Citation Nr: 1753089 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 05-40 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for right knee disability claimed as right knee arthritis, to include as secondary to posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for disability of the elbows, to include as secondary to PTSD. 3. Entitlement to service connection for disability of the feet, to include as secondary to PTSD. 4. Entitlement to service connection for bilateral hand disability, to include as secondary to PTSD. 5. Entitlement to service connection for disability of the lumbar spine with radiculopathy, to include as secondary to PTSD. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD T. Henry, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1966 to February 1968. These issues come before the Board of Veterans Appeals Board on appeal from a July 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In November 2009, April 2012 and 2013, and March 2014, the Board remanded the claims for further development. In August 2015, the Board denied service connection for the disorders on appeal. The Veteran appealed to the United States Court of Appeals for Veterans Claims (CAVC). The Board notes this case was subject to a June 21, 2017, Joint Motion for Partial Remand of the Board's August 2015 denial of service connection for right knee disability, disability of the elbows, disability of the feet, bilateral hand disability, and disability of the lumbar spine with radiculopathy all as secondary to service-connected PTSD. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran contends that his PTSD causes or aggravates the disabilities on appeal. In June 2017, CAVC remanded this matter after granting an Amended Joint Motion for Partial Remand, which indicated that the Board committed administrative error when it relied on inadequate VA examinations. The Court vacated only that portion of the decision that addressed service connection on a secondary basis. The appeal of a denial of service connection on a direct basis was dismissed and that portion of the Board decision remained undisturbed. In May 2011 in a Third Party Statement, the Veteran's representative amended the Veteran's claims to include as due to service-connected PTSD. In support of the claims, the Veteran submitted an article which described the relationship between PTSD and physical health. The article stated that studies have found that people with PTSD are more likely to experience a number of physical health problems including for example arthritis and pain. In July 2012, the Veteran was afforded a VA examination to determine the nature and etiology of his disabilities. The examiner stated that "there is no evidence-based medical literature that I am aware of that states that bilateral foot elbow and hand disabilities as well as right knee and lumbar spine with radiculopathy disabilities are caused or aggravated by posttraumatic stress disorder." In a December 2012 Third Party Statement, the Veteran's representative characterized the issues as claims for service connection for rheumatoid arthritis of multiple joints and osteoarthritis of multiple joints. Additionally, the representative submitted additional evidence of medical research from VA's National Center for PTSD's own quarterly publication and from a database off of VA's website. The studies address physical health outcomes and PTSD and several specifically address arthritis and rheumatoid arthritis. In August 2013, the Veteran was afforded a VA examination to determine the nature and etiology of his disabilities to include as secondary to PTSD. The examiner stated that "there is no evidence-based medical literature that I am aware of that states that bilateral foot, elbow, and hand disabilities, as well as right knee and lumbar spine with radiculopathy disabilities occur secondary to a psychiatric condition of posttraumatic stress disorder." In November 2014, a VA clinical psychologist reviewed and commented on a body of research that supported correlational relationships of health problems in patients with PTSD but do not suggest that PTSD causes or exacerbates these health problems. However, the psychologist could not provide an opinion in this Veteran's case, acknowledged that the issue was outside the scope of her expertise, and recommended an opinion be obtained from a medical physician who is knowledgeable in this area of medicine. In January 2015, a VA rheumatologist found that the Veteran rheumatoid arthritis is a disease of unknown cause and arose after service. In the June 201, the parties to the Amended Joint Motion for Partial Remand found that the Board's reliance on the November 2014 was in error and directed that an opinion be obtained from an appropriate medical examiner and that a rheumatologist may be the most appropriate and competent examiner to provide an opinion that addresses the medical treatise evidence and an opinion whether the disorders on appeal are due to his PTSD. Therefore, in accordance with the June 21, 2017 CAVC order, the Board must remand the claim for a new opinion which considers the literature submitted by the Veteran's representative and also provides the Veteran a VA examination performed by a rheumatologist. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain any outstanding VA treatment records and associate those documents with the Veteran's claims file. 2. Obtain any necessary authorization from the Veteran; then, obtain all outstanding private treatment records. The RO should make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 3. After completion of the foregoing, schedule the Veteran for a VA examination with a rheumatologist to address the nature and etiology of all joint disorders and any and all manifestations of the claimant's arthritis. The rheumatologist should review the claims file and examination report should reflect consideration of the Veteran's documented medical history and assertions. The rheumatologist should then address the following: Whether it is at least as likely as not (a 50 percent or better probability) that the rheumatoid arthritis has its onset in service or is the result of a disease or injury in service. The reasons for any opinion should be provided. 4. The rheumatologist should review the May 2011, December 2012, and July 2015 literature submitted by the Veteran and his representative regarding PTSD and physical health. a. After reviewing the claims folder and the research regarding PTSD and physical health, provide an opinion as to whether it is at least as likely as not (a 50 percent or better probability) that the Veteran's disabilities have been caused or aggravated by his service-connected PTSD. If the rheumatologist finds that any disability has been aggravated by the service-connected PTSD, the examiner must identify the baseline level of disability prior to aggravation. The reasons for any opinion should be provided. 5. Then readjudicate the Veteran's claims. If any benefit remains denied, issue an appropriate Supplemental Statement of the Case, and give the Veteran and his representative an appropriate opportunity to respond. The case should then be returned to the Board, if otherwise in order, for further appellate review. The Veteran 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 2014). _________________________________________________ J.W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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) (2017).