Citation Nr: 21004077 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 14-06 817 DATE: January 25, 2021 REMANDED Entitlement to service connection for a neurological disability of the bilateral upper extremities (BUE) is remanded. Entitlement to service connection for a neurological disability of the bilateral lower extremities (BLE) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1969 to January 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of an August 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2018 and June 2020, the Board remanded the claims for additional development. 1. Entitlement to service connection for a BUE neurological disability. 2. Entitlement to service connection for a BLE neurological disability. Issues 1 & 2: The Veteran contends that his upper and lower extremity disabilities are related to service. Specifically, he contends that they are related to in-service events and/or injuries: (1) an illness he had in Okinawa; (2) jet fuel exposure when he attempted to assist the crew of the plane (the Veteran reported in a February 2010 statement that he witnessed a cargo plane crash during service); and (3) symptoms of hand tremor that started during service. The Board finds that remand is again necessary as neither the April 2019, with a July 2019 addendum, nor the July 2020 VA opinion (VAMO) is adequate. 38 C.F.R. § 3.159(c); Stegall v. West, 11 Vet. App. 268 (1998). Most recently, in June 2020, the Board remanded the Veteran’s claims, finding that the 2019 VA examination and addendum opinion provided speculative findings, with instructions for a medical opinion to (1) provide whether the Veteran’s in-service jet fuel exposure had any impact on his development of peripheral neuropathy, (2) specifically comment on the lay statements of record, and (3) state whether the need to speculate is due to a deficiency in the state of general medical knowledge, the record, or the examiner does not have the knowledge or training. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). It is uncontroverted that the Veteran has current diagnoses of bilateral upper and lower extremity neurological disability, including chronic sensorimotor polyneuropathy, carpal tunnel syndrome and peripheral neuropathy. Further, in July 2010, the RO confirmed the plane crash incident reported by the Veteran. Service treatment records (STRs) reflect complaints of leg swelling. A July 1969 STR at service entry noted right leg swelling after an auto accident. See STR-Medical (November 2009). A June 1971 STR shows that the Veteran reported persistent leg swelling and back pain. Id. A February 1973 VA examination report reflects histor of back pain and left leg pain, with an occurrence in January 1973 of pain in the left calf which felt like the muscles were being squeezed and lasted about 15 minutes. See VA Examination (February 1973). An April 1973 report of medical history at service separation reflects history of leg cramps and treatment for crabs in Okinawa in 1970. Post-service treatment records reflect various diagnoses of the upper extremities, including peripheral neuropathy, chronic neuropathic pain, essential tremor, carpal tunnel syndrome, and Raynaud’s syndrome. A May 2003 VA treatment shows a diagnosis of chronic neuropathic pain to lower extremities; status post carpal tunnel syndrome; and Raynaud’s syndrome per Veteran. See Medical Treatment Record - Government Facility (August 2012). A June 2003 VA treatment record shows that the Veteran reported a history of febrile illness and chills during service. Id. A March 2012 lay statement from the Veteran’s brother noted that the Veteran had a noticeable tremor after he got out of the Air Force. Although an April 2019 VA examination, with a July 2019 addendum, and a July 2020 VA medical opinion (VAMO) were obtained, they are inadequate because the negative conclusions reached are not supported with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25. Further, the examination and opinions do not contain clear conclusions and provide no reasoned medical explanation connecting the conclusion to any identified supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). First, the VAMOs do not address whether the Veteran’s carpal tunnel syndrome is attributable to his active duty service. While the July 2020 VAMO noted medical history significant for bilateral carpal syndrome, it did not provide etiology of the diagnosed carpal tunnel syndrome, which is a neurological disorder of the upper extremities. Moreover, the etiology for the Veteran’s Raynaud’s phenomenon, if present, has not been addressed. It is noted that the “other organic diseases of the nervous system” are considered chronic diseases under 38 C.F.R. § 3.309 and, by virtue thereof, are entitled to consideration of the entitlement on a presumptive basis under 38 C.F.R. § 3.307(a) and § 3.309(a). On remand, an opinion should be obtained addressing whether carpal tunnel syndrome and/or Raynaud’s disease began in service, manifested to a compensable degree within one year after the Veteran’s discharge or is otherwise etiologically related to in-service injury or disease, with consideration of the theories advanced by the Veteran. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Second, the VA examination and opinions relied on normal findings at enlistment and separation to support the negative conclusion reached. Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). The April 2019 VA examination and the July 2020 VAMO do not reflect any meaningful consideration of lay statements indicating that the Veteran began experiencing symptoms of peripheral neuropathy in service and has since experienced similar symptoms. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) (“the VA examiner’s failure to consider [the Veteran’s] testimony when formulating her opinion renders that opinion inadequate.”). Significantly, the VAMO makes no mention of the Veteran’s lay statements, despite the Board’s specific instructions to do so. See Stegall, supra. Third, the July 2020 VAMO was based on general medical studies from the American Journal of Medicine without addressing the Veteran’s specific disability picture. See Bailey v. O’Rourke, 30 Vet. App. 54, 60 (2018). While the examiner acknowledged that exposure to “these chemicals” can cause peripheral neuropathy, “it should be noted that 74% of the Veterans did not have this finding. Thus, this Veteran may be affected by other causes of peripheral neuropathy.” The opinion here provides no clear conclusion and no adequate application of the medical studies to the Veteran’s particular circumstances. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (although general medical research may be considered, it cannot be the sole basis for examiner’s conclusion). Fourth, the July 2020 VAMO provides that “we do not have a definitive cause for this… I cannot assign a single cause to the Veteran’s symptoms and peripheral neuropathy.” The Board observes that service connection may still be established if in-service injuries or service incurrence are one of the causes of the Veteran’s disability, even if it is not the only cause. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001); 38 C.F.R. § 4.2. The July 2020 VAMO clearly assumed that there can be only one cause of the Veteran’s disability, and that his in-service complaints of pain and/or jet fuel exposure could not be one of the causes. See, e.g., Taylor v. McDonald, 27 Vet. App. 158, 166 (2014) (faulting the Board, with respect to a claim that a current disability was caused by in-service exposure to Agent Orange, for relying on a medical opinion suggesting that the disability was related to an intervening post-service infection, where the opinion did not discuss the possibility of Agent Orange as a contributory cause). The examiner’s opinion shows that he did not entertain the possibility that the Veteran’s in-service assessment with pain and muscle discomfort were one of the causes even if not the sole cause of his claimed peripheral neuropathy. Therefore, the medical opinion is inadequate. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Significantly, the Board specifically asked for an opinion to provide whether the Veteran’s in-service jet fuel exposure had any impact on his development of peripheral neuropathy. Such has not been accomplished. See Stegall, supra. Given the above, and to ensure that VA has met its duty to assist, remand is necessary. Accordingly, the matters are REMANDED for the following action: 1. Obtain all the Veteran’s VA treatment records from April 2020 to the Present. 2. Thereafter, obtain an addendum opinion from an appropriate clinician who has not examined the Veteran in connection with this appeal to determine the nature and etiology of the Veteran’s BLE and BUE disability. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Detail the Veteran’s reported symptoms in service and thereafter, including the nature, onset, progression and severity of his reported symptoms; if there is any medical reason to accept or reject the proposition that his reported symptoms in service and thereafter represented the onset of any current neurological disability of the upper and/or lower extremities, this should be noted. The clinician should opine on the following: Whether the Veteran has a neurological disorder of the upper and/or lower extremities, to include carpal tunnel syndrome and/or Raynaud’s disease, that at least as likely as not (a) began in service, (b) manifested to a compensable degree within one year after the Veteran’s discharge, or (c) is otherwise etiologically related to in-service injury or disease. Consider Veteran’s report that he had: (1) an illness he had in Okinawa; (2) exposure to jet fuel exposure when he attempted to assist the crew of the plane; and (3) symptoms of hand tremor that started during service. Indicate whether the Veteran’s report of symptoms align with how the currently diagnosed disability is known to develop or are his reports generally inconsistent with medical knowledge or implausible. Explain. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). NOTE 1: An in-service event or injury or disease (e.g. the Veteran’s documented in-service notations of pain and confirmed exposure to jet fuels) do not need to be the only cause of the current disability, but must be at least as likely as not that one of the causes. NOTE 2: Reliance on the absence of medical literature supporting nexus without discussing the specific facts of the case renders an opinion inadequate. 3. Ensure that the VA medical opinions obtained includes a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin 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.