Citation Nr: 1237282 Decision Date: 10/26/12 Archive Date: 11/09/12 DOCKET NO. 08-26 903 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for a left wrist disability, to include as secondary to the service connected cervical spine degenerative disc disease and due to an undiagnosed illness. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD Sara Schinnerer, Associate Counsel INTRODUCTION The Veteran had active service from April 1986 to April 2006. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a May 2006 rating action of the Department of Veterans Affairs (VA), Regional Office (RO) in Winston, Salem, North Carolina. Jurisdiction was subsequently transferred to the RO in Los Angeles, California. The Board remanded the case in March 2010 and February 2012 for additional development. While some of the directives were complied with, there has not been substantial compliance with all of the remand directives and the appeal must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). 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 When the Board last reviewed the claim, it noted that the June 2010 VA examination report and November 2011 addendum report, as well as the August 2011 VA examination report, were insufficient in analyzing the Veteran's left wrist disability for adjudication purposes. The June 2010 VA examiner diagnosed left C6 radiculopathy. The November 2011 VA examiner opined that the Veteran's left wrist symptoms were unrelated to the service-connected cervical radiculopathy disability; however no rationale was provided. The August 2011 VA examiner diagnosed cervical radiculopathy that resulted in left wrist pain; however, the rationale provided for the negative opinion was only relevant to the Veteran's knee disability. In the February 2012 remand instructions, the Board reiterated its March 2010 remand instructions. Specifically, the examiner was to determine the etiology of any left wrist disorder, including whether it was caused or aggravated by the service-connected cervical spine disability; whether any pathology unrelated to the left wrist was at least as likely not related to the September 2004 in-service complaints; and, if there was no pathology, whether it was at least as likely as not due to an undiagnosed illness related to service in Southwest Asia during the Persian Gulf War. In the October 2012 supplemental statement of the case, the RO referred to an August 2012 VA examination report. Such report is not of record; however, in a report dated in August 2011 (which appears to be the report the RO referred to), the VA examiner diagnosed cervical spine radiculopathy of the left upper extremity including the hand and wrist. The examiner opined that such disability was at least as likely as not due to the Veteran's cervical spine radiculopathy. Significantly, the Veteran is separately service-connected for left upper extremity radiculopathy. The examiner, however, further opined that the radiculopathy did not cause crepitus or "popping" in a joint, and such symptoms were independent of the Veteran's cervical spine radiculopathy of the left upper extremity. While the examiner determined that the left wrist radiculopathy (left upper extremity radiculopathy) was due to the cervical spine disability, he also noted that the crepitus or "popping" was independent of such radiculopathy. The examiner, however, failed to address whether the crepitus or "popping" was at least as likely as not due to an undiagnosed illness related to service in Southwest Asia during the Persian Gulf War, as directed by the March 2010 and February 2012 Board remands. A new medical examination and opinion are necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA Persian Gulf War Syndrome examination by an appropriate medical professional to address his left wrist disorder to include crepitus and popping (excluding his diagnosed left upper extremity radiculopathy). The claims file must be made available to and reviewed by the examiner in conjunction with the examination. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All indicated evaluations, studies, and tests deemed to be necessary must be accomplished. The examiner must answer the following questions: a. Is the Veteran's left wrist disorder(s) associated with a known clinical diagnoses? b. If the Veteran's left wrist disorder (s) are associated with a known clinical diagnoses, for each diagnosed disorder address whether it at least as likely as not (50 percent probability or more) that the disorder had its onset during his military service or has continued since that time? In answering questions (a) and (b), the examiner is instructed to consider only those left wrist symptoms that are independent of the service-connected left upper extremity radiculopathy disability. In answering questions (a) and (b), the examiner must consider the Veteran's September 2004 in-service complaints. c. If the Veteran's left wrist disorder cannot be associated with a known clinical diagnosis, specify whether it is at least as likely as not (50 percent probability or more) that he has objective indications of a chronic disability resulting from an illness manifested by a wrist disorder as established by history, physical examination, and laboratory tests, that have either: (1) existed for 6 months or more at any time during the pendency of the appeal or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period at any time during the pendency of the appeal. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 2. Thereafter, readjudicate the Veteran's claim, with application of all appropriate laws and regulations, including consideration of any additional information obtained as a result of this remand. If the decision with respect to the claim remains adverse to the Veteran, he and his representative must be furnished a supplemental statement of the case and afforded a reasonable period of time within which to respond. 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.A. §§ 5109B, 7112 (West Supp. 2011). _________________________________________________ RONALD W. SCHOLZ 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) (2011).