Citation Nr: 18158478 Decision Date: 12/17/18 Archive Date: 12/17/18 DOCKET NO. 09-42 021A DATE: December 17, 2018 REMANDED Entitlement to service connection for right elbow disability, to include lateral epicondylitis, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1967 to August 1971 and from November 1976 to December 1992. His awards include the Air Medal with “V” Device, Combat Infantryman Badge, Bronze Star Medal, and Army Commendation Medal. This matter initially came before the Board of Veterans’ Appeals (Board) from a September 2010 rating decision. In November 2015, the Board remanded this matter to schedule the Veteran for a Board hearing before a Veterans Law Judge (VLJ). The Veteran testified before the Board at a January 2017 hearing and a transcript of the hearing has been associated with his claims file. In July 2018, the Board remanded this matter for further development. As for characterization of the issue on appeal, in light of the Veteran’s reported symptoms and contentions and to encompass all disorders that are reasonably raised by the record, the Board has re-characterized the claim of service connection for right elbow lateral epicondylitis as a claim of service connection for right elbow disability, to include lateral epicondylitis. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim). Entitlement to service connection for right elbow disability, to include lateral epicondylitis, is remanded. The Veteran contends that he has current right elbow disability which had its onset in service. His service treatment records reflect that he was treated for a 3 month history of right elbow pain in 1989 or 1990 (the Veteran was 41 years old at the time of his in-service elbow treatment) and that he was diagnosed as having right lateral epicondylitis. He contends that he has continued to experience right elbow pain ever since service and he was diagnosed as having a right elbow strain during a September 2012 VA examination. In its July 2018 remand, the Board instructed the agency of original jurisdiction (AOJ) to obtain a medical opinion addressing the etiology of the Veteran’s claimed right elbow disability. In October 2018, the nurse practitioner who conducted the September 2012 examination reviewed the Veteran’s claims file and opined that his current right elbow disability was not likely caused by or a result of his right elbow problems in service. This opinion, however, is entirely based on the absence of objective clinical evidence of treatment for right elbow problems for many years following service. The nurse practitioner did not acknowledge or comment on the Veteran’s competent and credible reports of continuous right elbow symptoms in the years since service. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran’s reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). The Board cannot make a fully-informed decision on the issue of entitlement to service connection for right elbow disability because no VA examiner has adequately opined whether the Veteran’s current right elbow disability was incurred in service. In light of this fact and the fact that he was most recently afforded an examination in 2012, an appropriate examination should be conducted upon remand. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Gainesville Vista electronic records system and are dated to February 2013. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal. A remand is required to allow VA to obtain them. The matter is REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for right elbow disability, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for right elbow disability from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records contained in the Gainesville Vista electronic records system for the period since February 2013; and all such relevant records from any other sufficiently identified VA facility. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current right elbow disability. The examiner must opine whether any right elbow disability experienced by the Veteran since approximately May 2010 at least as likely as not (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (3) is related to an in-service injury, event, or disease, including the right elbow problems documented in the Veteran’s service treatment records. The examiner must provide a rationale for each opinion given. In this regard, the examiner must acknowledge and comment on the Veteran’s competent and credible reports of continuous right elbow pain since his treatment for elbow problems in service. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Elwood, Counsel