Citation Nr: 1342275 Decision Date: 12/20/13 Archive Date: 12/31/13 DOCKET NO. 09-28 311 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for claimed rheumatoid arthritis. 2. Entitlement to service connection for a claimed bilateral knee disorder. 3. Entitlement to service connection for claimed bilateral carpel tunnel syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and her spouse ATTORNEY FOR THE BOARD G. Jackson, Counsel INTRODUCTION The Veteran served on active duty from August 1972 to May 1983. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision by the RO. In January 2011, the Veteran testified at a hearing held at the RO before the undersigned Veterans Law Judge; a transcript of the hearing is associated with the claims file. In June 2011, the Board remanded the issues on appeal for further development of the record. Some of the development was completed. The appeal is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. REMAND With regard to the claimed bilateral knee disorder, the Veteran was afforded a VA examination in September 2011. Three knee disorders were diagnosed: bilateral chondromalacia, s/p (status post) left meniscal tear and bilateral DJD (degenerative joint disease) of knees. The examiner indicated "the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness." In this regard, the examiner explained that the Veteran was seen many times in service for generalized multiple joint pains. Regarding the knees, she was seen one time for knee contusions sustained in an automobile accident. She was treated conservatively and improved. The examiner also noted that the Veteran was diagnosed with chondromalacia patella in service after complaining of nontraumatic knee pain worse with cold weather. The X-ray reports were normal, as was the examination. Years later, the Veteran underwent two arthroscopic knees surgeries for a nonservice-related injury. Additionally, the examiner noted that, at the separation examination, the Veteran denied having a knee disorder; however, there was mention of multiple joint, non-specific chronic arthralgias. The examiner also noted there was a post service treatment record that documented treatment for left knee pain of two months duration following an episode of stepping off a chair. The Board finds this examination is inadequate. To the extent that the examiner finds that a claimed bilateral knee disorder is not directly related to service, the supporting rationale is deficient. Given that three disorders have been diagnosed, it is unclear which disorder the examiner finds unrelated to service or if she found that all three disorders were unrelated to service. Given the in-service diagnosis of chondromalacia, the examiner does not adequately explain the relationship (or lack thereof) between the in-service diagnosis and the current diagnosis of chondromalacia. Given the Veteran's history of in-service traumatic injury (automobile accident), the examiner does not adequately explain how current DJD is unrelated to the in-service traumatic injury or if other in-service knee diagnoses are characteristic manifestations sufficient to identify the DJD. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Given the inadequacy of the VA examination as noted above, a remand is warranted to obtain a more thorough opinion. With regard to the claimed bilateral carpal tunnel syndrome, the Veteran was afforded a VA examination in September 2011. The relevant diagnosis was carpal tunnel, with a date of diagnosis in 2005. The examiner indicated that "the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness." In this regard, the examiner explained that the Veteran was seen in the ER after injuries sustained in an automobile accident. She was treated for a superficial laceration to the dorsum of the left hand with normal motor and sensory exam as well as a negative x-ray studies of the hands and wrists on more than one occasion. The examiner concluded that there was no injury that would contribute to the development of carpal tunnel syndrome over 10 years later. The Board finds this examination inadequate. To that end, the VA examiner failed to address the Veteran's actual assertions with regard to etiology of the claimed bilateral carpal tunnel syndrome. The Veteran asserts that her carpal tunnel syndrome is a result of the constant repetitive motion due to use of a microscope in the performance of her military job functions. The Board notes that the Veteran's military occupational specialties were medical laboratory specialist and cytology specialist. Thus, the Board finds the Veteran's assertions that her carpal tunnel syndrome is related to the repetitive motions involved in performance of her military job functions to be both competent and credible. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir.2007); Layno v. Brown, 6 Vet. App. 465 (1994). Given the inadequacy of the VA examination in failing to address the Veteran's credible lay, remand is warranted to obtain a more thorough opinion. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). With regard to the claimed rheumatoid arthritis, the Veteran also was afforded a VA examination in September 2011. In response to the question "does the Veteran now have or has he/she ever been diagnosed with inflammatory, autoimmune, crystalline or infectious arthritis or dysbaric osteonecrosis (Caisson disease)" the examiner indicated "yes" and indicated the diagnosis was rheumatoid arthritis (atrophic), date of diagnosis was unknown. Laboratory studies were reported as follows: Erythrocyte sedimentation rate (ESR), 68; C-reactive protein, .708; rheumatoid factor, 2.1; antinuclear antibodies (ANA), negative; and, anti-cyclic citrullinated peptide (anti-CCP) antibodies, normal. The examiner indicated "the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness." The examiner explained that "the veteran ha[d] complained of generalized joint pain/arthralgias since her time in the service, but after an in-depth review of her C-file and all medical records [the examiner was] unable to find laboratory evidence of Rheumatoid Arthritis." The examiner noted that the first evidence of a diagnosis was a February 2008 private treatment record, documenting treatment the Veteran received from a rheumatologist. The examiner stated that all previous records mentioned multiple joint pain with osteoarthritis. The examiner observed that the February 2008 record mentioned a clinical diagnosis of rheumatoid arthritis without laboratory evidence. Thus, on this record, the examiner was unable to determine that Rheumatoid arthritis existed during the Veteran's time in service. The Board finds this examination inadequate. First, it is unclear if the examiner finds that the Veteran has a definitive, current diagnosis of rheumatoid arthritis. To the extent that the examiner seems to find that rheumatoid arthritis is not directly related to service, her supporting rationale ("unable to determine that Rheumatoid arthritis existed during the Veteran's time in service") is deficient. The Board reiterates service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In any event, the Board notes that the Veteran's service treatment records document a long standing history of complaints of multiple joint pains, arthralgias and myalgias. A March 1981 service treatment record documents an assessment of "clinical history most consistent with early rheumatoid process." A January 1983 treatment record documented a diagnosis of rheumatism. A March 1983 service treatment record documented a "history of arthritis - undiagnosed type." Thus, clarity is needed as to whether there is a definitive, current diagnosis of rheumatoid arthritis and, if so, what is its relationship (or lack thereof) of events noted during the Veteran's period of service. In so doing, the examiner should address whether in-service complaints/diagnoses (arthralgias/myalgias, rheumatism, rheumatoid process) are characteristic manifestations sufficient to identify the rheumatoid arthritis. Given the inadequacy of the VA examination with regard to this claim for service connection for rheumatoid arthritis, remand is warranted to obtain a more thorough opinion. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the case is REMANDED for the following action: 1. The RO should take appropriate action to obtain an addendum opinion regarding the likely etiology of the claimed bilateral knee disorder from the VA examiner who conducted the September 2011 examination or from a suitable substitute. The entire claims file (i.e., both the paper claims file and any electronic medical records) should be made available to and be reviewed by the examiner. If the examiner does not have access to electronic medical records, any such relevant treatment records must be printed and associated with the paper claims file so they can be available to the examiner for review. If the examiner determines an examination is required, such an examination shall be provided. The rationale for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the opinion report, and a rationale provided for that conclusion. The examiner must identify each diagnosed knee disorder. Then with respect to each diagnosis, the examiner must provide an opinion, in light of prior examination findings and the service and post-service evidence of record whether it is at least as likely as not (50 percent or greater probability) that the diagnosed disability had its clinical onset during service or otherwise is due to disease or injury in service. To the extent that the Veteran has a current diagnosis that was also diagnosed in service (chondromalacia), the examiner should explain why the current diagnosis is (or is not) related to the diagnosis noted in service. To the extent that arthritis is diagnosed, the examiner should address whether any symptoms in service represented the characteristic manifestations sufficient to identify arthritis. 2. The RO also should take all indicated action to obtain an addendum opinion regarding the likely etiology of the claimed bilateral carpal tunnel syndrome from the VA examiner who conducted the September 2011 examination or from a suitable substitute. The entire claims file (i.e., both the paper claims file and any electronic medical records) should be made available to and be reviewed by the examiner. If the examiner does not have access to electronic medical records, any such relevant treatment records must be printed and associated with the paper claims file so they can be available to the examiner for review. If the examiner determines an examination is required, such an examination shall be provided. The rationale for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the opinion report, and a rationale provided for that conclusion. The examiner must provide an opinion, in light of prior examination findings and the service and post-service evidence of record whether it is at least as likely as not (50 percent or greater probability) that the any current bilateral carpal tunnel syndrome had its clinical onset during service or otherwise is due to an injury during service, to include the reported constant, repetitive motion in using a microscope in the performance of her military job functions. 3. Finally, the RO should take all indicated action to obtain an addendum opinion regarding the diagnosis and likely etiology of the claimed rheumatoid arthritis from a specialist in rheumatology. The entire claims file (i.e., both the paper claims file and any electronic medical records) should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. If the rheumatologist does not have access to electronic medical records, any such relevant treatment records must be printed and associated with the paper claims file so they can be available to the examiner for review. If the examiner determines an examination is required, such an examination shall be provided. The rationale for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the opinion report, and a rationale provided for that conclusion. The rheumatologist should, in accordance with sound medical principle, prior examination findings and the service and post-service evidence of record, provide a clear diagnosis (or lack thereof) referable to the claimed rheumatoid arthritis, to include explanation of the laboratory findings and significance of such related thereto. If a diagnosis of rheumatoid arthritis is made, the rheumatologist must provide an opinion, in light of prior examination findings and the service and post-service evidence of record whether it is at least as likely as not (50 percent or greater probability) that any current rheumatoid arthritis had its clinical onset during service or otherwise is due to an event or incident of the Veteran's period of active service. To the extent that rheumatoid arthritis is diagnosed, the rheumatologist should address whether the arthralgias/myalgias, rheumatism, rheumatoid process noted in service represent the characteristic manifestations sufficient to identify any current rheumatoid arthritis. 4. After completing all indicated development, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran 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. 2013). _________________________________________________ STEPHEN L. WILKINS 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).