Citation Nr: 18132309
Decision Date: 09/06/18	Archive Date: 09/06/18

DOCKET NO. 13-27 419
DATE:	September 6, 2018
REMANDED
Service connection for depression is remanded.
Evaluation of left shoulder strain, currently rated as 20 percent disabling, is remanded.
Evaluation of status-post left elbow fracture, currently rated as 20 percent disabling, is remanded.
Evaluation of lumbosacral degenerative disc disease and lumbar intervertebral disc syndrome, currently rated as 40 percent disabling, is remanded.
Evaluation of left knee patellofemoral syndrome based on limitation of flexion, currently rated as 10 percent disabling prior to April 14, 2014, 20 percent disabling from April 14, 2014 to May 19, 2015, and 10 percent disabling from May 20, 2015, is remanded.
Evaluation of right knee patellofemoral syndrome based on limitation of flexion, currently rated as 10 percent disabling prior to April 14, 2014, 20 percent disabling from April 14, 2014 to May 19, 2015, and 10 percent disabling from May 20, 2015, is remanded.
Evaluation of left knee patellofemoral syndrome based on limitation of extension, currently rated as noncompensable, is remanded.
Evaluation of right knee patellofemoral syndrome based on limitation of extension, currently rated as noncompensable, is remanded.
Evaluation of costochondritis, currently rated as noncompensable, is remanded.
Evaluation of Gastroesophageal Reflux Disease (GERD), currently rated as 10 percent disabling, is remanded.
Evaluation of left ulnar nerve subluxation, status-post ulnar nerve transposition, currently rated as 10 percent disabling, is remanded.
Evaluation of left lower extremity neuropathy of the sciatic nerve, currently rated as 10 percent disabling prior to May 20, 2015, and 20 percent disabling from May 20, 2015, is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the United States Army from August 1977 to August 1999, including more than 11 years of foreign service.  The Veteran was awarded many medals and decorations over the course of his service, including the Meritorious Service Medal and the Army Commendation Medal
1. Service connection for depression is remanded.
Regarding the claim of service connection for depression, the Veteran submitted a timely notice of disagreement with the August 2010 rating decision on appeal.  No statement of the case (SOC) has yet been issued.  Although the RO included this issue in the March 2016 supplemental statement of the case noting that no SOC was issued, the regulations require that a SOC must be issued and the Veteran must be afforded an opportunity to appeal.  A remand is required for the AOJ to issue a SOC.  38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999).

2. Evaluation of left shoulder strain, status-post left elbow fracture, lumbosacral degenerative disc disease and lumbar intervertebral disc syndrome, left knee patellofemoral syndrome based on limitation of flexion, right knee patellofemoral syndrome based on limitation of flexion, left knee patellofemoral syndrome based on limitation of extension, right knee patellofemoral syndrome based on limitation of extension, costochondritis, GERD, left ulnar nerve subluxation, and left lower extremity neuropathy of the sciatic nerve are remanded.
The Veteran was last afforded a VA examination for his service-connected left shoulder disability, spine disability, left knee disability and right knee disability in May 2015 and for his left elbow disability in October 2016.   These examinations did not meet the requirements set forth in Correia v. McDonald, 28 Vet. App. 158 (2016), which provides a precedential finding that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.  Given this, a new examination is necessary.  38 C.F.R. § 3.159(c)(4).
Regarding the Veteran’s costochondritis, he was afforded a VA examination in May 2015 in which the examiner noted the Veteran’s complaints of pain; however, the examiner did not discuss whether that pain caused any impairment.  Given this, a new examination is necessary.  38 C.F.R. § 3.159(c)(4).
Finally, the most recent VA treatment records are dated in February 2017 and there is no indication that the Veteran has discontinued treatment for his claimed disabilities.  As such, the Veteran’s VA treatment records must be obtained on remand.
The matters are REMANDED for the following action:
1. Obtain the Veteran’s VA treatment records from February 2017 and thereafter.  
2. After the development above has been completed, schedule the Veteran for a VA examination to determine the current severity of his service-connected left shoulder disability, spine disability, left knee disability, right knee disability, left elbow disability and costochondritis. The claim file must be made available to and reviewed by the examiner prior to the examination. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report.
Regarding the Veteran’s left shoulder disability, spine disability, left knee disability, right knee disability, and left elbow disability, the examiner should conduct range of motion testing (expressed in degrees) in active motion, passive motion, and (where appropriate) weight-bearing and non-weight-bearing settings. The examiner should render specific findings as to whether there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If pain on motion is observed, the examiner should indicate the point at which pain begins (expressed in degrees). In addition, the examiner should indicate whether, and to what extent, the Veteran experiences likely functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use. To the extent possible, the examiner should express any such additional functional loss due to flare-ups in terms of additional degrees of limited motion.
If the examination does not take place during a flare-up or after repeated use over time, the examiner should attempt to offer an estimate derived from information procured from relevant sources, including the Veteran’s lay statements. An examination that fails to attempt to ascertain adequate information from relevant sources regarding frequency, duration, characteristics, severity, or functional loss during flare-ups or repeated use over time will be considered inadequate. See Sharp v. Shulkin, 29 Vet. App. 26 (2017).
Regarding the Veteran’s costochondritis, the examiner must describe any associated symptoms and assess the severity of the Veteran’s chest pain and any functional limitations it may cause. 
A rationale for all opinions rendered, to include if one cannot be provided without resorting to mere speculation, must be provided.
3. Send the Veteran and his representative a statement of the case that addresses the issue of service connection for depression.  If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration.


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4. If upon completion of the above action the claims remain denied, the case should be returned to the Board after compliance with appellate procedures.
 
Evan M. Deichert
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	J. Meawad, Counsel

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