Citation Nr: 18160251 Decision Date: 12/27/18 Archive Date: 12/26/18 DOCKET NO. 17-25 581 DATE: December 27, 2018 ORDER Entitlement to service connection for bilateral plantar fasciitis, to include as secondary to service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities, is granted. Entitlement to an effective date of service connection earlier than July 12, 2016, for varicose veins and lipedema/lymphedema of the left lower extremity (LLE) due to clear and unmistakable error (CUE) is denied. Entitlement to an effective date of service connection earlier than July 12, 2016, for varicose veins and lipedema/lymphedema of the right lower extremity (RLE) due to CUE is denied. Entitlement to a rating in excess of 20 percent for varicose veins and lipedema/lymphedema of the LLE is denied. Entitlement to a rating in excess of 20 percent for varicose veins and lipedema/lymphedema of the RLE is denied. Entitlement to a compensable rating for chronic pelvic pain syndrome (claimed as abdominal pain and C-section residuals) is denied. REMANDED Entitlement to service connection for right knee patellofemoral syndrome with degenerative arthrosis, to include as secondary to service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities, is remanded. Entitlement to service connection for left knee osteoarthritis, to include as secondary to service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities, is remanded. Entitlement to service connection for chronic left wrist sprain, to include as secondary to service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities, is remanded. Entitlement to service connection for chronic right wrist sprain, to include as secondary to service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities, is remanded. FINDINGS OF FACT 1. The Veteran’s bilateral plantar fasciitis is proximately due to her service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities. 2. There was no CUE in the assignment of the effective date of service connection as July 12, 2016, for varicose veins and lipedema/lymphedema of the LLE. 3. There was no CUE in the assignment of the effective date of service connection as July 12, 2016, for varicose veins and lipedema/lymphedema of the RLE. 4. The manifestations of the Veteran’s varicose veins and lipedema/lymphedema of the LLE most closely approximate those contemplated by a 20 percent rating. 5. The manifestations of the Veteran’s varicose veins and lipedema/lymphedema of the RLE most closely approximate those contemplated by a 20 percent rating. 6. The manifestations of the Veteran’s chronic pelvic pain syndrome most closely approximate those contemplated by a noncompensable rating. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral plantar fasciitis have been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.310 (2017). 2. The criteria for entitlement to an effective date of service connection earlier than July 12, 2016, for varicose veins and lipedema/lymphedema of the LLE have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.1(p), 3.102, 3.114, 3.400 (2017); 38 C.F.R. § 3.155 (2011) (repealed 2015). 3. The criteria for entitlement to an effective date of service connection earlier than July 12, 2016, for varicose veins and lipedema/lymphedema of the RLE have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.1(p), 3.102, 3.114, 3.400 (2017); 38 C.F.R. § 3.155 (2011) (repealed 2015). 4. The criteria for entitlement to a rating in excess of 20 percent for varicose veins and lipedema/lymphedema of the LLE have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.25, 4.104, Diagnostic Code (DC) 7120 (2017). 5. The criteria for entitlement to a rating in excess of 20 percent for varicose veins and lipedema/lymphedema of the RLE have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.25, 4.104, DC 7120 (2017). 6. The criteria for entitlement to a compensable rating for chronic pelvic pain syndrome have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.25, 4.116, DC 7614, General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had qualifying service from October 1982 to October 1987. Service Connection Direct service connection generally requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Secondary service connection may be granted for disabilities which were proximately due to, the result of, or aggravated beyond natural progression by a service-connected disability. 38 C.F.R. § 3.310(a). 1. Bilateral Plantar Fasciitis In the July 2015 Notice of Disagreement, the Veteran contended that her plantar fasciitis was caused by strenuous physical training in service. In May 2017, the Veteran submitted an internet article describing the causes of and risk factors for plantar fasciitis. A July 2017 VA examiner opined that the Veteran’s bilateral plantar fasciitis was not secondary to her service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities; the examiner explained that, after medical literature review and research, there was no known direct causation or correlation between the two conditions. However, in December 2017, a VA examiner opined that the Veteran’s bilateral plantar fasciitis was at least as likely as not proximately due to or the result of her service-connected varicose and lipedema/lymphedema of the bilateral lower extremities condition; the examiner explained that the bilateral lipedema has caused significant, persistent, chronic, extreme swelling of the bilateral lower extremities for decades and that this increased swelling, pressure, and weight could certainly lead to chronic foot pain. Both the July 2017 and December 2017 examiners provided adequate rationale based on their review of medical literature and the Veteran’s claims filed; accordingly, both examiners are accorded probative weight. However, as the evidence is at least in equipoise, the Board resolves all doubt in the Veteran’s favor to find that her bilateral plantar fasciitis is at least as likely as not proximately due to her service-connected varicose and lipedema/lymphedema of the bilateral lower extremities. Thus, secondary service connection is granted. Earlier Effective Dates Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5100; 38 C.F.R. § 3.400. If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400 (b)(2). Otherwise, it is the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. A specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA (unless the claim or appeal was filed on or after March 24, 2015, via any communication or action that indicated an intent to apply for one or more VA benefits and identified the benefit sought). 38 U.S.C. § 5101 (a); 38 C.F.R. §§ 3.151 (a), 3.155(a) (repealed 2015); 79 Fed. Reg. 57,660 (Sept. 25, 2014) (eff. Mar. 24, 2015); Brannon v. West, 12 Vet. App. 32, 34-5 (1998). The mere existence of a disability does not constitute a claim of service connection for such disability and VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. Brannon v. West, 12 Vet. App. 32 (1998); Talbert v. Brown, 7 Vet. App. 352 (1995). 2. Varicose Veins and Lipedema/Lymphedema of the LLE Both LLE and RLE varicose veins and lipedema/lymphedema have an effective date of service connection of July 12, 2016. See February 2018 Codesheet. The Veteran generally contends that both effective dates should be May 31, 2013. See April 2017 Statement; July 2017 Notice of Disagreement; September 2017 VA Form 9. The Veteran was discharged in October 1987 and filed a claim for “bilateral leg conditions” on May 31, 2013. See May 2013 VA Form 21-526. June 2014 VA examiners diagnosed, among other conditions: bilateral hip strain with arthritis and right patellofemoral syndrome. In the November 2014 Rating Decision, the agency of original jurisdiction (AOJ) denied service connection, in pertinent part, for: (a) left hip strain with arthritis (claimed as left leg condition); (b) right hip strain with arthritis (claimed as left leg condition); and (c) right patellofemoral syndrome (claimed as left leg condition). The November 2014 Rating Decision clearly interpreted the Veteran’s unspecific claim for “bilateral leg conditions” as claims for bilateral hip strain with arthritis and right patellofemoral syndrome. In a January 2015 Statement, the Veteran specifically requested reconsideration of the November 2014 denials of bilateral hip strain with arthritis and right knee condition; she also specifically contended that her bilateral hip condition and right knee condition were caused by her military training (marches and running). The Veteran never asserted that the AOJ misinterpreted her claim and actually seemed to affirm that interpretation by providing further contentions for the bilateral hips and right knee. In the May 2015 Rating Decision, the AOJ continued the denial of service connection for the bilateral hips and right knee condition; the Veteran was concurrently notified of this decision in May 2015. In a July 2015 Notice of Disagreement, the Veteran reiterated her contentions from the January 2015 Statement (that her bilateral hip and right knee conditions were caused by strenuous physical training); again, the Veteran never asserted that the AOJ misinterpreted her claim. On July 12, 2016, the Veteran submitted a VA Form 21-526EZ application for the disabilities of “bilateral leg condition, swelling, pain” and “vein condition of bilateral lower legs.” This July 12, 2016, submission is the earliest record of communication or action indicating intent to apply for entitlement to service connection for the disability of varicose veins and lipedema/lymphedema of the bilateral lower legs. Through the March 2017 Rating Decision, the AOJ granted entitlement to service connection for varicose veins and lipedema/lymphedema of the bilateral lower legs, assigning the effective date as July 12, 2016. The Veteran subsequently contended that the effective date should be May 31, 2013, because the AOJ misinterpreted her May 2013 claim (she contended that she was actually claiming the varicose veins and lipedema/lymphedema disability when she wrote “bilateral leg conditions”). See April 2017 Statement; July 2017 Notice of Disagreement; September 2017 VA Form 9. However, the mere existence of a disability does not constitute a claim of service connection for such disability and VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. Brannon, 12 Vet. App. 32; Talbert, 7 Vet. App. 352. The Veteran’s May 2013 application for “bilateral leg conditions” was vague and unspecific. After the July 2014 VA examiners evaluated the Veteran and provided diagnoses, the AOJ reasonably interpreted the Veteran’s claim to be for her hips and knee. The Veteran had several opportunities to correct the AOJ’s interpretation of her claim, but failed to do so. The Veteran never communicated or indicated intent to apply for entitlement to service connection for a bilateral leg disability manifested by swelling, pain, and varicose veins until July 12, 2016. Accordingly, the date of claim for entitlement to service connection for bilateral lower extremity varicose veins and lipedema/lymphedema is July 12, 2016. As the Veteran did not file this claim within one year of discharge, the earliest effective date allowed by law is the date of receipt of the claim (July 12, 2016). 38 C.F.R. § 3.400. Thus, the Board must deny the claim. 3. Varicose Veins and Lipedema/Lymphedema of the RLE This issue is denied on the same reasons and bases described immediately above for the issue of entitlement to an earlier effective date for varicose veins and lipedema/lymphedema of the LLE. Increased Rating In determining the severity of a disability, the Board applies the criteria set forth in the Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C. 1155; 38 C.F.R. 4.1. If the disability more closely approximates the criteria for the higher of two ratings, the higher rating is assigned. 38 C.F.R. 4.7. 4. Varicose Veins and Lipedema/Lymphedema of the LLE Since the effective date of service connection (July 12, 2016), each lower extremity has been rated at 20 percent under DC 7120, which contemplates: persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. 38 C.F.R. § 4.104, DC 7120; February 2018 Codesheet. A 40 percent rating contemplates: persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent rating contemplates: persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 100 percent rating is the maximum schedular rating and contemplates: massive board-like edema with constant pain at rest. June 2014 and August 2014 records from Goshen Medical Center documented normal skin color without rash. An April 2015 record from Onslow Memorial Hospital also documented normal skin color. The February 2017 VA skin diseases examiner did not diagnose a skin condition, but noted the Veteran’s history of lipedema. The examiner observed no: dermatitis; eczema; bullous disorder; psoriasis; skin infections; cutaneous manifestations of collagen-vascular disease; papulosquamous disorder; acne; chloracne; vitiligo; alopecia; hyperhydrosis; tumors; or neoplasms. The February 2017 VA artery and vein conditions and hematologic and lymphatic conditions examiner diagnosed bilateral lower extremity varicose veins and lipedema. The examiner noted the following bilateral symptoms: aching and fatigue after prolonged standing and walking that is relieved through elevation; persistent edema that is incompletely relieved through elevation; persistent subcutaneous induration; and constant pain at rest. The examiner found no: beginning of persistent stasis pigmentation; beginning or persistent eczema; intermittent or persistent ulceration; or massive board-like edema. The examiner described the condition as: non-pitting, columnar-like swelling of extremities from lower anterior pelvis to buttocks to ankles; subcutaneous fatty nodular mass, non-tender on anterior thigh; bilateral cottage cheese or dimpling of buttocks and upper thighs; and bilateral sparred feet. The examiner opined that the condition impacts ability to work because: she falls and trips because her legs feel heavy from the lipedema; standing and sitting are limited from pain after five minutes; and she needs to shift positions. A March 2017 record from Onslow Surgical Clinic documented no: rash or itching; skin color changes; or change in hair, nails, or varicose veins. The provider recommended compression stockings and leg elevation when possible. An April 2017 record from the same provider documented symptoms of: bilateral lower extremity swelling in the legs with some pitting; better skin quality with less firm swelling; sparing of the feet; normal strength and gait; no cyanosis (skin discoloration); and normal capillary refill. The treatment plan consisted of using compression stockings daily and elevating the legs when possible. Another April 2017 record from the same provider documented the Veteran’s reports of improvement in pain and swelling after using a Tactical pump at least one hour per day on both lower extremities; the Veteran reported that she ordered the compression stockings, but they had not yet arrived, and that she does not take pain medication for lower extremity pain. The August 2017 VA hematologic and lymphatic conditions examiner diagnosed lymphedema and lipedema of the bilateral lower extremities. The Veteran described: her left leg larger than the right leg; a lump on her left leg; swelling around her ankles and very tight swelling from the knees to ankles without improvement through stockings or pump; leg rashes and pain; painful to touch around lower legs; and legs feeling heavy and tired. The Veteran also reported using pneumatic compression stockings and pumps daily. The examiner found no other signs or symptoms, but noted the Veteran’s fear of falling or legs giving out. In an October 2017 Correspondence, the Veteran described symptoms of: the appearance of rings around her ankles; fat pads on her knees and hips with chronic pain at rest; and the left leg larger than the right leg. An October 2017 record from Onslow Surgical Clinic showed active, daily treatment with compression stockings. During the December 2017 VA knee and lower leg conditions examination, the Veteran described weakness in her bilateral knees and swelling with pain in her bilateral knees and legs. In the February 2018 VA Form 9, the Veteran described symptoms of: heaviness and change in gait because of the fat pads on her legs, which has resulted in arthritis and frequent falls. In sum, the Board finds that the manifestations of the Veteran’s varicose veins and lipedema/lymphedema of the bilateral lower extremities most closely approximate those contemplated by a 20 percent rating. As previously delineated, a 40 percent rating requires evidence of persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. However, none of the evidence above, or any other VA or private records associated with the claims file, documents stasis pigmentation or eczema; thus, an increased rating of 40 percent is not warranted. Further, the 60 percent rating requires evidence of persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. However, none of the evidence above, or any other VA or private records associated with the claims file, documents stasis pigmentation, eczema, or ulceration; thus, an increased rating of 60 percent is not warranted. Finally, the 100 percent rating requires evidence of massive board-like edema with constant pain at rest. However, although the evidence documents constant pain at rest, none of the evidence above, or any other VA or private records associated with the claims file, documents massive board-like edema; thus, an increased rating of 100 percent is not warranted. 5. Varicose Veins and Lipedema/Lymphedema of the RLE This issue is denied on the same reasons and bases described immediately above for the issue of entitlement to an increased rating for varicose veins and lipedema/lymphedema of the LLE. 6. Chronic Pelvic Pain Syndrome Since the effective date of service connection (May 31, 2013), this disability has been rated as noncompensable under DC 7614, which contemplates: symptoms that do not require continuous treatment. 38 C.F.R. § 4.116, DC 7614, General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs; February 2018 Codesheet. A 10 percent rating contemplates: symptoms that require continuous treatment. A 30 percent rating is the maximum schedular rating and contemplates: symptoms not controlled by continuous treatment. Of note, the Veteran was already separately service connected for other C-section residuals, including urinary incontinence and scar; thus, the chronic pelvic pain syndrome rating specifically excludes those manifestations. A July 2013 record from Goshen Medical Center documented the Veteran’s report of abdominal pain; however, the provider attributed it to irregular bowel movements and encouraged the Veteran to try Metamucil. The June 2014 VA stomach and duodenal conditions examiner noted the Veteran’s reports of daily abdominal pain in the left side of the abdomen that sometimes increases in severity and feels like jumping/spasms. The examiner also noted that the Veteran’s treatment plan did not include taking continuous medication. An April 2015 record from Onslow Memorial Hospital documented the Veteran’s report of left side abdominal pain; however, a CT of the abdomen/pelvis was unremarkable except for a lot of stool seen in the right colon. The provider concluded that there was no acute process in the abdomen or pelvis and did not prescribe treatment. The February 2017 VA gynecological conditions examiner diagnosed chronic pelvic pain syndrome and noted symptoms of: moderate, constant pain; irregular menstruation; mild, diffuse tenderness upon pelvic examination; mild whitish physiologic discharge upon inspection; and urinary stress incontinence. The examiner also noted the Veteran’s reports of: stabbing pains twice per month and constant pain in her pelvic area, although she works through the pain. The examiner also: (a) noted the Veteran’s report that she had not had treatment for these symptoms; and (b) found that the Veteran did not currently require treatment or medications for her symptoms. In the May 2017 Notice of Disagreement, the Veteran contended continuous treatment of her chronic pelvic pain syndrome because she used her compression therapy device for her leg condition and pelvic condition. The Veteran attached a general diagram that described how leg devices can include enhanced programming and an additional core accessory to extend treatment into the trunk region when clinically appropriate. In a July 2017 Correspondence attached to the July 2017 VA Form 9, the Veteran described a pins and needles pain and stated that the decongestive therapy device prescribed for her bilateral leg condition also wraps around and compresses her abdomen. An October 2017 record from Fayetteville VAMC documented the Veteran’s report of abdominal/pelvic pain, but an ultrasound and laparoscopy were normal. The provider did not prescribe any pertinent treatment. In, sum, the Board finds that the manifestations of the Veteran’s chronic pelvic pain syndrome most closely approximate those contemplated by a noncompensable rating. As previously delineated, the 10 percent and 30 percent ratings both require evidence that the condition requires continuous treatment. However, none of the evidence previously discussed, or any other VA or private records associated with the claims file, documents a requirement for continuous treatment specific to this condition. Although the Veteran contended that her leg therapy device also compresses her abdomen, her compression stockings and pump device were only prescribed as treatment for her varicose veins and lipedema/lymphedema of the bilateral lower extremities, not as treatment for her abdominal/pelvic pain. Thus, a compensable rating is not warranted. REASONS FOR REMAND 1. Right Knee Patellofemoral Syndrome The July 2017 VA examiner rendered a negative nexus opinion for the right knee disability, explaining that review of medical literature and research resulted in no known direct causation or correlation between the right knee disability and the service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities. However, the Board finds this opinion inadequate because it did not specifically consider: (a) potentially favorable medical literature submitted by the Veteran; or (b) her November 2015 Notice of Disagreement contention that the right knee disability was caused by strenuous physical training during service. See Lipedema and Joint Complications, The Lipedema Liposuction Center, Undated (patients with lipedema often experience joint pain in the hips, knees, and ankles due to the excessive weight of fat and fluid accumulation; over a period of time, normal posture is compromised as the body attempts to adjust to a more comfortable position when walking or at rest; this abnormal adjustment places pressure on the joints and soft tissue resulting in pain with inflammation; common symptoms include degenerative changes in the joints due to wrongly placed stress and excess weight); Liposuction of Lipedema to Prevent Later Joint Complications (English Translation), Vasomed, Volume 23, January 2011 (osteoarthritis of the large leg joints represents the most severe orthopedic complication of lipedema); Treatment for Lipoedema, The Lymphoedema Clinic London, Undated (lipedema may cause joint pain, particularly in the knees, pins and needles sensation, flat feet, restricted mobility, and osteoarthritis in the hips or knees); Recognition, Diagnosis and Treatment of Lipodema Vs. Lymphoedema, Lymphoedema Association of Australia (knee joints may be affected by both lymphoedema and extra leg weight and may cause pain such as arthritis); Lipedema Fat and Signs and Symptoms of Illness, Increase with Advancing Stage, University of Arizona Department of Medicine; Lipedema Description, Fat Disorders Research Society; Lymphedema vs. Lipedema, Plastic and Reconstructive Surgery, Jay W. Granzow, MD. Thus, remand is required to obtain an adequate nexus opinion. 2. Left Knee Osteoarthritis The January 2018 VA examiner rendered a negative nexus opinion for the left knee disability, explaining that: (a) the left knee disability and the service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities are entirely separate entities and medically unrelated; and (b) medical literature does not support a medical relationship. However, the Board finds this opinion inadequate because it did not specifically consider the potentially favorable medical literature submitted by the Veteran. See Lipedema and Joint Complications, The Lipedema Liposuction Center, Undated; Liposuction of Lipedema to Prevent Later Joint Complications (English Translation), Vasomed, Volume 23, January 2011; Treatment for Lipoedema, The Lymphoedema Clinic London, Undated; Recognition, Diagnosis and Treatment of Lipodema Vs. Lymphoedema, Lymphoedema Association of Australia; Lipedema Fat and Signs and Symptoms of Illness, Increase with Advancing Stage, University of Arizona Department of Medicine; Lipedema Description, Fat Disorders Research Society; Lymphedema vs. Lipedema, Plastic and Reconstructive Surgery, Jay W. Granzow, MD. Thus, remand is required to obtain an adequate nexus opinion. 3. Chronic Left Wrist Sprain The July 2017 VA examiner rendered a negative nexus opinion for the left wrist disability, explaining that review of medical literature and research resulted in no known direct causation or correlation between the left wrist disability and the service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities. However, the Board finds this opinion inadequate because it did not specifically consider: (a) potentially favorable medical literature submitted by the Veteran; or (b) her January 2015 Statement and November 2015 Notice of Disagreement contention that the left wrist disability was caused by typing while a Morse code operator during service. See Lipedema and Joint Complications, The Lipedema Liposuction Center, Undated; Liposuction of Lipedema to Prevent Later Joint Complications (English Translation), Vasomed, Volume 23, January 2011; Treatment for Lipoedema, The Lymphoedema Clinic London, Undated; Recognition, Diagnosis and Treatment of Lipodema Vs. Lymphoedema, Lymphoedema Association of Australia; Lipedema Fat and Signs and Symptoms of Illness, Increase with Advancing Stage, University of Arizona Department of Medicine; Lipedema Description, Fat Disorders Research Society; Lymphedema vs. Lipedema, Plastic and Reconstructive Surgery, Jay W. Granzow, MD. Thus, remand is required to obtain an adequate nexus opinion. 4. Chronic Right Wrist Sprain The July 2017 VA examiner rendered a negative nexus opinion for the right wrist disability, explaining that review of medical literature and research resulted in no known direct causation or correlation between the right wrist disability and the service-connected varicose veins and lipedema/lymphedema of the bilateral lower extremities. However, the Board finds this opinion inadequate because it did not specifically consider: (a) potentially favorable medical literature submitted by the Veteran; or (b) her January 2015 Statement and November 2015 Notice of Disagreement contention that the right wrist disability was caused by typing while a Morse code operator during service. See Lipedema and Joint Complications, The Lipedema Liposuction Center, Undated; Liposuction of Lipedema to Prevent Later Joint Complications (English Translation), Vasomed, Volume 23, January 2011; Treatment for Lipoedema, The Lymphoedema Clinic London, Undated; Recognition, Diagnosis and Treatment of Lipodema Vs. Lymphoedema, Lymphoedema Association of Australia; Lipedema Fat and Signs and Symptoms of Illness, Increase with Advancing Stage, University of Arizona Department of Medicine; Lipedema Description, Fat Disorders Research Society; Lymphedema vs. Lipedema, Plastic and Reconstructive Surgery, Jay W. Granzow, MD. Thus, remand is required to obtain an adequate nexus opinion. The matters are REMANDED for the following action: 1. For all remanded claims, obtain addendum nexus opinions that specifically consider the potentially favorable medical literature submitted by the Veteran and her contentions of in-service injury (pertinent July 2017 and January 2018 opinions are inadequate for the reasons discussed above in the Remand body). 2. Readjudicate the appeal. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Daus, Associate Counsel