Citation Nr: 20052913 Decision Date: 08/10/20 Archive Date: 08/10/20 DOCKET NO. 16-20 963 DATE: August 10, 2020 REMANDED Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for muscle spasms, to include as due to Gulf War environmental hazard exposure is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1989 to November 1993. This matter came before the Board of Veterans Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veteran’s Law Judge during an August 2019 hearing. The transcript of the hearing is of record. A January 2020 Board decision granted service connection for left and right knee disabilities and remanded the issues of service connection for muscle spasms and left shoulder and left elbow disabilities for further development. The Board notes that at the August 2019 Board hearing, the Veteran stated on the record that he was dropping the contention that his left shoulder and left elbow disability were due to exposure to Gulf War environmental hazards. The Board has recharacterized those issues accordingly. 1. Entitlement to service connection for a left elbow disability A January 2020 VA examination diagnosed left medial epicondylitis. The examiner found that the Veteran’s left elbow disability was not due to service, stating that there was no evidence of chronicity during service and after and that it was therefore not likely incurred in service and also was not likely due to wear and tear from loading/unloading during service. Since the January 2020 examinations, the Veteran submitted his June 1992 Army Physical Fitness scorecards which showed a decrease in scores before and after deployment and noted that the Veteran had joint pains and spasms since returning from the Gulf. Particularly as the January 2020 opinion relied on a lack of evidence of chronicity of elbow pain and after service, the Board finds that the issue should be remanded for a new examination to consider the new evidence of record. 2. Entitlement to service connection for a left shoulder disability A January 2020 VA examination diagnosed bilateral shoulder strain and left shoulder arthritis. The examiner noted the Veteran’s reports of pain during deployment and doing a lot of lifting and carrying. The examiner opined that there was no evidence of left shoulder disability due to wear and tear and loading and unloading during service. The examiner also found that the degenerative changes shown in the February 2020 left shoulder x-ray were not due to service. The Board notes that the examiner did not provide an explanation for either of these conclusions. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Remand for a new examination and opinion is therefore required. In addition, as noted above, since the January 2020 examination the Veteran submitted June 1992 Army Physical Fitness scorecards noting joint pain since deployment. That evidence should also be addressed upon remand. 3. Entitlement to service connection for muscle spasms, to include as due to Gulf War environmental hazard exposure A January 2020 examination diagnosed muscle spasms of unknown etiology but found that they were not likely due to exposures in Southwest Asia as they were a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner further stated that muscle spasms were common and often due to overuse and muscle fatigue, dehydration and electrolyte abnormalities. In a separate January 2020 opinion, the examiner also opined that spasms were not due to service as there was no evidence of spasms in service and continuing after. The Board notes that the report is inconsistent as the examiner diagnosed muscle spasms of unknown etiology and then opined that the etiology was partially explained. The report is silent for an explanation of the difference in findings between the diagnosis and the opinion. In addition, as noted above since the examination the Veteran submitted his June 1992 Army Physical Fitness scorecards noting spasms since deployment. The Board therefore finds that the issue should be remanded to consider the additional evidence and to clarify the Veteran’s diagnosis. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current left elbow and left shoulder disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current left elbow or left shoulder disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service, to include whether it is due to wear and tear from loading and unloading supplies and equipment as part of the Veteran’s MOS. The opinion should address the June 1992 Army Physical Fitness scorecards submitted by the Veteran noting joint pain since deployment. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. 2. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current muscle spasm disability. The examiner should review the file and provide a complete rationale for all opinions expressed. In providing all opinions, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. The following opinions are requested: a) For any current muscle spasm disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service, to include whether it is related to environmental exposures in Southwest Asia. The opinion should address the June 1992 Army Physical Fitness scorecards submitted by the Veteran noting spasms since deployment b) If no diagnosed disability is found, the examiner should indicate whether the reported muscle spasms constitute signs and symptoms of an undiagnosed disability or medically unexplained multi-symptoms illness (MUCMI). a. If the examiner finds an undiagnosed disability or MUCMI, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service, to include environmental exposures in Southwest Asia. b. If the examiner does not find signs and symptoms of an undiagnosed illness or MUCMI, the examiner should explain why. 3. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Arnold, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.