Citation Nr: 1806366 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 10-44 603 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right knee disability claimed as secondary to service-connected left knee disability. 2. Entitlement to service connection for erectile dysfunction claimed as secondary to medications for service-connected left knee and low back disabilities. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for bilateral lower extremity radiculopathy claimed as secondary to service-connected low back disability. 5. Entitlement to a rating in excess of 10 percent for service-connected left knee degenerative joint disease (DJD) (left knee disability). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD M. Yuan, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1981 to January 1985. These matters are before the Board of Veterans' Appeals (Board) on appeal from October 2009 and October 2010 rating decisions of a Department of Veteran Affairs (VA) Regional Office (RO). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Regarding the right knee disability on appeal, the Board notes that the July 2010 VA examination report includes an inadequate nexus opinion that does not properly address all facets of the Veteran's secondary theory of entitlement. Instead, the examiner only opines as to whether the Veteran's diagnosed right knee disability is caused by service-connected left knee disability. Thus, a new examination is needed. On July 2010 VA genitourinary examination, the examiner opined that the Veteran's erectile dysfunction is unrelated to his low back disability, noting that it is more likely of a multifactorial etiology, to include his nonservice-connected diabetes or certain medications (but does not specify which medications, precisely). However, the Veteran subsequently contended specifically that his erectile dysfunction is either caused or aggravated by medications prescribed for his low back and left knee disabilities. Thus, a new examination is needed that addresses this new theory of contention. On July 2010 VA cardiovascular examination, the Veteran was found to have hypertension that the examiner opined was unrelated to his service because hypertension was first diagnosed in 2007 and there were only two isolated instances of elevated blood pressure in May 1983 (134/102) and September 1983 (140/102), which was not felt to constitute persistent hypertension. However, a review of the record shows there were additional notations of elevated blood pressure that were not considered by the examiner during that examination (May 1983-118/90, November 1983-140/110, and, most notably, a borderline reading of 125/90 on separation examination). Thus, a new examination is needed. With respect to the Veteran's claimed lower extremity radiculopathy, the medical evidence is unclear as to whether the Veteran actually has such a disability. Notwithstanding the August 2009 VA examination report indicating no lower extremity neurological problems were found on nerve conduction and electromyography (EMG) testing, the Board notes that MRIs as early as March 1993 suggest neurological involvement of low back nerve roots associated with right leg complaints. Specifically, there is a March 1993 record indicating fasciculations in the right L5-S1 lumbosacral paraspinal muscles and fibrillation and fasciculation in the right extensor hallucis longus; a February 2008 VA spine examination report noting positive Lasegue's sign (which suggests disc herniation and, in turn, possible radicular or neuropathic symptoms); and a February 2008 MRI suggesting impingement of the left L4 and L5 nerve roots, all of which suggest some neurological involvement that could account for the lower extremity symptoms the Veteran reports. The August 2009 VA examination does not reconcile its negative findings with the records noted above or otherwise consider or discuss their significance. Thus, a new examination is needed. Finally, the Veteran's most recent examination assessing his left knee disability was in July 2010. As he has continued to receive treatment for that disability since then, records of such treatment suggest it has worsened, and the Veteran himself submitted an October 2010 statement suggesting his disability had worsened, the Board finds a contemporaneous examination is needed. Accordingly, the case is REMANDED for the following action: 1. Obtain all updated records of VA or adequately identified private evaluations or treatment the Veteran has received for the disabilities remaining on appeal. 2. Then, arrange for the Veteran to be examined by a neurologist to determine the nature and likely etiology of his claimed bilateral lower extremity radiculopathy. Based on an examination, review of the record, and any tests or studies deemed necessary (including, but not limited to, nerve conduction or EMG tests), the examiner should provide opinions responding to the following: a. Does the Veteran currently have neurological disability or involvement either the right or left lower extremity? b. If so, please opine whether such is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) related to the Veteran's service-connected low back disability. In resolving the diagnostic and etiological questions posed above, the examiner should also consider and discuss the positive evidence in the record, including-but not limited to-March 1993 records documenting fasciculation of the lumbar paraspinal muscles, fibrillation and fasciculation in the right extensor hallucis longus; a February 2008 VA spine examination report noting positive Lasegue's sign and reduced reflexes in the lower extremities; and a February 2008 MRI suggesting impingement of the left L4 and L5 nerve roots. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 3. Then, arrange for the Veteran to be examined by an orthopedist to determine the nature and likely etiology of his right knee disability and the current severity of his left knee disability. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should provide opinions responding to the following: a. Please identify, by medical diagnosis, each right knee disability entity found. b. For each right knee disability entity diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is CAUSED BY OR PROXIMATELY DUE TO his service-connected left knee disability, to include as a result of compensating for such disability by using the right knee. c. For each right knee disability entity diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is AGGRAVATED BY his service-connected left knee disability, to include as a result of compensating for such disability by using the right knee. The examiner should also describe all left knee pathology, symptoms (frequency and severity), and associated impairment of function in sufficient detail to allow for application of the pertinent rating criteria. Range of motion studies must be completed, and must include active and passive motion and weight-bearing and non-weight-bearing. The examiner should also note any further functional limitations due to pain, weakness, fatigue, incoordination, or any other such factors. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 4. Then, arrange for the Veteran to be examined by an urologist to determine the nature and likely etiology of his erectile dysfunction. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should respond to the following: a. Please identify and note all medications that the Veteran takes or has been prescribed for his low back and left knee disabilities. b. Then, the examiner should opine as to whether the Veteran's erectile dysfunction is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) CAUSED OR AGGRAVATED BY medications prescribed for his low back and left knee disabilities. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 5. Then, arrange for the Veteran to be examined by a cardiologist to determine the nature and likely etiology of his hypertension. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's hypertension is related to his military service or notations of elevated blood pressure therein, to include-but not limited to-readings in May 1983 (134/102), September 1983 (140/102), May 1983 (118/90), November 1983 (140/110), and on separation examination (125/90). A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 6. The AOJ should then review the record and readjudicate the claims. If any remain denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative opportunity to respond, and return the record to the Board. The Veteran has the right to submit additional evidence and argument on the remanded matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). As a remand, this matter must be handled expeditiously. 38 U.S.C.A. §§ 5109B, 7112 (2014). _________________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Only a decision of the Board of Veterans' Appeals can be appealed to the United States Court of Appeals for Veterans Claims. 38 U.S.C.A. § 7252 (West 2014). This remand is a preliminary order and not an appealable decision on the merits of the claim(s). 38 C.F.R. § 20.1100(b) (2016).