Citation Nr: 1808309 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 09-38 165 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a disability manifested by chronic joint pain, claimed as secondary to service-connected diabetes mellitus and peripheral neuropathy of the upper and lower extremities. REPRESENTATION Appellant represented by: Jan D. Dils, Attorney ATTORNEY FOR THE BOARD M. G. Perkins, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1968 to May 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. Jurisdiction has subsequently transferred to the Roanoke, Virginia RO. This matter was most recently before the Board in December 2016 and remanded for further development. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Further development is required prior to adjudicating the claim. The rationales from the previous VA medical opinions are inadequate; a supplemental opinion is warranted. Barr v. Nicholson, 21 Vet. App. 303 (2007). In December 2016, the Board remanded the Veteran's claim to afford the Veteran a VA examination to determine whether he has a current disability affecting the joints and, if so, whether it was caused or aggravated his service-connected diabetes mellitus and peripheral neuropathy of the upper and lower extremities. The remand also sought clarification from the examiner's December 2013 opinion where the examiner stated that the Veteran's service-connected diabetes and peripheral neuropathy did not cause or aggravate the Veteran's joint pain, but the rationale referenced medical literature that suggests that diabetes may cause or aggravate diabetes. In response, the examiner opined in January 2017, that "... diabetes may [be] listed as aggravation but not causing osteoarthritis and not included in list of cause of osteoarthritis ..." The examiner also noted that diabetes causes musculoskeletal changes that lead to symptoms such as joint pain and stiffness. These references to the medical literature conflict with the examiner's opinion that the Veteran's diabetes did not aggravate his joint pain. On remand the RO should schedule the Veteran for a VA examination to determine whether his service-connected diabetes or peripheral neuropathy caused or aggravated his joint pain. The examiner should also identify the specific joints involved. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination (with a different examiner from the examiner who offered the January 2017 opinion, if possible) to determine the nature and likely etiology of his claimed chronic joint pain. Forward the claims file and copies of all pertinent records to the examiner. Based on a review of the record and examination of the Veteran, the examiner should address the following: (a) List all, if any, diagnoses for the Veteran's chronic joint pain. The examiner should ask the Veteran to identify what he considers all affected joints. (b) Is it as least as likely as not that any diagnosed chronic joint pain is causally related to active service? (c) If the answer to (b) is no, then is it at least as likely as not that any diagnosed chronic joint pain was caused or aggravated by the Veteran's service-connected diabetes or peripheral neuropathy? The examiner is informed that aggravation here is defined as any increase in disability. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. The examiner is also advised that the Veteran is competent to provide evidence of symptomatology readily apparent to him, regardless of whether the symptoms are noted in the service medical records or on the date of examination. In answering the above questions, the examiner should specifically consider, and discuss as necessary, the following: (i) the December 2013 VA examiner's reference to medical literature suggesting an association between osteoarthritis and diabetes; (ii) the January 2017 VA examiner's opinion that per the Mayo clinic, diabetes and peripheral neuropathy may contribute to various bone and joint disorders; (iii) medical literature submitted by the Veteran on January 20, 2014 linking diabetes to joint pain, and: (iv) the July 2001 article from the American Diabetes Association, submitted by the Veteran on January 20, 2014 stating that diabetes can cause musculoskeletal changes causing joint pain. Any opinion expressed by the VA examiner must be accompanied by a complete rationale. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 2. Thereafter, readjudicate the claim. If any benefit sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case and an opportunity to respond. Then return the case to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter 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. §§ 5109B, 7112 (2012). _________________________________________________ M. E. LARKIN 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).