Citation Nr: 21067670 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 15-16 195 DATE: November 5, 2021 REMANDED The issue of entitlement to an initial evaluation in excess of 10 percent disabling for the period prior to October 1, 2021, and a compensable rating for the period thereafter, to include propriety of the reduction, for service-connected degenerative arthritis left knee, limitation of flexion, is remanded. The issue of entitlement to an initial evaluation in excess of 10 percent disabling for service-connected degenerative arthritis left knee, limitation of extension, is remanded. The issue of entitlement to an initial evaluation in excess of 10 percent disabling for service-connected left knee instability, associated with degenerative arthritis left knee limitation of flexion, is remanded. The issue of entitlement to service connection for primary vitiligo is remanded. REASONS FOR REMAND The record shows periods of active service from January 2004 to September 2007, from April to September 2009, and in September 2012. In November 2017, the Veteran testified under oath at a travel board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In February 2021, the Board remanded the appeal for additional development. For the reasons outlined below, the Board finds that remand is again needed. Following the February 2021 Board remand, service connection was granted for left hand carpal tunnel syndrome, median nerve, as well as for median nerve, right hand carpal tunnel syndrome (major). See Rating Decision, August 2021. As this constitutes a full grant of the benefits sought, these issues are no longer on appeal. In addition, following the February 2021 Board remand, a 10 percent disability rating was awarded for service-connected left knee instability, associated with degenerative arthritis left knee limitation of flexion. See Rating Decision, August 2021. The Board has added this issue to the list of issues on appeal. Further, the evaluation for service-connected degenerative arthritis left knee limitation of flexion was decreased from 10 percent disabling to noncompensable, effective October 1, 2021. See Rating Decision, July 2021. The change in evaluation is reflected in the issues on appeal. 1. Entitlement to increased evaluations for the left knee disability. The Board finds that remand is again needed in this matter. First, the Board finds that a new VA examination is needed regarding the Veteran's left knee disability. In the February 2021 remand, the Board directed that fully range of motion (ROM) testing be conducted on both knees. However, in the April 2021 VA examination report, there does not appear to be information provided for the right knee for observed repetitive use ROM, repeated use over time, and flare-ups. The Board asks that results for testing of both knees be provided upon remand. See Correia v. McDonald, 28 Vet. App. 158 (2016). 2. Entitlement to service connection for primary vitiligo. In addition, the Board finds that a new opinion is needed regarding the claimed primary vitiligo. The Board acknowledges the April 2021 VA opinion, but finds that it does not provide an adequate rationale to justify the conclusions reached. For example, the rationale states: Vitiligo is an autoimmune disorder, and while the exact pathophysiology is not understood, there exists both a genetic predisposition and non genetic influence; neg opinion warranted. In response, the veteran's primary vitiligo, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by anthrax vaccination during service. However, the basis for the conclusion that the disability "clearly and unmistakably existed prior to service" and that it "was not aggravated beyond its natural progression by anthrax vaccination during service" remains unclear to the Board. For example, the opinion does not cite treatment records specific to the Veteran, nor does it reference medical treatises to support the conclusions reached. The Board also acknowledges a statement later in the opinion that: "There is insufficient clinical evidence to support vitiligo stemming from a vaccination, etiology is largely genetic; neg opinion warranted." However, again, this statement does not cite specific evidence, nor does it address potential aggravation. Further, the Board highlights the following from the Veteran's service treatment records, and requests that this evidence be considered by an examiner: (1) April 1986, January 1990, and November 1994 treatment records that indicate normal "skin, lymphatics"; (2) November 1999 treatment records that indicate normal skin and no past/current medical history of skin diseases; (3) a January 2004 treatment record that states: "Vitiligo in Oct 2003 progression arrested [with] topical steroid. Now req'ing no tx'd. Med cleared to activate"; (4) a January 2004 treatment record that states "New onset vitiligo [approximately] Oct 03; Tx'd [with] cream fluticasone [with] arrest of progression; (5) a March 2005 treatment record for vitiligo that states that the Veteran's "Sx worsen when go TDY + miss treatments"; (6) a January 2005 treatment record that states: "Missed 3 wks of therapy b/c of short notice TDY. Here for f/u vitiligo worsen over 3 mo [without] therapy. More patches on trunk/extremities, spreading + lighter in color." The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for a VA examination to evaluate the current level of severity of his knee disabilities. The claim folder and all pertinent treatment records should be made available to the examiner for review, and review of such records should be noted in any subsequent report. 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. The examiner is asked specifically to provide ROM for both knees for active motion, passive motion, weight-bearing, and nonweight-bearing. Full ROM testing also must be conducted on the opposite joint unless the opposite joint is damaged, which includes any disorder that would make the joint in question abnormal. If the opposite joint is determined to be damaged, and no ROM of testing is conducted, this must be explained in the report. In addition, for both knees the examiner must discuss pain for ROM movements on active, passive, and repetitive use testing. The examiner is asked to address the following questions: (a) Are any ROM movements painful on active, passive, and repetitive use testing? If yes, identify whether active, passive, and repetitive use. (b) If yes (there are painful movements), does the pain contribute to functional loss or additional limitation of ROM? Please further describe the functional loss or additional limitation of ROM. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. In addition, for both knees the examiner must discuss pain when used in weight-bearing or in nonweight-bearing. The examiner is asked to address the following questions: (a) Is there pain when the joint is used in weight-bearing or nonweight-bearing? If yes, identify whether weight-bearing or nonweight-bearing. (b) If yes (there is pain when used in weight-bearing or nonweight-bearing), does the pain contribute to functional loss or additional limitation of ROM? Please further describe these limitations. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. For all ranges and planes of motion where pain is noted, the exact point at which pain starts must be clearly noted. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups, as expressed in range of motion. To the extent possible, the examiner should identify any symptoms and functional impairments due to the knee disabilities and discuss the effect of the Veteran's knee disabilities on any occupational functioning and activities of daily living. The examiner should state whether or not there is any neurologic disability, to include of the lower extremities, that is the result of the knee disabilities. 3. Upon completion of the above, obtain an addendum opinion that addresses the claimed primary vitiligo. The examiner is asked to address the following: (a) Whether it is at least as likely as not that the disability clearly and unmistakably pre-existed service. (b) If there is clear and unmistakable evidence that the claimed disability pre-existed service, then the examiner should address whether there is clear and unmistakable evidence that the claimed disability was not permanently aggravated by service. If not, the examiner should then address whether it is at least as likely as not that it was caused by the Veteran's active duty service. The Board notes that a pre-existing injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38C.F.R. §3.306 (a). (c) If it is determined that the claimed disability did not clearly and unmistakably pre-exist service, then the examiner should address whether it is at least as likely as not that it was caused by the Veteran's active duty service. The examiner is asked to address the Veteran's contentions that when he first started his deployments, he went through a series of anthrax vaccinations and right after that, he noticed the pigmentation of his skin. The Board asks that the new VA opinion address the Veteran's contentions regarding his vaccinations. Further, the Board highlights the following from the Veteran's service treatment records, and requests that this evidence be considered by an examiner: (1) April 1986, January 1990, and November 1994 treatment records that indicate normal "skin, lymphatics"; (2) November 1999 treatment records that indicate normal skin and no past/current medical history of skin diseases; (3) a January 2004 treatment record that states: "Vitiligo in Oct 2003 progression arrested [with] topical steroid. Now req'ing no tx'd. Med cleared to activate"; (4) a January 2004 treatment record that states "New onset vitiligo [approximately] Oct 03; Tx'd [with] cream fluticasone [with] arrest of progression; (5) a March 2005 treatment record for vitiligo that states that the Veteran's "Sx worsen when go TDY + miss treatments"; (6) a January 2005 treatment record that states: "Missed 3 wks of therapy b/c of short notice TDY. Here for f/u vitiligo worsen over 3 mo [without] therapy. More patches on trunk/extremities, spreading + lighter in color." The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 4. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Foster, 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.