Citation Nr: 21061478 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 17-06 049 DATE: October 4, 2021 REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for a left foot disorder (other than pes planus with plantar fasciitis) is remanded. Entitlement to service connection for a right foot disorder (other than pes planus with plantar fasciitis) is remanded. Entitlement to service connection for varicose veins of the left leg is remanded. Entitlement to service connection for varicose veins of the right leg is remanded. Entitlement to service connection for carpal tunnel syndrome of the left hand is remanded. Entitlement to service connection for carpal tunnel syndrome of the right hand is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for diabetes mellitus type II is remanded. REASONS FOR REMAND The Veteran had active service from September 1973 to December 1977. The Board remanded this case in November 2018 and December 2020. 1. Entitlement to service connection for a low back disorder is remanded. 2. Entitlement to service connection for a left knee disorder is remanded. 3. Entitlement to service connection for a left ankle disorder is remanded. 4. Entitlement to service connection for a left foot disorder (other than pes planus with plantar fasciitis) is remanded. 5. Entitlement to service connection for a right foot disorder (other than pes planus with plantar fasciitis) is remanded. 6. Entitlement to service connection for varicose veins of the left leg is remanded. 7. Entitlement to service connection for varicose veins of the right leg is remanded. Pursuant to the December 2020 Board remand, the agency of original jurisdiction (AOJ) afforded the Veteran VA examinations as to her claimed low back, left knee, left ankle, and bilateral foot disorders and claimed varicose veins of the bilateral legs in June 2021. However, the opinions provided by the June 2021 VA examiner are inadequate for decision-making purposes because they do not address the Veteran's contentions and rely exclusively on a lack of contemporaneous medical records to find the Veteran not credible in her reports. Specifically, the Veteran has contended that the claimed disorders are related the long hours of standing she did during service as a dental assistant; that she altered her gait due to her service-connected right knee and right ankle disabilities, which in turn caused or aggravated the claimed conditions; and that the claimed varicose veins of the bilateral legs are caused or aggravated by the braces she uses for her service-connected right knee disability. The examiner did not address those contentions and instead stated only that there is no evidence that the conditions were diagnosed during service or that the conditions were caused or aggravated by the service-connected disabilities. Additionally, regarding the claimed conditions of the bilateral feet, the examiner merely said that the Veteran does not have any additional foot conditions other than the already service-connected pes planus and plantar fasciitis, but the record shows that the Veteran has been diagnosed with ganglion cysts of the bilateral feet. A remand is required to obtain an addendum opinion. 8. Entitlement to service connection for carpal tunnel syndrome of the left hand is remanded. 9. Entitlement to service connection for carpal tunnel syndrome of the right hand is remanded. The June 2021 VA examiner's opinions as to the Veteran's claimed carpal tunnel syndrome of the bilateral hands are inadequate for decision-making purposes because they do not address relevant evidence, do not address the Veteran's contentions, and rely exclusively on a lack of contemporaneous medical records to find the Veteran not credible in her reports. Specifically, the service treatment records show that the Veteran had in-service complaints relating to her right wrist, index finger, and middle finger. The Veteran has reported that she had problems with her hands during her active service, and she has contended that her current carpal tunnel syndrome is related to working with her hands as a dental assistant during service. The examiner did not address those contentions and instead stated only that there is no evidence that the conditions were diagnosed during service. A remand is required to obtain an addendum opinion. 10. Entitlement to service connection for hypertension is remanded. 11. Entitlement to service connection for diabetes mellitus type II is remanded. The June 2021 VA examiner's opinions as to the Veteran's claimed hypertension and diabetes mellitus type II are inadequate for decision-making purposes because they do not address the Veteran's contentions. Specifically, the Veteran contends that her hypertension is due to stress she experienced during her active service or stress that she has experienced due to pain from her service-connected disabilities. She has also contended that she has been unable to exercise due to her service-connected disabilities, that she has gained weight due to the lack of exercise, and that the weight gain has in turn caused or aggravated her hypertension and diabetes mellitus type II. The examiner did not address the contention of in-service and post-service stress or provide an opinion as to whether the Veteran's obesity may have been an intermediate step between her service-connected disabilities and her hypertension and diabetes mellitus type II. A remand is required to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's claimed low back, left knee, left ankle, and bilateral foot disorders and claimed varicose veins of the bilateral legs are at least as likely as not (50 percent probability or greater) related to long hours of standing she did during service as a dental assistant. In providing this opinion, the examiner should note that the Veteran has reported she also worked as a dental assistant for many years after her separation from active service. See, e.g., VA Form 9, Appeal to Board of Veterans' Appeals, received in February 2017. If not, the examiner should also provide an opinion as to whether it at least as likely as not that the disorders are proximately due to or aggravated beyond their natural progression by one or more of the Veteran's service-connected disabilities. In providing this opinion, the examiner must address the Veteran's contentions that her service-connected right knee and right ankle disabilities caused her to alter her gait, which in turn caused or aggravated the claimed disorders; and that the claimed varicose veins of the bilateral legs are caused or aggravated by the braces she uses for her service-connected right knee disability, which she says compress the leg veins. Regarding the claimed bilateral foot conditions, the examiner must consider the Veteran's diagnosed ganglion cysts of the bilateral feet. The examiner must note that lack of contemporaneous medical evidence does not, in and of itself, render lay evidence not credible. Therefore, the examiner must not treat the Veteran's competent reports of pain and other symptoms as not credible solely based on a lack of contemporaneous medical evidence documenting treatment for low back, left knee, left ankle, and foot disorders, and varicose veins of the bilateral legs during active service and since separation from active service. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's bilateral carpal tunnel syndrome is at least as likely as not (50 percent probability or greater) related to working with her hands as a dental assistant during her active service. In providing this opinion, the examiner should note that the Veteran has reported she also worked as a dental assistant for many years after her separation from active service. See, e.g., VA Form 9, Appeal to Board of Veterans' Appeals, received in February 2017. The examiner must address the service treatment records showing that the Veteran had in-service complaints relating to her right wrist, index finger, and middle finger. The examiner must note that lack of contemporaneous medical evidence does not, in and of itself, render lay evidence not credible. Therefore, the examiner must not treat the Veteran's competent reports of pain and other symptoms as not credible solely based on a lack of contemporaneous medical evidence documenting treatment for carpal tunnel syndrome during active service and since separation from active service. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's claimed hypertension is at least as likely as not (50 percent probability or greater) related to stress she experienced during her active service. If not, the examiner should also provide an opinion as to whether it is at least as likely as not that the hypertension is proximately due to or aggravated beyond its natural progression by one or more of the Veteran's service-connected disabilities. In providing this opinion, the examiner must address the Veteran's contentions that pain from her service-connected right knee disability, right ankle disability, and headaches caused or aggravated her hypertension. The examiner must also address whether the Veteran's obesity acted as an intermediate step between her service-connected disabilities and the claimed hypertension. In so doing, the examiner should respond to the following: (a.) Is it at least as likely as not that the Veteran's service-connected disabilities caused her to become obese? The opinion must reflect consideration of the lay statements of record indicating that the service-connected disabilities prevented the Veteran from exercising, which in turn caused her obesity. (b.) If so, was the obesity, as a result of the service-connected disabilities, a substantial factor in causing or aggravating the Veteran's hypertension? (c.) Would the Veteran's hypertension have not occurred but for the obesity caused by the service-connected disabilities? The examiner must note that lack of contemporaneous medical evidence does not, in and of itself, render lay evidence not credible. Therefore, the examiner must not treat the Veteran's competent reports of in-service and post-service stress symptoms as not credible solely based on a lack of contemporaneous medical evidence documenting treatment for stress or hypertension during active service and since separation from active service. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's claimed diabetes mellitus type II is at least as likely as not (50 percent probability or greater) proximately due to or aggravated beyond its natural progression by one or more of her service-connected disabilities. In providing this opinion, the examiner must address whether the Veteran's obesity acted as an intermediate step between her service-connected disabilities and her claimed diabetes mellitus type II. In so doing, the examiner should respond to the following: (a.) Is it at least as likely as not that the Veteran's service-connected disabilities caused her to become obese? The opinion must reflect consideration of the lay statements of record indicating that the service-connected disabilities prevented the Veteran from exercising, which in turn caused her obesity. (b.) If so, was the obesity, as a result of the service-connected disabilities, a substantial factor in causing or aggravating the Veteran's diabetes mellitus type II? (c.) Would the Veteran's diabetes mellitus type II have not occurred but for the obesity caused by the service-connected disabilities? MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. J. Anthony, 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.