Citation Nr: 1334088 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 07-24 164A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for lumbar spine disability. 2. Entitlement to service connection for right knee disability (claimed as anterior cruciate ligament (ACL)) tear. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to service connection for a right shoulder disability, to include as secondary to a right wrist disability. 5. Entitlement to service connection for a right elbow disability, to include as secondary to a right wrist disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from July 1997 to November 2002. He had periods of Reserve service between 2002 and 2009. He had National Guard service from January 2010. These matters come before the Board of Veterans' Appeals (Board) from an August 2005 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Albuquerque, New Mexico. These matters were previously before the Board in January 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. 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 The Veteran avers that he has numerous disabilities due to active service, reserve service, and/or National Guard service, and/or due to a service connected disability. There are no service treatment records (STRS) from the Veteran's active service between July 1997 to November 2002 which reflect complaints of, or treatment for the above stated claimed disabilities. An August 1999 report of medical history reflects that the Veteran reported that he was in "excellent medical health." He noted only a problem with "ear, nose, and throat" related to swollen glands. The Veteran's May 2001 report of medical history for an Officer Commission Program reflects that he reported that he was in "GREAT health." He did not list any complaints or disabilities. The Veteran's June 18, 2002 report of medical history for separation purposes reflects that he denied back and knee complaints. June 2002 records reflect that the Veteran injured his right wrist and that an arthrogram was positive for a TFCC (triangular fibrocartilage complex) tear. The Veteran separated from active service in November 2002. A subsequent December 2003 VA (Pueblo) clinical record is negative for any complaints of the back, knees, shoulder, and/or wrist. Lumbar Spine The earliest clinical evidence of a back complaint after the Veteran's separation from active Marine duty is in March 2004 when the Veteran reported some back pain over the perilumbar region. The Veteran denied any acute trauma. The examiner stated that the back problem is a "chronic problem most likely brought about and or exacerbated by his job as truck driver and posture." A May 2004 Cooper Clinic record reflects that the Veteran reported that, while on "maneuvers," he fell into a creek and twisted his left knee and injured his back. The assessment was "torque to the left knee causing twisting of the left low lumbar." A July 2005 VA examination report reflects that the Veteran was employed as a truck driver. The record reflects that he had a "history of low back pain and left knee pain related to weight lifting and fitness activities." The diagnosis was trauma to L4 probably secondary to weight lifting with pain and limited extension of lumbar spine. An August 2006 VA chiropractic record reflects that the Veteran reported chronic lower back pain with radiculitis into the buttocks for approximately three years. It was noted that the Veteran had been tightening a bolt and felt a pain in his lower back approximately three months earlier. A January 15, 2010 VA clinical record reflects that the Veteran was seen as a pre-requisite for entrance into the New Mexico Military Officer Training program. The record reflects that "[a]s per patient, the medical issues listed on his VA record have been well taken care of and he no longer has any problem with his shoulder, his knee, or his back." It was further noted that his back pain resolved with chiropractic care and physical therapy. A January 24, 2011 VA clinical record reflects that the Veteran reported that his back pain started in 2000 with no specific injury, but the Veteran believed it happened from marching with a heavy rucksack and heavy truck driving in service. A January 2011 VA examination report with a March 2011 addendum reflects the opinion of the examiner that it is less likely than not that the Veteran's lumbar spine disability had its onset in service or is caused by, or aggravated by, the left knee. Subsequent to the March 2011 VA clinical addendum, the Veteran submitted evidence of a back injury in 2012. July 24, 2012 Eastern New Mexico Medical Center records reflect that the Veteran sought treatment for back pain. He reported the onset was four days earlier. He reported that he had been playing volleyball and fell, hurting his right ankle and lower back. An x-ray of the lumbar spine reflected L4 Limbus Vertebra of "little if any clinical significance." The clinical impression was acute lumbar myofascial strain, acute low back pain, and L4 limbus vertebra. He was noted to have a contusion and L4 abnormality. A DA Form 2173 (Statement of Medical examination and duty status) dated in July 2012 reflects that the Veteran was on active duty for training at the time of the incident on July 21, 2012 and that "during company organized physical training the soldier stepped in an obscured hole and twisted his [right] ankle and his lower back as he fell to the ground." Based on the additional evidence, the Board finds that another VA examination and opinion is warranted. The Board finds that an opinion and rationale which discusses the above pertinent evidence may be useful to the Board in adjudicating the claim. The examiner should, if reasonably possible, differentiate between the Veteran's various diagnoses and which if any, are at least as likely related to service, and if so, which period of service. Right Shoulder The Veteran has averred that he has a right shoulder disability as due to service, or his service-connected right wrist disability. The earliest clinical evidence of a right shoulder complaint after the Veteran's separation from active Marine duty is in April 2004. An April 14, 2004 Cooper Clinic record reflects that the Veteran stated that "his right shoulder has been popping when performing pushups and overhead activities." The Veteran reported that he has no previous history of shoulder injury. The assessment was pectoralis tendonitis. An April 21, 2004 Cooper Clinic record reflects that the Veteran reported that his right shoulder continues to pop but he does not have any pain with the popping. He reported that "he lifts weights on his own when not participating in regular P.T." The July 2005 VA examination report reflects that the Veteran was seen in March 2005 and had rotator cuff tendonitis and right elbow medial epicondilitis related to weight lifting. The March 2005 record is not associated with the claims file. The Board finds that VA should attempt to obtain this record. A July 2005 VA examination report reflects that the Veteran reported the onset of right shoulder pain in 2002. He reported that he injured his right shoulder doing physical training prior to discharge from active duty and that he has aggravated it during Reserve training. A July 2006 VA PT (physical therapy) consult record reflects a diagnosis of recurrent rotator cuff tendonitis, supraspinatus. The Veteran reported that the onset of shoulder pain was in 2001 or 2002 and due to pull ups in the military and that compensating for an injured non-service connected right elbow contributes to right shoulder pain. An October 2006 VA examination report reflects that the Veteran reported a gradual onset or right shoulder pain in approximately 2000, which was exacerbated by lifting weights. The report reflects that the Veteran reported that he does not recall being treated in Marine Corps. Radiographs of the ipsilateral shoulder were normal. There was no apparent osseous, articular, or gross soft tissue abnormality. No degenerative changes were appreciated. The assessment was rotator cuff tendinitis with impingement of right shoulder. The examiner found no clear etiology between the Veteran's right wrist disability and a right shoulder disability. The examiner opined that the right shoulder disability was less likely as not the result of a wrist disability. An August 2009 VA clinical record reflects that the Veteran reported severe pain in the right shoulder. He stated that his injury occurred during training. As noted above, a January 2010 VA clinical record reflects that the Veteran reported that he no longer has any problems with his shoulder. It was noted that his rotator cuff tendonitis resolved after steroid injection and physical therapy. A July 22, 2010 VA record reflects that the Veteran reported that he threw a ball during dodge ball in physical training and aggravated his right shoulder. A December 2010 MRI of the right shoulder reflects moderate degeneration for the Veteran's age, moderate tendinopathy, abnormal subscapularis tendon, nondisplaced SLAP tear, mild edema, and moderate acromioclavicular degeneration. A DA Form 2173, dated in December 2010 reflects that the Veteran aggravated a preexisting right shoulder disability. It was noted that the Veteran was on inactive duty training between December 3 and December 5, 2010. A January 2011 VA examination with March 2011 addendum report reflects that the opinion of the examiner that it is less likely than not that the Veteran has a currently diagnosed shoulder condition with its onset in service or caused or aggravated by a service connected wrist disability. A February 2012 line of duty memorandum for Joint Forces Headquarters reflects that on December 4, 2010, the Veteran was "participating in combatives when he felt pain in his right shoulder. After a multiple of testing including xrays and MRI, [service member] was found to have a partial tear of his right shoulder rotator cuff." An October 2012 record reflects that the Veteran had a right shoulder arthroscopy. The Board finds that a more thorough rationale which provides a discussion of the Veteran's various diagnoses may be useful to the Board in adjudicating the Veteran's claim. Right elbow, to include as secondary to right wrist disability In November 2004, the Veteran filed a claim for entitlement to service connection for right elbow tendonitis secondary to his right wrist disability. A March 26, 2004 Cooper Clinic record reflects that the Veteran complained of his right forearm hurting for three weeks. He reported a previous history of a right forearm injury during Marine Corps service when he tore a ligament. The March 2004 assessment was "right medial epicondylitis caused by muscular weakness from previous injury." The record does not reflect that the examiner was aware that the injury in service was a triangular fibrocartilage complex tear. March 2004 VA records reflect that the Veteran reported pain over the right elbow. He denied any acute trauma to the area. There was tenderness over the medial epicondylar region of humerus. A September 2004 VA Comprehensive New Patient clinical record reflects that the Veteran reported right elbow pain. A July 2005 VA examination report reflects that the Veteran reported the onset of right elbow pain in 2001. It was noted that he had been diagnosed with tendonitis and medial epicondylitis for the right elbow pain associated with weight training and pull-ups. The course since onset was described as intermittent with remissions. It was noted that the Veteran was seen in March 2005 for right elbow medial epicondilitis related to weight lifting. This record is not associated with the claim file. An October 2006 VA examination report reflects that the Veteran reported chronic pain and weakness in the right elbow with a gradual onset in approximately 2000. A radiograph of the ipsilateral elbow was normal with no apparent osseous, articular, or gross soft tissue abnormality. No degenerative change was appreciated. The diagnosis was medial epicondylitis of the right elbow. The examiner found no clear etiology relationship between elbow and wrist. The examiner opined that it was less likely as not that the Veteran has a right elbow disability caused by or a result of the Veteran's service-connected right wrist disability. The Board finds that a more thorough rationale which discusses the Veteran's service-connected right wrist disability and the current elbow disability would be helpful to the Board. Right Knee The earliest clinical evidence of a right knee complaint after the Veteran's separation from active Marine duty is in September 2004. A September 2004 record reflects that the Veteran reported that he injured his right knee while on patrol when he lost his footing and inverted his leg. The assessment was right MCL strain. The July 2005 VA examination report states that the Veteran reported a right knee ACL injury while on reserve duty. However, it also notes that the Veteran reported the onset of his disability in 2001 when he reportedly had a right knee injury while playing basketball and was told that he had an ACL tear. A January 2011 VA examination report reflects that the Veteran reported that his knee problems began in 2000 while on active duty due to ongoing strain from running. His chief complaint was peripatellar pain and recent medial tenderness. The Veteran was diagnosed with patellofemoral pain syndrome of the knees. In a March 2011 addendum, the examiner opined that it is less likely than not that the Veteran's current disability had its onset in service. In a January 2011 statement, the Veteran contends that he injured both knees in a 10 mile hike in September 2010. No records from this are associated with the claims file. Left Knee The earliest clinical evidence of a left knee complaint after the Veteran's separation from active Marine duty is May 2004. A May 2004 record from the Cooper Clinic reflects that the Veteran reported that during tactical maneuvers, he fell into a creek, stepping into the mud and hyper extended and twisted his left knee. He reported that he had no previous history of injury to the left knee. The assessment was "possible lateral meniscus tear." It was noted that the Veteran would need to have his left knee examined by an orthopedic physician for possibly lateral meniscus tear. The July 2005 VA examination report reflect that the Veteran reported that the onset of left knee was in 2001 when he was running, and fell and twisted his knee in a pot hole during Reserve service. He reported that he was told that he had a right meniscus injury and treated with crutches and light duty for several months. The Board notes that the Veteran was on active duty in 2001, and that he denied any knee injuries upon separation in 2002. An April 2007 VA record reflects that the Veteran reported that he initially injured his knee during tactical training in 2003. He reported that his knee gave out on him and fell over backwards. Recently, he was running on the treadmill and fell off secondary to his knee hyper-extending. A January 2011 VA examination report reflects that the Veteran reported knee problems back to 2000. His chief complaint was peripatellar pain and recent medial tenderness. The Veteran was diagnosed with patellofemoral pain syndrome of the knees. In a March 2011 addendum, the examiner opined that it is less likely than not that the Veteran's current disability had its onset in service. As noted above, the Veteran, in a January 2011 statement, contended that he injured both knees in a fall during a 10 mile hike in September 2010. Accordingly, the case is REMANDED for the following action: 1. Request the appellant to identify all providers (VA and private) from whom he has received treatment for his right shoulder and/or right elbow in March 2005 and complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for each provider. After obtaining completed VA Forms 21-4142, the AOJ should attempt to obtain all identified pertinent medical records, to include to all VA records from Livermore, California VAMC. Request the appellant to provide records of military profiles, if he has such, for any period for which he was on crutches. 2. After completion of the foregoing, schedule the Veteran for a VA examination and obtain a clinical opinion as to whether it is as likely as not (50 percent or greater) that the Veteran has a lumbar spine disability which is at least as likely as not (50 percent or more) causally related to, or aggravated by, service. The examiner should provide an adequate rationale which considers the entire claims file, to include: a.) the August 1999 report of medical history, b.) the May 2001 report of medical history, c.) the June 2002 report of medical history, d.) the March 2004 VA clinical opinion that the Veteran has a chronic back problem most likely brought about and or exacerbated by his job as truck driver and posture., e.) the May 2004 Cooper Clinic record, f.) the July 2005 VA examination report which reflects trauma to L4 probably secondary to weight lifting, g.) the August 2006 VA chiropractic record, h.) the January 15, 2010 VA clinical record which reflects the Veteran reported that he no longer has any back problem, i.) the July 24, 2012 Eastern New Mexico Medical Center records, i.) the July 2012 DA Form 2173 (Statement of Medical examination and duty status), j.) the Veteran's contention that he has had chronic pain since service due to marching with a heavy rucksack and truck driving in service, and k.) whether the severity of the Veteran's disability indicates if it is related to trauma or to aging. 3. Schedule the Veteran for a VA examination and obtain a clinical opinion as to whether it is as likely as not (50 percent or greater) that the Veteran has a right shoulder disability which is at least as likely as not (50 percent or more) causally related to, or aggravated by, active service, and/or a right wrist disability. The examiner should provide an adequate rationale which considers the entire claims file, to include: a.) the August 1999 report of medical history, b.) the May 2001 report of medical history, c.) the June 2002 report of medical history, d.) the April 14 and 21, 2004 Cooper Clinic records, e.) the July 2005 VA examination report, f.) the Veteran's contentions that he has had right shoulder pain since service, g.) the October 2006 VA examination report with radiograph findings, h.) the January 2010 VA clinical record reflects that the Veteran reported he no longer had a shoulder problem, i.) the July 22, 2010 VA record, j.) the December 2010 MRI and DA Form 2173, k.) the January 2011 VA examination report, l.) the February 2012 line of duty memorandum for Joint Forces Headquarters, m.) the October 2012 record reflects that the Veteran had a right shoulder arthroscopy, n.) the Veteran's contention that his shoulder disability is due to compensating for his wrist injury, and o.) the Veteran's history of weight-lifting. The Examiner should differentiate between the Veteran's different diagnoses of the shoulder, residuals of any disabilities, and which disabilities, if any, are as likely as not due to service or a service-connected disability, and if so, which period of service. 4. Schedule the Veteran for a VA examination and obtain a clinical opinion as to whether it is as likely as not (50 percent or greater) that the Veteran has a right elbow disability which is at least as likely as not (50 percent or more) causally related to, or aggravated by, active service, and/or a right wrist disability. The examiner should provide an adequate rationale which considers the entire claims file, to include: a.) the August 1999 report of medical history, b.) the May 2001 report of medical history, c.) the June 2002 report of medical history, d.) the March 26, 2004 and April 2004 Cooper Clinic records with an assessment that the Veteran had a right medial epicondylitis caused by muscular weakness from previous injury. e.) the March 2004 VA clinical record, f.) the July 2005 VA examination report, g.) the October 2006 VA examination report, and h.) the Veteran's contention that he had elbow pains since service, i.) and the Veteran's 2002 TFCC (triangular fibrocartilage complex) tear, j.) the Veteran's history of weight lifting. 5. Schedule the Veteran for a VA examination and obtain a clinical opinion as to whether it is as likely as not (50 percent or greater) that the Veteran has a right knee disability and/or a left knee disability which is at least as likely as not (50 percent or more) causally related to, or aggravated by, active service. The examiner should provide an adequate rationale which considers the entire claims file, to include: a.) the August 1999 report of medical history, b.) the May 2001 report of medical history, c.) the June 2002 report of medical history, d.) the September 2004 record of a right MCL strain, e.) the May 2004 record from the Cooper Clinic which reflects no previous history of injury to the left knee, and an assessment of "possible lateral meniscus tear, f.) the July 2005 VA examination report, g.) the April 2007 VA record of his knee hyperextending, h) the January 2011 VA examination report, and i.) the Veteran's contentions that he has had knee pain, since 2000, due to marching in service, and falling during a 10 mile hike in September 2010. The examiner should differentiate between the Veteran's different diagnoses of the knees, residuals of any disabilities, and which disabilities, if any, are as likely as not due to service, and if so, which period of service. 6. Thereafter, readjudicate the claims. If any benefit sought is not granted, issue a supplemental statement of the case and afford the appellant and his representative an appropriate opportunity to respond. Thereafter, the case should be returned to the Board, as warranted. The appellant has the right to submit additional evidence and argument on the matters 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. 2012). _________________________________________________ M. E. LARKIN 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) (2012).