Citation Nr: 21069379 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 12-03 653 DATE: November 18, 2021 REMANDED Entitlement to service connection for aching joints and muscles is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1983 to March 1986 and from June 1991 to December 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision. The Veteran testified at a hearing before the undersigned Veterans Law Judge in June 2017. A transcript is of record. The Board remanded the case for further development in September 2017, June 2019, and November 2020. The case has since been returned to the Board for appellate review. The Board notes that the Veteran's appeal originally included the issues of entitlement to service connection for migraine headaches and posttraumatic stress disorder (PTSD). However, in a November 2018 rating decision, the agency of original jurisdiction (AOJ) granted service connection for those disabilities. The grant of service connection constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Therefore, those issues are no longer in appellate status, and no further consideration is necessary. In an April 2020 rating decision, the RO granted service connection for degenerative disc disease at L-2 and L5-S1. The issue of entitlement to service connection for aching joints other than the service-connected lumbar spine disability remains on appeal. Upon review, the Board finds that additional development is needed prior to adjudication of the issue on appeal. The AOJ obtained a VA medical opinion in January 2021. The examiner opined that the Veteran did not have a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multisystem illness. In so finding, the examiner stated that the Veteran had an extensive list of greater than 10 objective medical conditions that caused joint and muscle pain. Although the examiner provided a detailed review of the medical evidence of record, the Board finds that an additional medical opinion is necessary to address some remaining medical questions. For example, the examiner stated that multiple medical conditions affected the Veteran's lower extremities, including a right hip muscle tear, a right leg gunshot wound, right leg cellulitis, and bilateral heel spurs. The examiner also stated that the Veteran's right leg cellulitis that was diagnosed in 2008 likely resulted in pain in his lower extremities. However, the examiner ultimately concluded that an opinion was not warranted for the right hip, right leg gunshot wound, and right leg cellulitis because the injuries or illnesses resolved. Notably, the examiner did not provide an explanation as to why the Veteran's right leg cellulitis resulted in pain in both of his lower extremities. In addition, the examiner did not address the relevance, if any, of the VA medical records that document complaints of bilateral leg pain and left hip pain. See, e.g., September 2015 VA medical record (noting that the Veteran complained of left hip pain and an assessment of "chronic pain with likely pain generator due to central desensitization."); see also November 2020 VA medical record. Moreover, it is unclear whether the Veteran's right and left knee degenerative joint disease fully accounts for his reported lower extremity joint and muscle pain. In addition, the examiner stated that bilateral knee degenerative joint disease and cervical spine degenerative joint disease or degenerative disc disease are objective medical conditions and not undiagnosed illnesses. The examiner also stated that he agreed with the Veteran's treating physicians that his neck disorder was the most likely cause of his current shoulder and upper extremity symptoms. However, the examiner did not clearly address the pathophysiology of the Veteran's diagnosed disorders. See Stewart v. Wilkie, 30 Vet. App. 383, 390 (2018) (holding that an a medically unexplained multisymptom illness can occur when either the etiology or the pathophysiology of the illness is inconclusive). Moreover, the examiner did not provide an opinion as to whether the Veteran's diagnosed disorders were etiologically related to any in-service environmental exposures. Stegall v. West, 11 Vet. App. 268, 271 (1998). Based on the foregoing, a remand is necessary to obtain an additional VA medical opinion. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his joint pain. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of any joint and muscle pain other than pain associated with his service-connected degenerative disc disease of the lumbar spine. An additional physical examination should be performed only if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all disorders related to the Veteran's reported joint and muscle pain that have been present during the appeal period or within close proximity thereto. In so doing, he or she should fully address the Veteran's complaints of joint and muscle pain in his knees, legs, shoulders, arms, and cervical spine. The examiner should also address the prior diagnoses and VA examination findings of record, including the February 2004, March 2012, November 2017, and January 2020 VA examination reports. The examiner should also state whether there is any functional impairment caused by the Veteran's reported joint and muscle pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. For each diagnosis identified or any functional impairment resulting from pain, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested during active service or is otherwise causally or etiologically related to the Veteran's military service, to include any environmental exposures therein. If the examiner determines that the Veteran has any symptomatology that is not attributable to a diagnosed disorder of conclusive pathophysiology or etiology, the examiner should state whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multisymptom illness, as established by history, physical examination, and laboratory tests. If so, the examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) 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. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Wulff, 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.