Citation Nr: 1409245 Decision Date: 03/05/14 Archive Date: 03/12/14 DOCKET NO. 10-44 667 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a left knee disability, claimed as secondary to service-connected right knee disability. 2. Entitlement to service connection for diabetes mellitus, type II, as secondary to medications taken for service-connected disabilities. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from June 1978 to June 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In July 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the transcript is associated with the claims file and has been reviewed. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Service Connection for Diabetes Mellitus In his substantive appeal dated in October 2010, the Veteran asserted that diabetes mellitus is related to medications he takes for service-connected hypertension. At the Board hearing in July 2012, the Veteran testified that the medications which cause or aggravate his diabetes mellitus include Atenolol, Chlorothiazide, Seroquel and Abilify. The Veteran indicated that his wife, who is a registered nurse, has told him that the combination of Atenolol and Chlorothiazide will cause diabetes in a person who is heavy and sedentary. The Veteran also testified that diabetes is also related to inactivity due to his service-connected knee and hip disabilities. In June 2012, the Veteran's wife submitted medical journal articles regarding the relationship between hypertensive medications and the development of diabetes mellitus and the relationship between physical inactivity and the risk of developing diabetes. She also submitted journal articles about depressive symptoms and diabetes mellitus and the relationship between medications for service-connected depression and diabetes mellitus. A VA examination in July 2009 addressed the relationship between Wellbutrin, which is used to treat the Veteran's mood disorder, and diabetes mellitus. A VA examination in August 2009 addressed the relationship between medications taken for service-connected orthopedic disabilities, including Tramadol and Naproxen, and diabetes mellitus. The VA examinations in July 2009 and August 2009 did not address the Veteran's contention that diabetes mellitus is causally related to the use of Atenolol, Chlorothiazide, Seroquel and Abilify. The VA examinations did not address whether diabetes mellitus is caused and/or aggravated by physical inactivity associated with the Veteran's service-connected right knee and left hip disabilities. The Board finds the July 2009 and August 2009 VA examinations inadequate, as they do not fully address the Veteran's contentions regarding secondary service connection. Once VA undertakes the effort to provide an examination with respect to a claim of entitlement to service connection, whether or not statutorily obligated to do so, the duty to assist requires that it be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds that a remand is warranted in order to obtain a supplemental medical opinion which fully addresses the Veteran's contentions as well as the factual arguments and opinions presented in the June 2012 statement. Service Connection for Left Knee Disability The Veteran claims service connection for a left knee disability secondary to a service-connected right knee disability. The Veteran asserts that his service-connected right knee disability causes him to favor the left knee when walking. He asserts that he has developed pain and swelling in his left knee as a result of favoring the left knee. In October 2008, the Veteran had a VA examination of his left knee. The VA examiner diagnosed left knee medial compartment chondromalacia. The examiner noted the Veteran's contention that he compensated for his right knee symptoms by shifting his weight to his left knee. The examiner concluded that the Veteran's current left knee disability is related to obesity, muscular deconditioning and genetic predisposition. In June 2012, the Veteran submitted a statement from his wife, who, as noted previously, is a nurse. She stated that the Veteran severely injured his right knee in November 2006 and was treated at Jackson South emergency room. She stated that, since that date, the Veteran's gait has been affected in a manner that favors the right knee and that he has fallen multiple times and sustained trauma and strain of the left knee. She cited VA treatment records dated between 2006 and 2009, including an October 2007 report that the right knee buckled, straining his left knee and a December 2007 VA emergency room record which noted that the Veteran reported that he twisted his right knee and fell, hitting his left knee. The June 2012 statement from the Veteran's wife presents contentions and factual evidence regarding a medical relationship between the Veteran's service-connected right knee disability and his current left knee disability. The Board finds that a remand is warranted in order to obtain a supplemental VA medical opinion addressing the factual matters presented in the June 2012 statement. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the VA examiner who provided the July 2009 and August 2009 examinations for a supplemental opinion regarding the etiology of diabetes mellitus. If that examiner is not available, the opinion should be provided by another qualified VA physician. The claims file must be provided for the examiner's review, and the examination report must indicate that the claims file was reviewed. Following a review of the claims file, the examiner provide an opinion as to whether it is at least as likely as not (a 50 percent chance or greater) that diabetes mellitus is (1) proximately due to; or (2) aggravated (permanently made worse) by service-connected disabilities, including medications taken for service-connected disabilities. In answering this question, the examiner should address the following: a. the examiner should address whether diabetes mellitus is (1) proximately due to; or (2) aggravated by Atenolol, Hydrochlorothiazide, Seroquel or Abilify. b. the examiner should address whether diabetes mellitus is (1) proximately due to; or (2) aggravated by the combination of Atenolol and Hydrochlorothiazide, which the Veteran takes for service-connected hypertension. c. the VA examiner should address whether the Veteran's diabetes mellitus is (1) proximately due to; or (2) aggravated by his inactivity due to the service-connected left hip and right knee disabilities. d. the examiner should address whether diabetes mellitus is (1) proximately due to; or (2) aggravated by service-connected depression. The VA examiner should also consider the facts and evidence presented in the June 2012 statement from the Veteran's wife, as well as the medical journal articles submitted by the Veteran and his wife. The VA examiner should provide a detailed rationale for the opinions stated. If any of the requested opinions cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 3. Return the claims file to the October 2008 VA examiner for a supplemental opinion regarding the etiology of the claimed left knee disability. If that examiner is not available, the opinion should be provided by another qualified VA physician. The claims file must be provided for the examiner's review, and the examination report must indicate that the claims file was reviewed. Following a review of the claims file, the examiner should provide an opinion as to whether a current left knee disorder is at least as likely as not (50 percent or greater likelihood) proximately due to the Veteran's service-connected right knee disability; or (2) aggravated (made permanently worse beyond the natural progression of the disease) by his service-connected right knee disability. In answering this question, the VA examiner should consider the Veteran's contention that his right knee disorder has caused him to favor the left knee. The VA examiner should also consider the facts and evidence presented in the June 2012 statement submitted by the Veteran's wife. The examiner should address the opinion presented in the June 2012 statement that the Veteran's gait has been affected by his service-connected right knee injury, resulting in trauma and strain to the left knee. The VA examiner should provide a detailed rationale for the opinion stated. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 4. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, the RO should determine whether the examiners have responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2013). 5. After the requested development has been completed, the RO should readjudicate the merits of the Veteran's claims based on all the evidence of record. If the benefits sought on appeal remain denied, the Veteran and his representative, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (Continued on the next page) 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.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).