During the August 2018 VA artery and vein conditions examination, the examiner opined that the Veteran's occlusion of the right popliteal artery is less than likely proximately due to or the result of her right lower extremity runner's dystonia. The examiner stated that there is an absence of a pathophysiological connection linking these conditions. The examiner noted that the Veteran continues to have right lower extremity symptoms related to her dystonia. The examiner also noted that the Veteran underwent a resection of the right medial head of the gastrocnemius and tibial neurolysis to treat a right popliteal artery occlusion condition. The examiner noted that the Veteran currently has no symptoms due to the right popliteal artery occlusion. However, the examiner noted that the Veteran has reduced ankle-brachial index of the right lower extremity that is likely secondary to the occlusion of the right popliteal artery. * January and February 2020 private treatment records showing a diagnosis of abnormal motor behavior involving her right leg. * A January 2020 private treatment record indicates task-specific and/or paroxysmal dystonia primarily involving the right lower extremity when walking. * An April 2020 private treatment record shows a diagnosis of gait instability and right lower extremity stiffness, noted to have a suspected central etiology. The examiner also noted a diagnosis of LEMS. * An August 2020 private electromyogram and nerve conduction study of the right lower extremity shows results within normal limits, without evidence to support large fiber neuropathy, myopathy, or neuromuscular junction disorder. Clinical correlation was advised. * A September 2020 private lower extremity arterial duplex study shows right lower extremity weakness with popliteal artery entrapment syndrome. * During the October 2021 Board hearing, the Veteran testified to her belief that her service-connected right lower extremity condition is likely a neurological condition, that her VA examinations did not adequately address the nature of her condition, and that her condition has worsened. She testified that she has not driven since about 2015 because her right leg would seize when applying pressure from her right foot onto the gas and brake pedals. She testified that she is not able to execute heel to toe action when putting weight on her right side while walking, and she is unable to push off her right foot when attempting to ambulate forward. She testified that her right leg and hip tries to circumduct when walking, which causes difficulty in ambulating forward. She also testified to difficulty ascending stairs. In particular, she stated "it's like my [right] toe is just trying to reach for that step, and so I have to hold onto the rail [. . .] and I'm like leaning in toward the rail, and my body is going that way." She also testified to a fear of falling, especially if the surface changes, and that she is "always just very guarded and cautious." The Veteran testified that her condition is no longer limited to her right side; rather, her left side is now problematic. Specifically, she stated "it starts on the right, but it throws everything else off." She testified that "when I start moving, there is not a clear connection from what my brain is telling my muscles to do, and the feedback the muscles are giving to the brain." * In October 2021, a long-time friend of the Veteran reported witnessing the Veteran's difficulty with bringing her right foot forward when walking, and her difficulty with lifting her right foot, which causes her right leg to drag. * In October 2021, the Veteran's daughter reported that she has witnessed the Veteran struggle to walk due to a progressive gait abnormality for nearly 20 years. * In October 2021, the Veteran's son reported that he was witnessed the Veteran's difficulty with walking. * In October 2021, the Veteran's sister stated that she has witnessed that the Veteran has had difficulty with merely taking a step to walk for years. She also reported that the Veteran is fearful of the possibility of falling. She observed that the Veteran has difficulty with right foot heal to toe action, and that walking causes the Veteran to circumduct and drag her right leg because she is unable to bring the leg directly forward. Instead, she observed that the Veteran must swing her leg outward to the side, then forward to complete the step. * In November 2021, the Veteran submitted photographs showing her abnormal gait. * In November 2021, the Veteran submitted a CD containing a video showing her while walking. * In a November 2021 statement in support of claim, the Veteran reported that she is unable to engage in activities such as walking, running, and bicycling without discomfort. She reported difficulty traversing stairs. She reported that walking, even short distances, is awkward and very uncomfortable. Specifically, she reported that her body stiffens when starting to walk and that it is difficult for her to put one foot in front of the other. She reported that she is always on guard due to fear of hurting herself or others, to include a fear of tripping or bumping into others. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed, and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 5. Following the review and any additional development deemed necessary, re-adjudicate the claim. Should the claim not be granted in its entirety, issue an appropriate supplemental statement of the case (SSOC), and forward the claim to the Board for adjudication. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Timothy T. Emmart The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.