Citation Nr: 21065652 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 16-08 776 DATE: October 27, 2021 REMANDED Entitlement to service connection for any musculoskeletal pain disorder, to include Reiter's Syndrome (reactive arthritis), complex regional pain syndrome (CRPS), and fibromyalgia, is remanded. Entitlement to service connection for a low back disability, to include spondyloarthritis, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1968 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. In February 2019 and September 2020, the Board remanded these matters for further development. These matters have been advanced on the docket pursuant to 38 C.F.R. § 20.902. The Board has broadened the Veteran's service connection claim to include any musculoskeletal pain disorder reasonably raised by the record, to include Reiter's syndrome (reactive arthritis), CRPS, and fibromyalgia. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). The Board emphasizes that the claim has not been expanded to include a disorder called "musculoskeletal pain disorder" but rather any musculoskeletal disorder to account for pain. 1. Entitlement to service connection for any musculoskeletal pain disorder, to include Reiter's Syndrome (reactive arthritis), CRPS, and fibromyalgia is remanded. In September 2020, the Board remanded these matters for an expert opinion from rheumatologist pursuant to 38 C.F.R. § 20.906(a). In June 2021, the Veteran was examined by a general practitioner who informed the Veteran she "had just the day before studied what the symptoms were and what it meant to be burdened with Reiter's Syndrome." The Board notes that the reason an expert opinion by a rheumatologist was requested was due to the infrequency and relative complexity surrounding Reiter's Syndrome, which is evidenced by the general practitioner's admission that she was unfamiliar with the disorder until the day before the Veteran's June 2021 VA examinations. See June 2021 VA examination reports, August 2021 Veteran lay statement. Thus, all of the VA opinions regarding the etiology of any musculoskeletal disorder to account for pain, to include Reiter's Syndrome (reactive arthritis), CRPS, and fibromyalgia, are inadequate, as they were not offered by a specialist as requested. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 270 (1998). The Board finds that the RO has not substantially complied with the Board's prior remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105-106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The actions requested on remand are not optional, nor may the RO substitute its judgment for the Board's in this regard. Accordingly, these matters must be remanded for compliance with the September 2020 Board remand directives. All outstanding VA and any relevant private treatment records should also be obtained. The VHA examiner should also review the detailed history of the Veteran's disorders in the September 2020 Board remand. 2. Entitlement to service connection for a low back disability, to include spondyloarthritis, is remanded. Regarding the Veteran's low back disorders, a complete history is reviewed in the September 2020 Board remand. In this regard, the Board continues to note that the January 2020 VA examiner stated the Veteran does not have a diagnosis of scoliosis. The Board notes this is also inconsistent with the medical evidence of record. Notably, the Veteran had spinal surgery in May 2015 to correct scoliosis. A December 2015 VA rheumatologist noted scoliosis was indeed corrected by surgery. The Veteran's December 1967 enlistment examination demonstrates a diagnosis of scoliosis with occasional backache rendered by a medical doctor. Whether the Veteran's scoliosis was corrected in 2015 and is no longer present is inconsequential, as the diagnosis was present during the appeal period and clearly noted on the Veteran's enlistment examination. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). The January 2020 VA examination is inadequate in this regard. The July 2021 examiner opined that the Veteran's May 2015 surgery was to correct an injury from a motor vehicle accident and not scoliosis and that the Veteran did not have scoliosis on MRI in 2019. The Board notes that his reasoning for denying a diagnosis of scoliosis is illogical as is noted above, the December 2015 VA rheumatologist noted that the May 2015 surgery corrected scoliosis, which would explain why it was not detected four years post-operation to correct the condition. Additionally, while opining the Veteran does not have scoliosis, the June 2021 VA examiner also opined that the Veteran's scoliosis was not aggravated by service and did not have its onset during active-duty service. The Board cannot deduce from the multiple and directly opposing opinions whether the July 2021 examiner believes the Veteran does or does not have a diagnosis of scoliosis at any time during the appeal period, or from April 8, 2011. Thus, the July 2021 VA examiner's opinion is inadequate and of no probative value. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (Once the VA undertakes the effort to provide an examination, it must provide an adequate one). A new medical opinion must be obtained on remand. All outstanding VA and any relevant private treatment records should also be obtained. 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 relevant private treatment records. 3. Then, pursuant to 38 C.F.R. § 20.906(a), obtain an expert VHA medical opinion from a rheumatologist to determine the nature and etiology of his musculoskeletal pain disorder, including but not limited to Reiter's Syndrome, reactive arthritis, fibromyalgia, and complex regional pain syndrome (CRPS). The entire claims file including this remand and the September 2020 Board remand must made available to and reviewed by the examiner. No additional examination is required unless the examiner deems it necessary. (a.) Following a review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's Reiter's Syndrome, reactive arthritis, fibromyalgia, or CPRS had their onset in or is otherwise related to his active-duty service, to include in-service symptoms representing the prodromal phase of any of the diagnosed disorders therein. In addressing this question, the examiner must address the following in his or her written opinion: 1. the Veteran's right foot stress fracture with edema diagnosed in June 1968 but unverified by x-ray; 2. the Veteran's July 1968 right thigh pain and calcium deposit; 3. the Veteran's 1968 Rubella infection and whether it could trigger the Veteran's reactive arthritis; 4. the Veteran's April 1969 letter to his mother reporting severe body soreness after playing linebacker for several years for the US Navy team; 5. the Veteran's report of severe right lower extremity pain in an April 1969 lay statement; 6. the Veteran's report of left ankle pain in September 1969; 7. the Veteran's February 1970 reports of dizziness, vomiting, sharp abdominal pain, epigastric tenderness diagnosed as an unspecified viral gastroenteritis and whether this infection could represent the onset of reactive arthritis; 8. the July 1975 treatment for sore throat that progressed to extreme myalgias followed by Bell's palsy lasting several months; 9. the July 1975 reports from the Veteran that he was having trouble closing his left eye and had pain in his left arm, left leg, left shoulder, and sacroiliac joints and whether this represents the onset of reactive arthritis or a flare/episode; 10. the May 1978 positive H1A-B27 test for rheumatoid arthritis; 11. the December 1978 complaint of arthritic pain lasting continuously for 9 months and reports of aching subcutaneous nodules; 12. the January, February, March, April, June, and August 1979 diagnoses of Reiter's Syndrome; 13. the August 1979 Medical Grand Rounds report from Dr. S.M., specifically the noted episodes of scrotal lesions beginning during the Veteran's active-duty service, the onset of a fever accompanied by extreme weakness with paresis and numbness occurring in 1975, and why these were discussed in the context of identifying Reiter's Syndrome in a VA medical training document; 14. the Veteran's reports that he was treated on multiple occasions in service for genitourinary problems and penile lesions he believed were venereal diseases; 15. the continued diagnosis of Reiter's Syndrome by a VA medical doctors in October 2010, December 2011, March 2012, December 2015, March 2016, November 2016, and August 2019; 16. the February 2011 VA diagnosis of CRPS with a history of Reiter's Syndrome and whether CRPS is a progression or residual of Reiter's Syndrome; 17. the March and May 2012 VA diagnosis of FMS with a history of Reiter's Syndrome and whether FMS is a progression or residual of Reiter's Syndrome; 18. the March 2016 Veteran lay statement that he sought treatment for symptoms of penile lesions and generalized joint pain from the time of his discharge in 1970 at college clinics and informally with the doctor for whom his mother worked (which you are to assume as true); 19. the Veteran's testimony in October 2018 that he was informed that his thoracolumbar spine was calcifying in the context of phleboliths and reactive arthritis; 20. the July 2014 lay statement from R.D. regarding the Veteran's in-service venereal diseases; 21. the March 2016 lay statement from the Veteran that he habitually engaged with sex workers while stationed in Puerto Rico and recalls repeated venereal infections therefrom for which he was treated by co-workers without documentation. A complete rationale should be given for all opinions and conclusions expressed. If the examiner is unable to render an opinion without resorting to speculation, a full rationale must be provided for reaching that conclusion. The examiner is asked to consider the relative infrequency and novel nature of the Veteran's diagnoses such that it was the subject matter of a VAMC Medical Grand Rounds in 1979. (b.) Additionally, if Reiter's Syndrome, reactive arthritis, fibromyalgia, or CPRS is related to service but other diagnosed conditions are not, please also opine as to whether it is at least as likely as not (50 percent or greater probability) that any disorders not service-connected are: 1. proximately due to; or 2. aggravated (worsened) by the service-connected disorder. Please answer both questions separately and note that the service-connected condition need not be service-connected, or even diagnosed, at the time the non-service-connected conditions are incurred to establish secondary service connection, and reliance on this fact will render any opinion inadequate. 4. Then request an addendum opinion with an examiner other than the January 2020 and June 2021 examiners to determine the nature and etiology of the Veteran's low back disabilities. After a review of the claims file, the examiner is asked to address the following: (a.) Identify all back disabilities diagnosed since July 2010, to include scoliosis, spinal stenosis, and degenerative disc disease, even if such disabilities have resolved. If any of these diagnoses are not warranted, please reconcile these findings with the diagnoses of the same the VA treatment records and in the case of scoliosis, the Veteran's enlistment examination. (b.) Please discuss documented scoliosis and determine whether such diagnosis is a developmental defect or a developmental 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 the diagnosed scoliosis is determined to be a congenital or developmental 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 congenital defect during his military service that resulted in additional back disability, to include as a result of the cumulative impact of playing as a linebacker on the 10th Naval Fleet football team in Puerto Rico and his reports of back pain therein. If so, please describe the resultant disability. 2. If the Veteran's scoliosis is determined to be a congenital or developmental disease, then is there clear and unmistakable (obvious, manifest, and undebatable) evidence that such disability existed prior to service? Please discuss the December 1967 Report of Medical History and the written diagnosis of scoliosis from a medical doctor and any other medical evidence supporting your conclusion. 3. If the answer to question (2) is yes, is there clear and unmistakable (obvious, manifest, and undebatable) evidence that the pre-existing scoliosis WAS NOT aggravated (worsened beyond natural progression) during service? 4. If the answer to (3) is no, then is it at least as likely as not that scoliosis is related to an in-service injury, event, or disease, including any football injuries? See April and May 1969 lay statements. (c.) For any other back disability diagnosed, including scoliosis if determined to not have a congenital origin, please opine as to whether it is as least as likely as not (50 percent or greater probability) that such disability: 1. had its onset in or is otherwise related to service, to include as a result of the cumulative impact of playing as a linebacker on the 10th Naval Fleet football team in Puerto Rico and his reports of back pain therein; 2. is proximately due to Reiter's syndrome, CRPS, or fibromyalgia (if service-connected); or 3. has been aggravated (worsened) by Reiter's syndrome, CRPS, or fibromyalgia (if service-connected). In answering these questions, the examiner must address the following: 1. the Veteran's long-standing development of phleboliths, also identified as calcium deposits or calcifications, and their impact, if any, on the Veteran's back disorder. 2. April 1969 Veteran lay statement where he reports practicing with the 10th Naval Fleet championship team as a defensive end and being extremely sore from not having any protective pads during practices; 3. the Veteran's May 1969 lay statement wherein he describes playing an entire football game in multiple positions as a left linebacker, center linebacker, middle guard, defensive end, and offensive end that resulted in generalized body soreness and palpable phleboliths, described as solid pieces of calcium in his muscle tissue; 4. the Veteran's October 2018 testimony that VA doctors informed him that calcium deposits forming on his spine were the etiology of his back disorders. A complete rationale should be given for all opinions and conclusions expressed. In addressing question (c), please presume all diagnosed back disorders other than scoliosis were not present at service entrance. If unable to opine without resorting to speculation, please provide a basis for reaching this conclusion. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Rouse, 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.