Citation Nr: 21063890 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 16-17 097 DATE: October 18, 2021 REMANDED Entitlement to a compensable rating for a service-connected skin condition prior to October 20, 2020, and in excess of 30 percent thereafter is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a disability of the right wrist and thumb is remanded. Entitlement to service connection for a disability of the left wrist and thumb is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle 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. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1966 to May 1968. This case comes on appeal of a March 2014 rating decision. In February 2019, the Veteran testified at a videoconference hearing before the Board. This case was previously before the Board in August 2019. At that time, the Board, in pertinent part, remanded the matters below for further development. Notably, subsequent to the Board's remand, in October 2020, the agency of original jurisdiction (AOJ) granted entitlement to a rating of 30 percent for the Veteran's service-connected skin condition, effective October 20, 2020. However, the Veteran is presumed to seek the maximum benefit available throughout the period on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). As the AOJ's decision represents only a partial grant of benefits sought, the issue remains on appeal. The Board also notes that in an October 2020 supplemental statement of the case (SSOC), the AOJ adjudicated the issues of entitlement to service connection for left and right shoulder disabilities. The Veteran's representative also addressed these issues in a September 2021 brief. The Veteran filed a claim of service connection for these disabilities in April 2019. The AOJ denied the claim in a May 2019 rating decision. The Veteran has not appealed the issues of service connection for left and right shoulder disabilities. Moreover, as the initial rating decision came after February 2019, an appeal of these issues would fall under the framework of the modernized appeals system, and not the legacy appeal system. Accordingly, it appears that the AOJ adjudicated these issues in the October 2020 SSOC in error and they are not currently before the Board. The Board will discuss the individual circumstances of the remanded issues in more detail below. However, at the outset, the Board notes that when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). An adequate medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As it pertains to the issues of service connection in this case, the Veteran underwent a set of examinations for each disability in February 2020, all with the same examiner. In the corresponding medical opinions, the examiner provided negative nexus opinions that were supported only by recitations of the evidence of record, without any explanation as to how that evidence was medically significant in informing the conclusions. Specifically, the examiner repeatedly relied on the length of time between service and diagnosis of disability, as well as the absence of treatment records, without explaining why such evidence was relevant. The examiner also did not address the Veteran's competent lay statements regarding the onset and history of his symptoms, which are relevant to his theories of entitlement. Accordingly, on remand, new medical opinions are necessary that address the entirety of the medical and lay evidence, and are supported by adequate medical rationale. 1. Entitlement to a compensable rating for a service-connected skin condition prior to October 20, 2020, and in excess of 30 percent thereafter is remanded. The Board initially remanded this issue as the Veteran had made claims that his skin condition had worsened since his most recent VA examination, to include an increase in the percentage of his body area and exposed area that was affected by the disability. In October 2020, the Veteran underwent an examination that showed such an increase, and the AOJ granted an increased rating to 30 percent, effective the date of the examination. The AOJ simultaneously issued a SSOC denying entitlement to a compensable rating prior to October 2020, and in excess of 30 percent thereafter. Since the AOJ issued these decisions, the Veteran submitted new evidence in the form of records from the Veteran's private dermatologist and podiatrist. Those records note treatments of cyclosporine enalapril and Lotrisone, prior to the October 2020 examination. The October 2020 examination does not identify those medications as part of the Veteran's current treatment regimen, and the examiner did not have the opportunity to review these records. It is unclear based on the available evidence whether these treatments represent no more than topical therapy, or whether they may represent systemic therapy, potentially warranting a higher rating. The Board cannot fully evaluate the severity of the Veteran's skin condition without addressing this open medical question. Therefore, on remand, the AOJ should obtain a medical opinion to determine the nature of the Veteran's treatment based on these additional records. 2. Entitlement to service connection for a lumbar spine disability is remanded. 3. Entitlement to service connection for a disability of the right wrist and thumb is remanded. 4. Entitlement to service connection for a disability of the left wrist and thumb is remanded. According to the Veteran's hearing testimony, during service, he fell down a hill in Korea while wearing his full gear, resulting in an injury to his back and bilateral wrists. Service treatment records document multiple instances of injuries to the back and wrists. In December 1966, a treatment note states that the Veteran pulled a muscle in the lumbar region. In February 1967, the Veteran was observed to have injured his back when he fell on icy steps and was treated with the application of an Ace bandage. In January 1968, the Veteran was treated after spraining his wrist in the field two days prior. Although none of these records specifically identifies the fall the Veteran described in his testimony, they do show evidence of in-service injuries. At his Board, hearing, the Veteran testified that he had received private treatment for his back after service. The Veteran's wife also testified that when they met in 1970, the Veteran had trouble picking things up due to his back. In the February 2020 VA examination discussed above, the examiner did not address the documented in-service injuries. Instead, the examiner only addressed the fall to which the Veteran testified, emphasizing that the fall was undocumented. The examiner then provided a negative nexus opinion, referencing the length of time between service and the diagnosis of the Veteran's current back disability, as well as a lack of continuous treatment records since service. The examiner also dismissed a positive nexus statement provided by the Veteran's private physician, stating that it was difficult, if not impossible, to ascribe a causal relationship between a fall of five decades ago to the current back and wrist or thumb conditions. The examiner did not provide any medical explanation as to why such attribution was impossible, nor did the examiner provide any explanation as to the medical significance of the cited evidence. Accordingly, the examination is not adequate. On remand, the AOJ should obtain a new medical opinion regarding the etiology of the Veteran's back and bilateral wrist and thumb conditions. The examiner should base such opinion on a full review of the evidence of record, to include the Veteran's service treatment records and competent lay evidence, and the opinion should be supported by medical rationale. If the examiner determines it is necessary to examine the Veteran to provide such an opinion, a new examination should be arranged. 5. Entitlement to service connection for a right foot disability is remanded. 6. Entitlement to service connection for a left foot disability is remanded. 7. Entitlement to service connection for a right ankle disability is remanded. 8. Entitlement to service connection for a left ankle disability is remanded. 9. Entitlement to service connection for a right knee disability is remanded. 10. Entitlement to service connection for a left knee disability is remanded. The Veteran testified that he believed his bilateral foot injuries were due to running in boots during service. There was not one particular injury, rather it was the cumulative effects of this service over time. In turn, the Veteran believed that his foot injuries resulted in injuries to his bilateral ankles and knees. Service treatment records also document that the Veteran was treated for a twisted ankle over the course of approximately two weeks in October 1967. Recent treatment records show that the Veteran has been treated regularly for complaints of pain and swelling of both ankles. Private treatment examination has shown pain on active plantar flexion of the bilateral ankle joints. A large posterior process of the talus was noted on lateral x-rays of both ankles, and the Veteran has been assessed with os trigonum impingement, which his private podiatrist described as an asymptomatic congenital condition. The Veteran has also been diagnosed with osteoarthritis patellofemoral pain syndrome of the bilateral knees. In the February 2020 VA examination reports, the examiner provided negative nexus opinions, citing the length of time between treatment and diagnosis, as well as the lack of post-service treatment records until relatively recently. The examiner also dismissed a positive nexus statement provided by the Veteran's private physician, stating that it was difficult, if not impossible, to ascribe a causal relationship between a fall of five decades ago to the current foot, ankle, and knee conditions. The examiner did not provide any medical explanation as to why such attribution was impossible, nor did the examiner provide any explanation as to the medical significance of the cited evidence. Accordingly, the examination is not adequate. On remand, the AOJ should obtain a new medical opinion regarding the etiology of the Veteran's bilateral foot, ankle, and knee conditions. The examiner should base such opinion on a full review of the evidence of record, to include the Veteran's service treatment records and competent lay evidence, and the opinion should be supported by medical rationale. If the examiner determines it is necessary to examine the Veteran to provide such an opinion, a new examination should be arranged. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate examiner to address the severity of Veteran's skin disability during the period on appeal. Specifically, the examiner should review the Veteran's VA and private treatment records. The examiner should then identify all medications used to treat the Veteran's service-connected skin condition, to expressly include Cyclosporine Enalapril and Lotrisone, and address whether these medications represent no more than topical treatment, or whether they are considered systemic therapy. The examiner should present all findings in a written report. 2. Obtain a medical opinion from an appropriate examiner addressing the Veteran's current back disability. The examiner should review the entire claims file, to include a copy of this Remand, and the report of examination should include discussion of the Veteran's documented history and assertions. With respect to each diagnosed disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., approximately 50 percent probability) that the disability had onset in, or is otherwise related to service. In doing so, the examiner should specifically address the Veteran's competent lay testimony regarding an in-service fall while wearing full gear during service in Korea, as well as lay testimony from the Veteran's wife regarding the onset of his back condition. The examiner should also address the documented instances of treatment for back conditions during service. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. 3. Obtain a medical opinion from an appropriate examiner addressing the Veteran's current bilateral hand, thumb, and wrist disabilities. The examiner should review the entire claims file, to include a copy of this Remand, and the report of examination should include discussion of the Veteran's documented history and assertions. With respect to each diagnosed disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., approximately 50 percent probability) that the disability had onset in, or is otherwise related to service. In doing so, the examiner should specifically address the Veteran's competent lay testimony regarding an in-service fall while wearing full gear during service in Korea. The examiner should also address the documented instances of treatment for a sprained wrist during service. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. 4. Obtain a medical opinion from an appropriate examiner addressing the Veteran's current foot and ankle disabilities. The examiner should review the entire claims file, to include a copy of this Remand, and the report of examination should include discussion of the Veteran's documented history and assertions. With respect to each diagnosed disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., approximately 50 percent probability) that the disability had onset in, or is otherwise related to service. In doing so, the examiner should specifically address the Veteran's competent lay testimony regarding the gradual development of pain as due to his regular running in boots over the course of service. The examiner should also address the documented instances of treatment for a twisted ankle during service. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. 5. Obtain a medical opinion from an appropriate examiner addressing the Veteran's bilateral knee disability. The examiner should review the entire claims file, to include a copy of this Remand, and the report of examination should include discussion of the Veteran's documented history and assertions. With respect to each such diagnosed disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., approximately 50 percent probability) that the disability had onset in, or is otherwise related to service. In doing so, the examiner should address the Veteran's contention that the regular running in boots over the course of his service caused his current knee disabilities. The examiner should also render an opinion as to whether it is at least as likely as not that the disability was caused or aggravated by the Veteran's bilateral foot or ankle disabilities. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. (Continued on Next Page) 6. Once the above development has been achieved, as well as any other development deemed necessary thereafter, readjudicate the issues on appeal. If any benefits sought remain denied, issue a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Giaquinto, 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.