Citation Nr: 1339460 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 11-18 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for myotonic dystrophy. 2. Entitlement to an initial compensable disability rating for a fracture of the right fifth metacarpal. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD M. Caylor, Associate Counsel INTRODUCTION The Veteran had active naval service from December 1994 to December 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Winston-Salem, North Carolina. The Board has reviewed the physical claims file and the Virtual VA electronic claims file The issues on appeal are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND A. Myotonic dystrophy. The Veteran asserts that he has myotonic dystrophy that is etiologically related to his active service. He said his symptoms initially manifested after he suffered an in-service injury to his right-hand in 1997. See October 2010 notice of disagreement (NOD). "[O]nce the Secretary undertakes the effort to provide an examination when developing a service-connection claim, . . . he must provide an adequate one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An adequate medical opinion must consider all relevant evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). It must consider the veteran's prior pertinent medical history and must also include clear conclusions, supporting data, and a reasoned medical explanation. Barr, 21 Vet. App. at 311; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In September 2010, a VA physiatrist examined the Veteran and opined that he would have to resort to speculation to determine whether the Veteran's myotonic dystrophy was related to service. It was explained that whether the 1996 in-service injury to the right wrist ligament or a 1997 in-service injury to the right fifth metacarpal fracture were manifestations of his myotonic dystrophy was unknown. This opinion is inadequate because it does not provide a rationale explaining why the examiner would need to resort to speculation. In February 2011, a Social Security Administration consulting examiner opined that the Veteran's 1996 and 1997 right-hand injuries were "probably the first presentation of his disorder." This opinion is also inadequate, as it does not contain a rationale or explanation of any kind. In sum, there is insufficient evidence to decide the Veteran's claim. The record does not contain an adequate nexus opinion and the Board does not have the medical expertise to make a determination as to whether the Veteran's myotonic dystrophy is related to an in-service injury, disease, or event. See Colvin, 1 Vet. App. at 175. Given these circumstances, the Board requests that VA provide the Veteran with a new examination and obtain a new opinion from a neurologist that clearly addresses the etiology of the Veteran's myotonic dystrophy. B. Fracture of the right fifth metacarpal. The Veteran contends that a compensable initial disability rating should be assigned for his right fifth metacarpal fracture because his right little finger now hardly moves. See December 2010 statement. Service treatment records (STRs) dated from 1997 indicate that the Veteran was treated for a fifth right metacarpal fracture. VA treatment records reveal that in May 2010 he was diagnosed with myotonic dystrophy by a VA neurologist. The record shows that he currently has symptoms of pain, numbness, weakness, and stiffness and a reduced grip and difficulty with fine motion in both his left and right hands. The Board is unable to distinguish between the symptoms attributable to the right fifth metacarpal fracture and the symptoms attributable to myotonic dystrophy. In sum, there is insufficient evidence to decide the claim. The Board does not have the medical expertise to determine whether the Veteran's right-hand symptoms are attributable to his right fifth metacarpal fracture or his myotonic dystrophy. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board is not competent to substitute its own opinion for that of a medical expert). Given these circumstances, the Board requests that VA provide the Veteran with a new examination by an orthopedist that clearly addresses the symptomatology of his right fifth metacarpal fracture. Accordingly, the case is REMANDED for the following action: 1. First, undertake appropriate development to obtain any outstanding, pertinent medical records, to include from VA and the Social Security Administration. 2. Second, provide the Veteran with an examination by a neurologist to determine the nature and etiology of any current myotonic dystrophy. Provide the examiner with the claims file, including any pertinent evidence in Virtual VA that is not already in the claims file. The examiner should review the claims file and perform all indicated studies. The examiner should provide an opinion, based on examination results and the record, regarding whether it is at least as likely as not (a 50 percent or greater probability) that any current myotonic dystrophy is related to an in-service injury, disease, or event, to include the 1996 and 1997 injuries to the Veteran's right hand. The examiner should consider the March 2011 Social Security Administration consulting examiner's report and the Veteran's own allegations of onset. The opinion must contain a complete medical rationale. If unable to provide an opinion without resorting to speculation, the examiner should explain in detail why speculation would be required. 3. Third, provide the Veteran with an examination by an orthopedist concerning the current severity of his right fifth metacarpal fracture. Provide the examiner with the claims file, including any pertinent evidence in Virtual VA that is not already in the claims file. The examiner should review the claims file and perform all indicated studies. The examiner should clearly explain which of the Veteran's right-hand symptoms stem from his service-connected right fifth metacarpal fracture alone. If unable to determine which symptoms are attributable to the right fifth metacarpal fracture, the examiner should explain in detail why such a determination is not possible. The examiner should also address any functional impairment resulting from the Veteran's right fifth metacarpal and its effects on his ordinary activities. 4. Then, the RO or AMC should readjudicate the claims on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should receive a Supplemental Statement of the Case and an opportunity to respond. If necessary, the cases should then be returned to the Board for further appellate action. 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). 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). _________________________________________________ K. PARAKKAL 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).