Citation Nr: 21063308 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 19-02 570 DATE: October 13, 2021 REMANDED Entitlement to service connection for status post right knee replacement is remanded. Entitlement to a compensable rating for residuals of a fracture of the right tibia is remanded. Entitlement to a rating in excess of 10 percent for dyshidrotic eczema is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1974 to January 1976. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which confirmed and continued the previous denial of service connection for status post right knee replacement and continued the noncompensable rating for residuals of a fracture of the right tibia and the 10 percent rating for dyshidrotic eczema. In July 2020, the Veteran testified at a Board hearing in Washington, D.C., before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously before the Board in December 2020. At that time, the Board reopened the previously denied claim of service connection for status post right knee replacement and remanded the underlying service connection claim for further development. The Board also remanded the above captioned increased rating claims, as well as a newly raised claim for TDIU, for additional evidentiary development. 1. Entitlement to service connection for status post right knee replacement is remanded. The Veteran contends that his right knee disability had its onset in service. Alternatively, the Veteran contends that his right knee disability is secondary to his service-connected back, tibia, and/or ankle disabilities. See July 2020 Transcript of Hearing, page 8; September 2021 Appellate Brief. Pursuant to the Board's December 2020 remand instructions, the Veteran was afforded a VA examination in April 2021. The examiner noted a diagnosis of residuals status post multiple total knee arthroplasty. The examiner noted that the Veteran sustained a fracture of the right tibia in 1975 and that the Veteran was found to have advanced osteoarthritis of the right knee in 2013. The Veteran reported constant aching pain, swelling, stiffness, and limited motion of the right knee. After examination of the Veteran and review of the claims file, the examiner rendered a negative etiological opinion regarding the Veteran's right knee. The examiner opined, [T]here is no evidence of injury to the right knee on the service treatment record. Therefore, the condition is not caused by any injury or event during active service. A nexus has not been established. Regarding secondary service connection, the examiner opined in pertinent part, There is no clear evidence from review of orthopedic literature (Wheeless' Textbook of Orthopedics) to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or incomplete paralysis, or shortening of the injured limb resulting in length discrepancy of more than 5cm so that the individual[']s gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. This level of severity is not supported based on record review, history or exam. It is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. Therefore the Residuals status post multiple right total knee arthroplasty is less likely than not related to the Degenerative arthritis lumbar spine and right tibia fracture or right ankle sprain. Veteran was found to have severe osteoarthritis in 2013 prompting for him getting a total knee arthroplasty in 2015 and had repeated surgery in 2019 and 2021 due to severe pain and swelling after his first surgery. Therefore the right ankle sprain, status post fibular fracture, degenerative arthritis of the lumbar spine and residuals, [and] right tibia fracture did not cause the current diagnosis of Residuals status post multiple right total knee arthroplasty. Arthritis in one joint does not cause arthritis in another joint. A thorough review of medical literature failed to show such causal relationship . . . Therefore the residuals status post multiple right knee arthroplasty is less likely than not related to the degenerative joint disease, lumbar spine. A nexus has not been established. The Board finds that the VA examination is inadequate. In that regard, although the examiner addressed the issue of causation, she failed to address the question of aggravation. The U.S. Court of Veterans Appeals (Court) has held that because there are two prongs to a secondary service connection claim -- causation and aggravation, in order to be adequate, a medical opinion must provide explanations for both prongs. Atencio v. O'Rourke, 30 Vet. App. 74 (2018); El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Furthermore, subsequent to the VA examination, the Veteran submitted a statement indicating that he injured his right knee during service and that he has experienced symptoms associated with this injury continuously since that time. While the Board greatly regrets further delay, remand is required for an addendum medical opinion. Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to a compensable rating for residuals of a fracture of the right tibia is remanded. The Veteran contends that his residuals of a fracture of the right tibia is more severe than currently rated. At the July 2020 Board hearing, referenced above, the Veteran testified that he experienced flare-ups of pain in his right leg as well as intermittent swelling and a knot in the area of the fracture. See July 2020 Transcript of Hearing, pages 5-6. Pursuant to the Board's December 2020 remand instructions, the Veteran was afforded a VA examination in April 2021. The examiner noted diagnoses of residuals of a fracture of the right tibia and residuals status post multiple total knee arthroplasty. The Veteran reported occasional right shin pain related to his tibia residuals, which the examiner noted upon range of motion (ROM) testing. He reported constant aching pain, swelling, stiffness and limited motion of the right knee. The examiner determined that the Veteran's knee disability was a separate disability and not related to the Veteran's residuals of a fracture of the right tibia. The Board finds that the VA examination is inadequate. In that regard, the December 2020 Board remand directed the examiner to consider VA treatment records documenting the Veteran's complaints of leg pain, as well as the Veteran's July 2020 hearing testimony to the effect that his right leg occasionally swells and he has a knot on the leg in the area of his fracture. However, it does not appear that the examiner considered such in providing her description of the Veteran's disability. While the Board greatly regrets further delay, remand is required for an additional VA examination for full compliance with the Board's previous remand instructions. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). 3. Entitlement to a rating in excess of 10 percent for dyshidrotic eczema is remanded. The Veteran contends that his dyshidrotic eczema is more severe than currently rated. At the July 2020 Board hearing, noted above, the Veteran testified that his eczema was no longer limited to his hands and feet, but had spread to his groin area, neck, back, and both elbows. See July 2020 Transcript of Hearing, pages 2-3. Pursuant to the Board's December 2020 remand instructions, the Veteran was afforded a VA examination in April 2021. The examiner indicated a diagnosis of dyshidrotic eczema of the hands and feet. It was noted that the skin on the Veteran's bilateral knuckles and the dorsal part of his bilateral feet was scaly, rough, and dry. The examiner noted that according to the Veteran, his eczema had stayed the same. The examiner also noted that the Veteran was now given Benadryl for complaints of itching and hydrocortisone cream to be applied as needed. The examiner indicated that the Veteran's eczema covered less than 5 percent of exposed areas affected and at least 5 percent but less than 20 percent of the entire body. The examiner determined that the Veteran's eczema impacted his ability to work, as the Veteran stated that he was unable to get restful sleep due to itchiness at night. In correspondence received in August 2021, the Veteran reiterated that his eczema had progressed to his groin area and elbows and that he was taking pills and using cream to relieve his constant itching. See August 2021 Veteran's correspondence. The Board finds that the VA examination is inadequate. In that regard, the examiner's findings appear to contradict the Veteran's hearing testimony, as well as his subsequent correspondence dated in August 2021, indicating that his eczema had worsened and spread to other parts of his body, to include his groin area, neck, back, and elbows. While the Board notes that the Veteran is not competent to provide a diagnosis, he is competent to report having experienced symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Therefore, while the Board greatly regrets further delay, remand is required for an additional VA examination to determine the severity and manifestations of the Veteran's service-connected dyshidrotic eczema. 4. Entitlement to a TDIU due to service-connected disabilities is remanded. As resolution of the claims of entitlement to a compensable rating for residuals of a fracture of the right tibia and a rating in excess of 10 percent for dyshidrotic eczema may have an impact on the Veteran's claim of entitlement to a TDIU, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). Accordingly, the matters are REMANDED for the following action: 1. Obtain an addendum medical opinion addressing the nature and etiology of the Veteran's current right knee disability. Access to the claims file must be made available to the clinician for review in connection with the opinion. After reviewing the record, the clinician should provide an opinion, with supporting rationale, as to the following: Is it at least as likely as not that the Veteran's current right knee disability had its inception during active service or is otherwise causally related to service? If not, is it at least as likely as not that the Veteran's current right knee disability is causally related to his service-connected lumbar spine, right tibia, and/or right ankle disabilities, to include an altered gait produced by pain from those disabilities? If not, is it at least as likely as not that the Veteran's current right knee disability is aggravated by his service-connected lumbar spine, right tibia, and/or right ankle disability, to include an altered gait produced by pain from those disabilities? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinion, the clinician should consider the Veteran's reported injury and symptoms in service and thereafter, including the onset, progression and severity of the Veteran's reported symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? In providing the requested opinion, the clinician should reference the relevant evidence of record, to include the Veteran's correspondence dated in August 2021 indicating that he injured his knee during active duty and that he experienced symptoms associated with this injury continuously since that time. A complete explanation must be provided for any opinion offered. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected residuals of a fracture of the right tibia. Access to the claims file must be made available to the clinician for review in connection with the examination. After examining the Veteran and reviewing the record, the clinician should provide a full description of the residuals of a fracture of the right tibia disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In providing this description, the clinician should consider the relevant evidence of record, to include: (a) December 2017 and March 2018 VA treatment records documenting the Veteran's complaints of leg pain, and (b) the Veteran's July 2020 hearing testimony to the effect that his right leg occasionally swells and he has a knot on the leg in the area of his fracture. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the Veteran's service-connected dyshidrotic eczema disability. Access to the claims file must be made available to the clinician for review in connection with the examination. After examining the Veteran and reviewing the record, the clinician should provide a full description of the Veteran's dyshidrotic eczema disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In providing this description, the clinician should consider the relevant evidence of record, to include: (a) the Veteran's July 2020 hearing testimony to the effect that his eczema was no longer limited to his hands and feet, but had spread to his groin area, neck, back, and both elbows (b) the Veteran's correspondence dated in August 2021 reiterating that his eczema had progressed to his groin area and elbows and that he was taking pills and using cream to relieve his constant itching. (Continued on the next page) The clinician should specifically state whether the Veteran's eczema is present on his neck, back, elbows, and in his groin area. The clinician should also explain whether any medications or therapies used to treat the Veteran's service-connected dyshidrotic eczema disability are systemic, i.e. operate by affecting the body as a whole. The clinician should also opine as to whether the prescribed treatment is similar to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, 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.