Citation Nr: 18140988 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 09-22 235 DATE: October 9, 2018 REMANDED Service connection for orthopedic disability of the bilateral upper extremities is remanded. Service connection for orthopedic disability of the bilateral lower extremities is remanded. Service connection for peripheral neuropathy of the bilateral lower extremities is remanded. Service connection for removal of an osteophyte on the right metatarsophalangeal joint of the hallux is remanded. Service connection for sleep disturbance, to include sleep apnea, is remanded. REASONS FOR REMAND The Veteran served in the United States Army from December 1963 to October 1966. 1. Service connection for orthopedic disability of the bilateral upper extremities 2. Service connection for orthopedic disability of the bilateral lower extremities The December 2016 VA examinations diagnosed bilateral knee chondrocalcinosis, right wrist chondrocalcinosis, left wrist DJD, and bilateral hand DJD. The July 2017 Board remand requested medical opinion on whether any identified orthopedic disabilities of the upper and lower extremities were 1) etiologically related to service, to include his duties as a heavy equipment operator, and 2) caused or aggravated by his service-connected back condition. The March 2018 examiner opined on some of the Veteran’s upper and lower extremity diagnoses, but did not opine on his bilateral knee chondrocalcinosis, right wrist chondrocalcinosis, left wrist DJD, and bilateral hand DJD. The Board requests an addendum opinion to fully comply with the July 2017 Board remand instructions. 3. Service connection for peripheral neuropathy of the bilateral lower extremities, to include as secondary to herbicide agent exposure and service-connected low back disability The Board finds the VA examination opinions of record have not discussed the October 2008 private treatment statement that “toxic metabolic causes, including Agent Orange, while he was in Vietnam, can contribute to peripheral neuropathy.” The Board requests an addendum opinion that includes discussion of this opinion. 4. Service connection for removal of an osteophyte on the right metatarsophalangeal joint of the hallux The July 2017 Board remand found the May 2013 VA examiner did not address the Veteran’s credible statement that he dropped a heavy piece of equipment on his right foot during military service as the possible cause of the May 2005 removal of an osteophyte on the right metatarsophalangeal joint of the hallux. This contention was not addressed in post-remand examination opinions. The Board requests an addendum opinion to fully comply with the July 2017 Board remand instructions. 5. Service connection for sleep disturbance, to include sleep apnea, to include as secondary to service-connected PTSD The February 2018 VA sleep apnea examination opinion stated the Veteran had not been diagnosed with sleep apnea by sleep study, citing to a May 2001 sleep study. The examiner did not address the November 2017 statement submitted by the Veteran’s wife reporting the Veteran’s frightening sleep habits, horrendous snoring, and waking up gasping for air. The Board requests a sleep study and medical opinion addressing the etiology of the sleep symptoms reported in the claims file. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the February 2018 VA examiner, or if he is unavailable, another appropriate clinician, regarding the etiology of the Veteran’s bilateral knee chondrocalcinosis, right wrist chondrocalcinosis, left wrist DJD, and bilateral hand DJD. The examiner should opine: (a.) For each condition identified above, was the condition at least as likely as not (50 percent or greater probability) incurred in service or etiologically related to service, to include his duties as a heavy equipment operator? The examiner is advised the Board found the Veteran’s reports of lifting and moving heavy equipment during service to be consistent with the circumstances of his MOS as a construction equipment operator. See July 2017 Board remand directives. (b.) If any of the above conditions are determined to not have been incurred in service or etiologically related to service, is it at least as likely as not the condition was (i) proximately due to or (ii) aggravated beyond its natural progression by his service-connected back disability? The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Obtain an addendum opinion from the February 2018 VA examiner, or if he is unavailable, another appropriate clinician, regarding whether the Veteran’s bilateral lower extremity peripheral neuropathy is at least as likely as not (50 percent or greater probability) etiologically related to herbicide agent exposure in service? The examiner is advised the Board is cognizant that there is no presumption of service connection for delayed-onset peripheral neuropathy due to exposure to herbicide agents. Thus, the question is whether his peripheral neuropathy of the bilateral lower extremities is at least as likely as not related to his herbicide agent exposure in service, given his medical history, family history, risk factors, etc. The examiner must discuss the October 2008 treatment statement that “toxic metabolic causes, including Agent Orange, while he was in Vietnam, can contribute to peripheral neuropathy.” The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Obtain an addendum opinion from the February 2018 VA examiner, or if he is unavailable, another appropriate clinician, regarding whether the Veteran’s May 2005 removal of an osteophyte on the right metatarsophalangeal joint of the hallux was at least as likely as not related to dropping a heavy piece of equipment onto his right foot during military service? The examiner is advised the Board has determined the Veteran’s contention that he dropped a large object on his foot in service credible and consistent with his service duties. See July 2017 Board remand directives. The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sleep disturbances. The examination must include a sleep study. The examiner should then opine: (a.) If sleep apnea is diagnosed, is it at least as likely as not (50 percent or greater probability) the Veteran’s sleep apnea manifested in service or is etiologically related to service? The rationale should include discussion of the Veteran’s and his wife’s lay statements regarding sleep symptoms. (b.) If sleep apnea is diagnosed and determined not to be etiologically related to service, is it at least as likely as not that the Veteran’s sleep apnea is (i) proximately due to or (ii) aggravated beyond its natural progression by his service-connected PTSD. (c.) If sleep apnea is not diagnosed, the examiner should opine on the etiology of any sleep complaints during the appeal period, to include his May 2007 statement, September 2010 PTSD VA examination, and November 2017 wife statement. The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Winkler, Associate Counsel