Citation Nr: 21066660 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-45 918 DATE: November 1, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for joint pain is remanded. Entitlement to service connection for a right leg disability is remanded. Entitlement to service connection for a left leg disability is remanded. Entitlement to service connection for anemia claimed as fatigue is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from April 1987 to February 1993. She had active service in the Southwest Asia Theater of Operations during the Persian Gulf War. This matter comes before the Board of Veterans Appeals (Board) on appeal from October 2013 and February 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in May 2019 when it was remanded to the Agency of Original Jurisdiction (AOJ) for additional development. In May 2019, the Board also remanded the issues of service connection for migraine headaches and gastroesophageal reflux disease. In an October 2020 rating decision, the RO granted service connection for migraine headaches and gastroesophageal reflux disease, which constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, these matters are no longer in appellate status. 1. Entitlement to service connection for a low back disability is remanded. 2. Entitlement to service connection for a neck disability is remanded. 3. Entitlement to service connection for joint pain is remanded. 4. Entitlement to service connection for a right leg disability is remanded. 5. Entitlement to service connection for a left leg disability is remanded. The Veteran contends, through her representative, that her musculoskeletal conditions were caused or aggravated by weight gain secondary to her service-connected PTSD. See Third Party Correspondence, received November 2020. While obesity itself cannot be service-connected on a direct basis, it may potentially serve as an intermediate step between a service-connected disability and a claimed secondary disability. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). On remand, a supplemental medical opinion should be provided addressing whether the Veteran's musculoskeletal conditions are secondary to her service-connected PTSD, including on this basis. The May 2019 Board remand directed the examiner to address whether the Veteran's musculoskeletal conditions were due to her service-connected disabilities. While the Veteran was afforded examinations in August 2019, an opinion as to secondary service connection was not provided. Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The Board sincerely regrets the additional delay occasioned by multiple remands. However, the Board errs when it fails to ensure substantial compliance with a Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). Where the Board fails to ensure substantial compliance, remand is appropriate. Stegall, 11 Vet. App. at 271. 6. Entitlement to service connection for anemia claimed as fatigue is remanded. The Veteran contends, through her representative, that her fatigue constitutes a medically unexplained chronic multi-symptom illness (MUCMI) pursuant to 38 U.S.C. § 1117. See Third Party Correspondence, received November 2020. The Veteran received a VA examination in September 2013 diagnosing her with anemia. The Veteran's August 2019 examination revealed no diagnosis of anemia or fibromyalgia, despite still experiencing fatigue. The rationale provided did not address the Veteran's symptoms of fatigue. Accordingly, an examination to determine the nature and etiology of her fatigue symptoms is warranted. The matters are REMANDED for the following action: 1. Obtain an addendum opinion to determine the nature and etiology of the Veteran's low back disability, neck disability, right leg disability, left leg disability, and unspecified joint pain. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand, the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to factual matters of which she had first-hand knowledge. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. After examining the Veteranif deemed necessary by the examinerand considering her pertinent medical history and lay statements regarding her reported symptoms, the examiner should opine as to: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that her low back disability, neck disability, right leg disability, left leg disability, and/or unspecified joint pain were incurred in, aggravated by, or etiologically related to her military service, to include vibration exposure. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that her low back disability, neck disability, right leg disability, left leg disability, and/or unspecified joint pain were caused by or aggravated by her service-connected disabilities, to include PTSD. (c) Whether it is at least as likely as not (a 50 percent probability or greater) that her low back disability, neck disability, right leg disability, left leg disability, and/or unspecified joint pain were aggravated by her service-connected disabilities, to include PTSD. (d) The clinician should also provide an opinion as to whether it is at least as likely as not (a probability of 50 percent or greater) that any service-connected disability, either alone or in combination with another service-connected disability or disabilities, caused or aggravated the Veteran's weight gain or obesity. (e) If the answer to the above question is yes, whether it is at least as likely as not (50 percent or greater probability) that the weight gain or obesity resulting from the service-connected disability or disabilities was a substantial factor in causing or aggravating the Veteran's low back disability, neck disability, right leg disability, left leg disability, and/or unspecified joint pain. (f) If the answer to the above question is yes, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's low back disability, neck disability, right leg disability, left leg disability, and/or unspecified joint pain would not have occurred but for weight gain or caused or aggravated by the service-connected disability or disabilities. Aggravation is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. The examiner is advised that a finding that a disability was aggravated beyond the normal progression due to a service-connected disability does not require evidence of permanent worsening and may encompass any additional impairment in earning capacity resulting from an already service-connected condition. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. Obtain an addendum opinion to determine the nature and etiology of the Veteran's anemia claimed as fatigue. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand, the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to factual matters of which she had first-hand knowledge. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. After examining the Veteranif deemed necessary by the examinerand considering her pertinent medical history and lay statements regarding her reported symptoms, the examiner is requested to provide the following information: Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran exhibits signs or symptoms (with specific consideration to her reports of fatigue) that constitute: (a) an undiagnosed illness; (b) a medically unexplained chronic multi-symptom illness; or (c) if the claimed symptoms can be attributed to a known diagnosis. The absence of evidence of treatment for the claimed conditions in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Javed, 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.