Citation Nr: 21002006 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-25 537 DATE: January 12, 2021 ORDER Service connection for fibromyalgia is granted. REMANDED The claim for service connection for a right knee disability is remanded. FINDING OF FACT The weight of the evidence of record shows that it is at least as likely as not that the Veteran’s fibromyalgia was proximately caused by his service-connected post-traumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for fibromyalgia have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran honorably served on active duty from July 1987 to July 1991. In an August 2014 rating decision, the Regional Office (RO) denied his claim for service connection for fibromyalgia. In February 2019, he testified via a videoconference Board hearing, a transcript of which is of record. In September 2019, the Board remanded the claim for a supplemental medical opinion which the was obtained in July 2020. The July 2020 examination report reflects the examiner’s opinion that the Veteran’s clinical history is consistent with his genetic predisposition to fibromyalgia and his associated manifestation of psychiatric co-conditions that are known to trigger fibromyalgia. The examiner explains that fibromyalgia is a genetic disease which is usually triggered by physical trauma and psychosocial stressors encompassing a number of psychiatric disorders such as ADD/ADHD, anxiety disorder, depression, panic disorder, and PTSD. The examiner then emphasized that the literature fully supports the emotional stressors as triggers for fibromyalgia, whereas the Veteran’s records show a significant history of physical, emotional, and sexual abuse. Based on this medical opinion, absent any affirmative evidence to the contrary, the Board finds that it is at least as likely as not the Veteran’s fibromyalgia has been triggered by his service-connected PTSD with chronic delayed phase sleep syndrome and traumatic brain injury (TBI). Service connection is granted for a disability proximately caused by or resulting from an existing service-connected disability. See 38 C.F.R. § 3.310. Accordingly, service connection for fibromyalgia is granted. REASONS FOR REMAND Having considered the July 2020 examination report noting that the Veteran’s right knee pain may be etiologically related to his now service-connected fibromyalgia, the Board finds that an addendum medical opinion is necessary to decide the claim. Of note, the July 2020 report is further incomplete, as it appears to acknowledge but not to factor into the analysis the material facts potentially favorable to the Veteran. The Veteran has been diagnosed with degenerative joint disease in his right knee in 2016. His STRs reflect that in August 1989 he was involved in an accident on a dirt bike when it suddenly spun out from underneath him and causing him to strike his right knee. The STRs note that the Veteran was experiencing quite a bit of pain in the medial aspect of the knee, while he had not experienced any previous injuries to that area. At the time, the Veteran was diagnosed with sprained medial ligament of the right knee and his knee was placed in a knee immobilizer. In September 1989, the Veteran was again seen for complaints of right knee pain. The progress note reflects that the pain was resolving, but he showed negative laxity in his right knee as compared to his left knee. The July 2020 report does not address this evidence beyond acknowledging that the Veteran had right knee complaints during active service and then summarily concluding there were no further knee complaints for the remaining 2 years and had no knee complaints at the time of separation from active service. However, notwithstanding the September 1989 report of resolving pain, the STRs reflect the October 1989 progress notes from two discrete visits about two weeks apart and showing that continuing right knee pain is unimproved. Then, a February 1990 physical examination report reflects a history of a “trick” knee. The examiner then notes that the Veteran’s statement that after service he continued having the same pain that was getting worse with exercise. He would ice and put Bengay and other creams, but the knee pain has always been a problem. As such, despite the absence of the complaints of knee problems documented at separation, the Veteran’s STRs coupled with his competent reports as to the right knee pain suggest the possibility an ongoing knee problem possibly originating from the motorcycle accident and conceivably aggravated by his weight gain in service. Further, noting that the Veteran had gained 50 pounds in service and identifying obesity as an added factor for Veteran’s right knee pain, the examiner has not provided any rationale for the conclusion that such a factor is the Veteran’s post-service obesity rather than his weight gain of 50 pounds in service. As such, the Board finds that the July 2020 report is incomplete and thus triggers the VA’s duty to obtain an addendum medical opinion. Accordingly, the matter is REMANDED for the following action: Obtain a supplemental medical opinion as to the etiology of the Veteran’s right knee disability. The examiner is asked to answer the following questions: a) Is it at least as likely as not (meaning probability of 50 percent or greater) that the Veteran’s current right knee disability was incurred in or due to service, to include his right knee injury sustained in a motorcycle accident and/or wight gain of 50 pounds in service? Why or why not? In answering the Board’s questions, the examiner is asked to consider the Veteran’s lay statements as to the continuity of symptomatology associated with his right knee pain. b) Is it at least as likely as not (meaning probability of 50 percent or greater) that the Veteran’s current right knee disability was proximately caused by or resulted from his fibromyalgia? Why or why not? c) Is it at least as likely as not (meaning probability of 50 percent or greater) that the Veteran’s current right knee disability was aggravated (made worse) by his fibromyalgia? Why or why not? If aggravation is found, the examiner is asked to specify the disability baseline prior to aggravation and then indicate a measurable increase in the severity level resulting from aggravation since formatting, to be expressed insofar as practicable in the regulatory terms such as limitation in the range of motion. If such a determination cannon be made or cannot be made without resorting to speculation, the examiner is asked to explain why. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alex Bardin, 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.