Citation Nr: 21004226 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 13-32 747 DATE: January 26, 2021 REMANDED Entitlement to service connection for bilateral arm/hand disorder, to include carpal tunnel syndrome (CTS), to include as secondary to service-connected Raynaud's phenomenon, and to include as secondary to contaminated water exposure at Camp Lejeune, North Carolina, is remanded. Entitlement to service connection for a right leg disorder, to include right leg neuropathy, to include as secondary to service-connected knee disability, to include as secondary to service-connected Raynaud's phenomenon, and to include as secondary to contaminated water exposure at Camp Lejeune, North Carolina, is remanded. Entitlement to service connection for a back disorder, to include osteoarthritis arthritis and degenerative disc disease, to include as secondary to service-connected knee disability, to include as secondary to service-connected Raynaud's phenomenon, and to include as secondary to contaminated water exposure at Camp Lejeune, North Carolina, is remanded. REASONS FOR REMAND The Veteran had active service from January 1982 to July 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2009 Rating Decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran seeks entitlement to service connection for bilateral arm/hand disorder, a right leg disorder, and a back disorder. Unfortunately, the Board finds that additional development must be undertaken before these claims can be adjudicated on the merits. The Veteran underwent the most recent VA examination for his hands in July 2014. At that time, the examiner opined that the Veteran's bilateral CTS was less likely as not caused or aggravated by his service or service-connected condition. In support of this conclusion, the examiner stated that the Veteran developed CTS many years after discharge from service, and that his general arthritis more likely than not caused his bilateral CTS. The examiner added that Raynaud’s syndrome did not cause or aggravate CTS, and that the Veteran's current bilateral hand condition was less likely as not related to his service and service-connected condition, and more likely than not caused by his general arthritis and the aging process. The Veteran also underwent a back VA examination in July 2014. At that time, the examiner opined that the Veteran’s osteoarthritis and degenerative disc disease were less likely as not related to, or aggravated by, his service or service-connected conditions. The examiner stated that the Veteran was 50 years old and had general arthritis and degenerative disc disease that started in 2000, which was "many years after his discharge." The examiner additionally opined that being very active during a young age did not increase the chance of arthritis in older age; as such, the Veteran's degenerative disc disease and osteoarthritis were part of the natural aging process and less likely as not aggravated or started by his service or other service connected conditions. In an August 2014 addendum opinion, the VA examiner stated that the Veteran did not have any neurological diagnosis except degenerative disc disease and osteoarthritis of the lumbar spine. The examiner stated that the Veteran’s lower back pain radiated to his leg occasionally, but did not warrant a separate neurological diagnosis. The examiner opined that the Veteran's symptoms were less likely as not related to or aggravated by his service, and more likely as not caused by other non-service connected causes. In its December 2017 Remand, the Board found that additional addenda were required to the VA examinations that the Veteran underwent in July 2014. First, the Board noted that the VA examiner failed to opine as to whether the Veteran had any other bilateral arm disorders (other than CTS), and whether those disorders were related to the Veteran's active service, or to any of his service-connected disabilities. Second, the Board emphasized that the July 2014 VA examiner who examined the Veteran’s back based the entire opinion on an incorrect premise that the Veteran served on active duty for only one year. Furthermore, the VA examiner failed to opine as to whether the Veteran had any other right leg disorders (other than radiation of low back pain), and whether those disorders were related to the Veteran's active service, or to any of his service-connected disabilities. Finally, the Board noted that the Veteran’s representative indicated that the Veteran used a cane on a regular basis to maintain his balance due to abnormal gait from his service-connected knee disabilities, and argued that constant use of an assistive device can aggravate a current condition beyond the natural progression. In support of this argument, in his November 2017 Appellate Brief Presentation, the representative cited a medical article by entitled “The use of an assistive device is not without significant musculoskeletal and metabolic demands,” by Sara Bradley, MD, and Cameron Hernandez, MD, of the Mount Sinai School of Medicine, which stated that “[r]epetitive stress on upper extremity joints from assistive device use can also cause tendinopathy, osteoarthritis, and carpal tunnel syndrome.” In addition, the representative related that according to the University of Washington, Orthopedics and Sports Medicine, “Lower back pain can become more intense when osteoarthritis affects the hips or the knees. Osteoarthritis also can directly affect the spine, causing muscles, tendons, or ligaments to become strained, which can lead to back and/or neck pain.” As such, the Board’s December 2017 Remand asked that the VA examiner address these articles in an addendum opinion. Pursuant to the Board’s December 2017 Remand instructions, an addendum opinion was obtained in February 2018 from the VA staff physician who authored the July 2014 VA examination reports. This opinion stated that: In my opinion the veteran doesn't have any neurological diagnosis of right leg except his DDD and OA of lumbar spine. His lower back pain although radiate to his leg but he doesn't have right leg disorder. In my opinion the veteran's symptoms, his DDD and OA of lumbar spine are less likely than not caused or aggravated by his service or Reynaud’s phenomenon or his service connected bilateral knee condition and more likely than not are caused and aggravated by aging and his general arthritis. Rationale: In certain cases, the knee and hip conditions can cause lower back pain but for this veteran his back condition is clearly cause by his non-service connected general arthritis therefore his bilateral knee conditions are less likely than not caused or aggravated his back condition. Also in my knowledge Reynaud’s phenomenon, can't cause arthritis of lumbar spine therefore it is less likely than not his back condition caused or aggravated by Raynaud’s phenomenon. In a November 2018 treatment note, the Veteran’s private physician indicated that he suffered from back spasms likely related to an abnormal gait secondary to his knee pathology, which had been a long standing problem. This private physician further noted that the knees have been a contributing factor to his back for a long period of time. In an April 2019 progress note, the Veteran’s private chiropractor opined that: [The Veteran’s] spinal column pain is due to slowing continual degradation of changes in his spinal biomechanics originating from original injuries to his right knee and right lower extremity kinetic chain. [The Veteran’s] original injury to his right knee has a significant impact on his kinetic chain of the right lower extremity. This injury lead to gait alterations which forced him to compensate for his right lower extremity injury and to favor weight bearing the left knee. [The Veteran] has since walked with left favoring antalgia which has caused further compensations in posture and biomechanics in his spinal column overall. In February 2020, the same VA staff physician who authored the July 2014 VA examination reports issued a second addendum opinion which stated: 1) regarding back condition: The veteran's electronic medical records (VBMS and CPRS) were reviewed completely. Also the statement of UW regarding correlation between OA of knee and hip and lower back pain and the veteran's STRs in April 1992 and May 1992 and February of 1993 were reviewed. In my opinion the veteran doesn't have any neurological diagnosis of right leg and his symptoms are more likely than not are result of DDD and OA of lumbar spine. His lower back pain although radiate to his leg but he doesn't have right leg disorder. In my opinion the veteran's DDD and OA of lumbar spine are less likely than not caused or aggravated by his service or Reynaud's phenomenon or his service connected bilateral knee condition and more likely than not are caused and aggravated by aging and his general arthritis. Rationale: In certain cases, the knee and hip conditions can cause lower back pain but for this veteran his back condition is clearly cause by his non-service connected general arthritis therefore his bilateral knee conditions are less likely than not caused or aggravated his back condition. Also in my knowledge Reynaud's phenomenon, can't cause arthritis of lumbar spine therefore it is less likely than not his back condition caused or aggravated by Raynaud's phenomenon. 2) Regarding his arm/hand condition: The veteran's electronic medical records (VBMS and CPRS) were reviewed completely. Also, the published article in AAFP by Sara Bradley and Cameron Hernandez were reviewed completely. Based on this article elderly population who use cane, walker or crutches for extended period of time can develop CTS or aggravate their CTS. In my opinion the veteran's bilateral CTS is less likely than not caused or aggravated by his service connected condition of Raynaud's phenomenon and more likely than not caused by non-service connected OA of hands. There is no to support connection between Raynaud's phenomenon and CTS. Based on the Sara Bradley and Cameron Hernandez article, long term use of assistive devices for ambulation can cause or aggravate CTS. Therefore in my opinion the veteran's bilateral CTS is more likely than not aggravated by use of cane and walker secondary to service connected bilateral knee conditions. In July 2020, as a result of the VA examiner’s February 2020 opinion that the Veteran’s bilateral CTS was more likely than not aggravated by use of cane and walker secondary to his service-connected bilateral knee conditions, the RO requested that the examiner issue another addendum opinion. Specifically, the RO alleged that the examiner failed to give any rationale in support of his medical opinion and requested that he address the following medical issues to the extent possible: 1) The baseline manifestations of the Veteran's back disorder found prior to aggravation; and 2) The increased manifestations which, in the examiner's opinion, are proximately due to the service-connected knee disabilities. Additionally, the VA examiner was asked to comment on whether there were any additional bilateral arm disorders which were or were not related. In response, the same VA staff physician issued another addendum opinion, which stated: Although based on "Sara Bradley and Cameron Hernandez article", long term use of assistive devices for ambulation can cause or aggravate CTS but there is no evidence to support limited use of cane or walker can cause or aggravate CTS therefore in my opinion the veteran's CTS is more likely than not related and aggravated by his OA of hands. The veteran didn't have any other disability of his arms. 2) Regarding the veteran's DDD and OA of lumbar spine, there is no evidence that he had significant DDD and OA of lumbar spine in 1994 therefore his STRs dated 4/1992, 5/1992 and 2/1993 are less likely than not indicate even small amount of OA or DDD of lumbar spine. In my opinion the veteran's DDD and OA of lumbar spine are less likely than not caused or aggravated by his service or Raynaud's phenomenon or his service connected bilateral knee condition and more likely than not are caused and aggravated by aging and his general arthritis. The veteran has general arthritis. It is very likely that a person with significant general arthritis develops DDD and OA of lumbar spine. This condition has nothing to do with Raynaud's phenomenon or knee conditions. Regrettably, the Board finds that these opinions are again inadequate. A medical opinion will be considered adequate when it is based upon consideration of the Veteran's prior medical history and examinations and provides a sufficiently detailed description of the disability so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Green v. Derwinski, 1 Vet. App., 121, 124 (1991). Furthermore, an adequate examination requires that the examiner providing the report or opinion be fully cognizant of the veteran's past medical history. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). First, regarding the claim of entitlement to service connection for a disability of the bilateral arms, the VA examiner issued an opinion in February 2020 (based on the article suggesting that repetitive stress on upper extremity joints from assistive device use can cause CTS) that the Veteran's bilateral CTS was more likely than not aggravated by use of a cane and walker secondary to his service-connected bilateral knee conditions. However, when asked by the RO to issue another addendum opinion to address the degree of aggravation in July 2020, the VA examiner instead reversed his opinion and stated that “long term use of assistive devices for ambulation can cause or aggravate CTS but there is no evidence to support limited use of cane or walker can cause or aggravate CTS therefore in my opinion the veteran's CTS is more likely than not related and aggravated by his OA of hands.” Crucially, the VA examiner’s characterization of the Veteran’s cane use as merely “limited” in nature is not supported by the record. To the contrary, the last time the Veteran was physically examined by this VA examiner in July 2014 (over six years ago), it was noted that the Veteran regularly used a cane for ambulation. Additionally, VA treatment records dated as recently as July 2020 indicate that the Veteran still uses a cane for ambulation, while the report of a July 2018 VA Knee and Lower Leg Conditions examination indicated that he also occasionally used a rollator walker to assist with ambulation. As such, the Board fails to see how regular use of a cane for a period of six years, in addition to occasional use of a rollator walker, constitutes “limited” use. Furthermore, the VA examiner’s July 2020 addendum opinion indicated that the Veteran’s diagnosed CTS was more likely than not aggravated by the Veteran’s osteoarthritis of the bilateral hands, but did not offer an opinion as to the likelihood that the Veteran’s regular cane/walker use over a period of six years caused or aggravated this bilateral hand osteoarthritis. Given that it has been over six years since the Veteran’s bilateral upper extremities were last examined, and as this service-connection claim involves allegations of aggravation, the Board finds that he should be provided another VA examination to determine the likely nature and etiology of any diagnosed disability of the bilateral upper extremities. Furthermore, as the author of the July 2014 VA opinion has not provided an adequate opinion on these matters after multiple attempts, the Board requests that this examination and opinion be provided by a different medical professional. In regard to the claims of entitlement to service connection for low back and right leg disorders, the VA examiner simply concluded that the Veteran’s diagnosed degenerative disc disease and osteoarthritis of lumbar spine were less likely than not caused or aggravated by his service or Raynaud’s phenomenon or his service connected bilateral knee conditions and more likely than not are caused and aggravated by “aging and his general arthritis.” An adequate rationale was not provided for this opinion. Indeed, the Board emphasizes that the Veteran is service connected for right knee degenerative joint disease with meniscal tear, left knee degenerative joint disease, left ankle strain with instability, left knee instability, and right knee instability. The record also establishes that the Veteran is only 58 years of age yet has used a cane for years to assist with an antalgic gait caused by his knee disabilities. Significantly, the VA examiner failed to specify the scope of the “general arthritis” responsible for the Veteran’s back symptomatology and to explain how this “general arthritis,” as opposed to the Veteran’s service-connected knee arthritis in particular, was more likely responsible for the development of low back symptomatology. Additionally, the VA examiner did not provide an opinion as to the likelihood that the Veteran’s abnormal, antalgic gait caused or aggravated his back symptomatology. Finally, the VA examiner indicated in his July 2014 VA examination report that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. Curiously, in his February 2018 addendum opinion, the VA examiner indicated that the Veteran’s lower back pain did radiate to his leg but that the Veteran did not have a right leg disorder. No additional explanation was provided as to why the Veteran’s radiation of lower back pain into the right leg did not constitute a right leg disorder. Given that it has also been over six years since the Veteran’s lumbosacral spine was last examined, and as this service-connection claim involves allegations of aggravation, the Board finds that he should also be provided another VA for his back and leg, and this examination should be conducted by an examiner other than the examiner who conducted the July 2014 VA examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an examiner other than the one who authored the July 2014 VA examination report to determine the probable nature and etiology of any diagnosed disability of the bilateral upper extremities. Following a review of the Veteran’s claims file, to include a copy of this Remand, all medically-indicated tests should be accomplished. a) After completion of the above, the VA examiner is asked to provide diagnoses for each disorder of the bilateral upper extremities, to include CTS and osteoarthritis. b) For every diagnosed disability of the bilateral upper extremities, the VA examiner is asked to opine as to whether the disorder is at least as likely as not (50 percent or greater probability) incurred in or otherwise related to his active duty service. c) For every diagnosed disability of the bilateral upper extremities, the VA examiner is also asked to opine as to whether the disorder is at least as likely as not caused or aggravated (chronically worsened) by any of his service-connected disabilities, to include cane use due to the antalgic gait resulting from his various service-connected knee disabilities. To this end, the Board emphasizes that the Veteran regularly uses a cane and occasionally uses a rollator walker. d) In providing this opinion, the examiner is asked to consider and discuss the medical article entitled, "The use of an assistive device is not without significant musculoskeletal and metabolic demands," by Sara Bradley, MD, and Cameron Hernandez, MD, of the Mount Sinai School of Medicine, which stated that "[r]epetitive stress on upper extremity joints from assistive device use can also cause tendinopathy, osteoarthritis, and carpal tunnel syndrome." In formulating these opinions, the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. A complete and detailed rationale should be given for all opinions and conclusions expressed. 2. Schedule the Veteran for a VA examination with an examiner other than the one who authored the July 2014 VA examination report to determine the probable nature and etiology of any diagnosed disability of the low back and right leg, to include any possible radiculopathy in the right leg. Following a review of the Veteran’s claims file, to include a copy of this Remand, all medically-indicated tests should be accomplished. a) For every diagnosed disability of the low back, the VA examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) incurred in or otherwise related to his active duty service. b) For every diagnosed disability of the low back, the VA examiner is also asked to opine as to whether the disorder it is at least as likely as not caused or aggravated (chronically worsened) by any of his service-connected disabilities, to include as secondary to the antalgic gait resulting from his various service-connected knee disabilities. To this end, the Board emphasizes that the Veteran regularly uses a cane and occasionally uses a rollator walker. c) The examiner should discuss whether the Veteran has a current right leg disorder, including any right leg radiculopathy. If no right leg disorder is found, the examiner should discuss the cause of the Veteran’s symptoms of pain in his right leg. d) If the Veteran is diagnosed as having a right leg disorder that is unrelated to his diagnosed low back disability, then the examiner is asked to opine as to whether it is at least as likely as not related to his active duty service, as well as whether the disorder is at least as likely as not caused or aggravated by any of his service-connected disabilities, to include as secondary to the antalgic gait resulting from his knee disabilities. e) When opining regarding the Veteran's back and right leg disorders, the examiner must consider the statement by University of Washington, Orthopedics and Sports Medicine that, "Lower back pain can become more intense when osteoarthritis affects the hips or the knees. Osteoarthritis also can directly affect the spine, causing muscles, tendons, or ligaments to become strained, which can lead to back and/or neck pain." The examiner must also consider and discuss the November 2018 treatment note in which the Veteran’s private physician indicated that he suffered from back spasms likely related to an abnormal gait secondary to his knee pathology, which had been a long standing problem; and that the Veteran’s knees have been a contributing factor to his back for a long period of time. The VA examiner must also consider and discuss the April 2019 progress note in which the Veteran’s private chiropractor opined that the Veteran’s spinal column pain was due to slowing continual degradation of changes in his spinal biomechanics originating from original injuries to his right knee and right lower extremity kinetic chain, and that he walked with left favoring antalgia which has caused further compensations in posture and biomechanics in his spinal column overall. In formulating these opinions, the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. A complete and detailed rationale should be given for all opinions and conclusions expressed. 3. Following completion of the above, the RO must ensure that the VA examination reports are adequate. If the VA examination reports are deficient in any manner, then return the reports to the examiners as inadequate. Mary E. Rude Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Anthony M. Flamini 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.