Citation Nr: 21005010 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 16-19 610A DATE: January 28, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for gastrointestinal disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 2011 to October 2012, including service in Southwest Asia, with subsequent service in the Army National Guard. Among his decorations is the Combat Action Badge. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claims for further development in January 2019. Unfortunately, remand is again required. Pursuant to the Board’s January 2019 remand directives, the Veteran was afforded VA examinations in October 2020. For the Veteran’s claimed disabilities, the examiner was asked to address whether the disability pattern is consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis, and to reconcile any negative findings with diagnosed conditions noted in the record. The examiner found no objective diagnosable conditions upon examination. However, the examiner did not address the above-mentioned questions due to the Veteran’s Persian Gulf War service, nor did he reconcile his negative findings, as specifically requested by the Board. Rather, he speculated that “perhaps a gulf war syndrome is appropriate,” given the Veteran’s complaints and presentation after deployment. Thus, for these reasons, an addendum opinion is needed on remand to ensure substantial compliance with the Board’s prior remand. Stegall v. West, 11 Vet. App. 268 (1998). Any outstanding treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Then obtain an addendum opinion from an examiner other than the September 2014 and October 2020 VA examiners, preferably a physician, addressing the etiology of the Veteran’s back, bilateral knee, right ankle, and gastrointestinal disabilities. No additional examination is necessary, unless the examiner determines otherwise. The entire claims file must be made available to and reviewed by the examiner. After a review of the claims file, the examiner should address the following: (a) Please indicate whether the Veteran’s back, right knee, left knee, right ankle, and gastrointestinal symptoms are attributable to a known clinical diagnosis, and if so, identify the same. If diagnoses of lumbar spine degenerative joint disease and osteoarthritis, scoliosis, bilateral knee post traumatic residual degenerative joint disease and chronic sub patellar bursitis, right ankle post traumatic residual degenerative joint disease and chronic sprain, and gastroesophageal reflux (GERD) are not warranted, please reconcile these findings with the diagnoses of the same in the June 2013 private report and August 2015 VA treatment record. (b) If a diagnosis of GERD is warranted, please determine whether GERD is a functional gastrointestinal disorder or a structural gastrointestinal disease. (c) If a current diagnosis is not present, does the Veteran nevertheless have any functional impairment in the back, right knee, left knee, right ankle, and gastrointestinal tract related to pain? (d) If a diagnosis of scoliosis is warranted, please determine whether such diagnosis is a congenital defect or disease. (For VA purposes, a defect differs from a disease in that the former is more or less stationary in nature while the latter is capable of improving or deteriorating.) (1) If scoliosis does not have a congenital origin, please address the questions outlined beginning from part (e) below. (2) If scoliosis is identified as a congenital defect, please opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran incurred any superimposed disease or injury on such defect during service that resulted in additional disability. If so, please describe the resultant disability. (3) If scoliosis is identified as a congenital disease, please opine as to whether it is at least as likely as not (50 percent or greater probability) that such disease was aggravated (worsened beyond natural progression) by service, to include as a result of wearing heavy body armor and equipment. (e) Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness; (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology; (3) a diagnosable but medically unexplained chronic multisymptom illness of unknown pathophysiology; (4) a diagnosable chronic multi-symptom illness with a partially explained etiology and pathophysiology, or (5) a disease with a clear and specific etiology and diagnosis. (f) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern consistent with options (e)(4) or (e)(5) above, (i.e., either a diagnosable chronic multi-symptom illness with a partially explained etiology and pathophysiology or a disease with a clear and specific etiology and diagnosis), then please provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia (e.g., burn pits, oil fires, sandstorms). (g) If not, is it at least as likely as not (50 percent or greater probability) that any diagnosed disorder or functional impairment associated with the back, right knee, left knee, right ankle, or gastrointestinal tract had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, to include as a result of the documented complaints of back pain therein. See September 2012 Post Deployment Health Assessment. In addressing question (g), the examiner should discuss the Veteran’s reports of: (1) back pain from wearing heavy body armor and equipment in service, as well as from a fall (see June 2014 and August 2015 VA treatment records); (2) the onset of abdominal pain since serving in Afghanistan (see July 2013 VA treatment record); (3) ankle pain from running on gravel during service (see June 2018 VA treatment record; and (4) lay statements as to the onset of and continuous symptomatology since service (see January, February, and March 2016 lay statements; see also October 2020 VA examination reports). Please assume the Veteran’s statements are true and determine whether a nexus relationship is “medically plausible” given the same. A complete rationale should be given for all opinions and conclusions expressed. If the examiner is unable to opine without resorting to speculation, he or she should offer a rationale for reaching that conclusion. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.S. Mahoney 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.