Citation Nr: 1433701 Decision Date: 07/29/14 Archive Date: 08/04/14 DOCKET NO. 09-33 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for residuals, contusion and right forearm to include right biceps muscle tendon rupture with tendonitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Quander Forde, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1979 to July 1982, from January 1986 to May 1986, from November 1990 to June 1991 and from February 2003 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in August 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction of the case has since transferred to Wichita, Kansas. The Veteran testified at a Board hearing before the undersigned Acting Veterans Law Judge in December 2013. A transcript (Tr.) of those proceedings has been associated with the Veteran's claims file. As further development is needed prior to adjudication, the issue is REMANDED to the agency of original jurisdiction (AOJ). REMAND The Veteran seeks service connection for residuals, contusion, right forearm, to include right biceps muscle tendon rupture with tendinitis. The Veteran reported that his current right arm disability resulted from an injury in-service and has been productive of persistent symptoms since that time. Before the Board may reach a decision on the Veteran's claim, further development is needed. The Veteran's service treatment records (STRs) reveal that in November 2004, the Veteran suffered from a contusion of the right forearm caused by a trailer hitch falling on the Veteran's elbow. The Veteran's separation examination also indicates that the Veteran suffered from painful shoulder, elbow, or wrist. The Veteran testified that following the injury he experienced soreness and now he can only turn a screwdriver six times before he experiences muscle cramps (Tr. at 5). Following the Veteran's separation from service, he has not received medical treatment for his right arm disability (Tr. at 10). The Veteran testified that he noticed the muscle atrophy in 2005 (Tr. at 6), one year after service. The Veteran underwent a VA examination on August 2008, which resulted in findings of distal biceps tendon rupture with tendinitis, bicep atrophy and degenerative changes of the right elbow and right shoulder. The VA examiner opined that it is less likely as not that the November 2004 contusion of the elbow caused the right distal bicep tendon rupture. The VA examiner reasoned that the Veteran's reported spontaneous tendon ruptures and the length of time following the in-service injury made it less likely as not that the in-service injury caused the current disability. Therefore, the examiner concluded that the current stated residuals are not caused by the contusion of the the right elbow which has resolved without residuals. Although the VA examiner attributed the Veteran's current upper extremity disability to a "right distal biceps tendon rupture . . . following [his] release from active military service" it is unclear from the record that the Veteran in fact sustained such a post-service injury to his right arm. See VA Examination Report at 8. Indeed, while that report notes that the Veteran "currently works in a federal prison and turns up to 100 locks daily" - id. at 4 -- he has made no mention of any injury during his civilian employment that may have resulted in his current tendon rupture. Nor has the record otherwise established that such an injury occurred. Thus, without further explanation, the August 2008 VA examiner's report is inadequate for rating purposes . See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (finding that a medical opinion is adequate where it describes the disability in sufficient detail so the Board can make a fully informed evaluation of the disability). When VA undertakes the effort to provide an examination or medical opinion, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus the Board finds a new medical opinion is needed to address whether the Veteran's current right arm disability had its onset in, or is otherwise related to his active service. Moreover, as the Board itself is prohibited from providing its own medical judgment (see Colvin v. Derwinski, 1 Vet. App. 171 (1991)), the Veteran should be accorded a new VA examination for the requested opinion. On remand, all of the Veteran's outstanding treatment records dating from August 2008 should be associated with the claims file. See Bell v. Derwinski, 1 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain outstanding records of VA treatment for the Veteran's right upper extremity disability dated since August 2008 and associate them with the record. If no additional records are available, include documentation of the unavailability in the claims file. 2. Invite the Veteran to submit medical and hospitalization records, medical statements, and any other lay or medical evidence from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed, of the nature, extent, and severity of his right arm disability. He should be provided an appropriate amount of time to submit this evidence. 3. After associating any pertinent, outstanding records with the claims file, schedule the Veteran for an appropriate VA examination to determine the current nature, extent, and severity of his right arm disability. Please refer to the Veteran's recurrent and persistent symptoms (Tr. At 5). The claims file should be made available to and reviewed by the examiner, and all appropriate tests and studies should be conducted. The examiner should include specific findings that address the following: a. Identify all right arm disabilities found to be present. b. For each diagnosis, state whether it is at least as likely as not that the diagnosis is related to or had its onset during any of his periods of active service, to specifically include the November 2004 right forearm contusion noted in his STRs . In making these determinations, the VA examiner should expressly take into account the Veteran's reports of recurrent right arm pain and related symptoms persisting since his November 2004 in-service injury. 4. After undertaking any additional development necessary to ensure compliance with this remand, readjudicate the claim. If the full benefits sought on appeal are not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them a sufficient opportunity to respond. Then, return the case to the Board for further appellate review, if in order. The appellant 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. 2013). _________________________________________________ M. N. HYLAND Acting 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).