Citation Nr: 21067123 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 17-28 080 DATE: November 3, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome, including as due to an undiagnosed disability, is remanded. Entitlement to service connection for chronic constipation (claimed as a gastrointestinal disability), including as due to an undiagnosed disability, is remanded. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a bilateral hip disability, including as due to an undiagnosed disability, is remanded. Entitlement to service connection for a bilateral hand disability, including as due to an undiagnosed disability, is remanded. Entitlement to service connection for a bilateral foot disability, including as due to an undiagnosed disability, is remanded. Entitlement to service connection for a right elbow disability, including as due to an undiagnosed disability, is remanded. Entitlement to service connection for a left elbow disability, including as due to an undiagnosed disability, is remanded. Entitlement to service connection for a bilateral knee disability, including as due to an undiagnosed disability, is remanded. Entitlement to a rating in excess of 20 percent for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran had active service from September 1977 to September 1999. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2010, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the Veteran's electronic claims folder. All matters are remanded. In April 2021, the Board remanded the matters to obtain a VA medical opinion regarding the etiology and current severity of the claimed disabilities. First, the Veteran has contended that his multiple joint disabilities (and chronic constipation and chronic fatigue syndrome) may be related to an undiagnosed illness due to serving in the Persian Gulf. In July 2021 opinions, the examiner opined that it was less likely than not that the Veteran's claimed joint disabilities (and chronic constipation and chronic fatigue syndrome) were related to service. She reasoned that the Veteran's symptoms were related to an undiagnosed illness and could not confirm a nexus without resorting to speculation. The clinician does not specify whether further medical information is needed to provide a nexus opinion. See Jones v. Shinseki, 23 Vet. App. 382 (2010)( If the examiner determines that an opinion cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed disorder, or whether the actual cause is due to multiple potential causes). Therefore, the Board finds that a remand is necessary to obtain addendum opinions. Second, the Veteran has contended that he is entitled to service connection for PTSD. Service connection has been granted for other specified trauma and stressor related diagnosis. VA treatment records indicate a 2019 diagnosis of chronic PTSD. In July 2021, the Veteran was afforded a VA PTSD examination where the examiner opined that the Veteran did not meet the criteria for a PTSD diagnosis under the DSM-5. The examiner does not address favorable evidence of a PTSD diagnosis. Therefore, the Board finds that a remand is necessary to obtain an addendum opinion. Third, the Veteran has contended that he is entitled to a rating in excess of 20 percent for his left shoulder disability because he is unable to lift his arm to pick up a piece of paper. See Board Hearing Transcript, p. 7. Also, in a July 2021 VA shoulder and arm examination, the examiner noted that the Veteran reported that he was unable to lift or raise his arm. However, the examiner also noted that the Veteran's range of motion testing revealed flexion to 135 degrees, abduction to 130 degrees, internal rotation to 40 degrees and external rotation to 45 degrees. The Board finds that these reported findings to be inconsistent with the Veteran's reported inability to basically move his left shoulder. Therefore, the Board finds that a remand is necessary to obtain an addendum opinion which reconciles the conflicting evidence regarding the severity of the Veteran's left shoulder disability. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from a clinician qualified to assess disabilities related to Gulf War syndrome as it relates to the etiology of the Veteran's chronic fatigue syndrome, chronic constipation, bilateral hip, bilateral hip, bilateral hand, bilateral foot, right elbow, left elbow, and bilateral knee disabilities. The Veteran's electronic claims folder, including a copy of this remand, should be provided to the clinician. The clinician is requested to provide an opinion as to the following: (a) The examiner should provide a diagnosis of any disorder manifested or, in the case that no diagnosis can be made, opine whether it is at least as likely as not (50 percent probability or greater) the Veteran's symptom or symptoms are related to an undiagnosed illness or related to a medically unexplained chronic multi symptom illness. (b) If the Veteran's symptoms of chronic fatigue are related to a diagnosed disability, whether it is at least as likely as not (50 percent probability or greater) that any diagnosed disorder began in or is related to the Veteran's active-duty service. (c) If the Veteran's symptoms of constipation are related to a diagnosed disability, whether it is at least as likely as not (50 percent probability or greater) that any diagnosed disorder began in or is related to the Veteran's active duty service. (d) The examiner should provide a diagnosis of any disorder manifested or, in the case that no diagnosis can be made, opine whether it is at least as likely as not (50 percent probability or greater) the Veteran's symptom or symptoms are related to an undiagnosed illness or related to a medically unexplained chronic multi symptom illness. (e) If the Veteran's symptoms of joint pain of the bilateral hip, hand, foot, elbow and knees are related to a diagnosed disability, whether it is at least as likely as not (50 percent probability or greater) that any diagnosed disorder began in or is related to the Veteran's active-duty service. The examiner is requested to address the Veteran's Board testimony that he had 253 jumps during service. See Board Hearing Transcript, p. 6. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain and tingling in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). The examiner should provide a complete rationale for any opinion provided. If the examiner determines that an opinion cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed disorder, or whether the actual cause is due to multiple potential causes. In other words, simply stating that an opinion cannot be provided without resort to mere speculation is not acceptable without a detailed reason as to why this is so. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 2. Obtain an addendum opinion from the July 2021 VA examiner (or an appropriate medical professional) regarding the Veteran's claimed PTSD disability. The electronic claims folder and a copy of this remand must be made available to the examiner. The examiner is requested to provide an opinion as to the following: Whether it is at least as likely as not (50 percent probability or greater) that the Veteran suffers from PTSD. The examiner is requested to specifically address evidence that in April 2019, a VA clinician diagnosed the Veteran with chronic PTSD. If so, whether it is at least as likely as not (50 percent probability or greater) that the Veteran's PTSD began in or is related to the Veteran's active-duty service. A complete rationale, with citation to appropriate medical principles, is requested. 3. Obtain an addendum opinion from the July 2021 VA examiner (or an appropriate medical professional) regarding the severity of the Veteran's left shoulder disability. The electronic claims folder and a copy of this remand must be made available to the examiner. The examiner should specifically reconcile evidence that the Veteran cannot do any lifting or raising of his left arm and is unable to lift his arm to pick up a piece of paper with any range of motion testing results. See Board Hearing Transcript, p. 7; July 2021 VA examination report. The examination report should also include joint testing for pain on both active and passive motion, in weight-bearing and non weight-bearing, for both the joint in question and any paired joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. See Correia v. McDonald, 28 Vet. App. 158 (2016). 4. Thereafter, readjudicate the issues on appeal as noted above. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period to respond. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Baskerville 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.