Citation Nr: 21070566 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-49 293 DATE: November 24, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for a right hand disability is remanded. Entitlement to service connection for a left hand disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from March 1989 to November 1993, including a deployment to the Arabian Sea during the Persian Gulf War. These matters come before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued by the Department of Veterans Affairs (VA). In March 2021, the Board remanded these matters for further development. The agency of original jurisdiction (AOJ) was asked to obtain VA examinations and medical opinions considering, among other things, whether any of the Veteran's disorders had a fully-explained, partially-explained, or unexplained etiology. The Veteran appeared for VA examinations in June 2021. The June 2021 examiner provided an addendum medical opinion in September 2021. Regrettably, after reviewing the record, the Board finds that the opinions are not adequate and further clarification of the medical evidence is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (2011) (holding that the Board errs, as a matter of law, when it fails to ensure substantial compliance with its own remand directives). The September 2021 VA examiner made conflicting findings in his medical opinion. He stated that "I opine that the etiology of the [disabilities] experienced by the Veteran since approximately May 2018 to include arthritis is due to the veteran serving as a machinist during service. His role as a machinist could have caused wear and tear of his [body] over time." However, he further stated that it is less likely than not that the Veteran's claimed conditions had their onset in service, manifested within one year after separation from service, or are otherwise related to an injury or disease during service. These findings are facially contradictory, and leave the Board in doubt as to the question of a nexus between the Veteran's disabilities and military service. Further clarification of the medical evidence is necessary. The Board sincerely regrets the delay occasioned by multiple remands and appreciates the Veteran's patience as VA works to fulfill its statutory obligation to assist him in obtaining evidence necessary to support his claims for compensation. The matters are REMANDED for the following actions: 1. Secure for the record copies of complete updated clinical records of all VA and non-VA treatment the Veteran has received for the disorders on appeal. 2. Obtain an addendum medical opinion from a suitably qualified clinician other than the June 2021 examiner. The clinician is asked to review the claims file, and respond to the following: (I) For the Veteran's back disability: (a) Is the etiology of any back disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (b) Is the pathophysiology of any back disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (c) If both the etiology and pathophysiology for any back disability experienced by the Veteran since approximately May 2018are partially understood or fully understood, then is it at least as likely as not that the disability (1) had its onset in service; (2) manifested within one year after separation from service (in the case of any currently diagnosed arthritis); OR (3) is causally related to an event, injury, or disease during service? (II) For the Veteran's cervical spine disability: (a) Is the etiology of any cervical spine disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (b) Is the pathophysiology of any cervical spine disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (c) If both the etiology and pathophysiology for any cervical spine disability experienced by the Veteran since approximately May 2018 are partially understood or fully understood, then is it at least as likely as not that the disability (1) had its onset in service; (2) manifested within one year after separation from service (in the case of any currently diagnosed arthritis); OR (3) is causally related to an event, injury, or disease during service? (III) For the Veteran's knee disability: (a) Is the etiology of any knee disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (b) Is the pathophysiology of any knee disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (c) If both the etiology and pathophysiology for any knee disability experienced by the Veteran since approximately May 2018 are partially understood or fully understood, then is it at least as likely as not that the disability (1) had its onset in service; (2) manifested within one year after separation from service (in the case of any currently diagnosed arthritis); OR (3) is causally related to an event, injury, or disease during service? (IV) For the Veteran's ankle disability: (a) Is the etiology of any ankle disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (b) Is the pathophysiology of any ankle disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (c) If both the etiology and pathophysiology for any ankle disability experienced by the Veteran since approximately May 2018 are partially understood or fully understood, then is it at least as likely as not that the disability (1) had its onset in service; (2) manifested within one year after separation from service (in the case of any currently diagnosed arthritis); OR (3) is causally related to an event, injury, or disease during service? (V) For the Veteran's elbow disability: (a) Is the etiology of any elbow disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (b) Is the pathophysiology of any elbow disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (c) If both the etiology and pathophysiology for any elbow disability experienced by the Veteran since approximately May 2018 are partially understood or fully understood, then is it at least as likely as not that the disability (1) had its onset inservice; (2) manifested within one year after separation from service (in the case of any currently diagnosed arthritis); OR (3) is causally related to an event, injury, or disease during service? (VI) For the Veteran's hand disability: (a) Is the etiology of any hand disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (b) Is the pathophysiology of any hand disability experienced by the Veteran since approximately May 2018, to include degenerative joint disease, (1) inconclusive, (2) partially understood, or (3) fully understood? (c) If both the etiology and pathophysiology for any hand disability experienced by the Veteran since approximately May 2018 are partially understood or fully understood, then is it at least as likely as not that the disability (1) had its onset in service; (2) manifested within one year after separation from service (in the case of any currently diagnosed arthritis); OR (3) is causally related to an event, injury, or disease during service? A complete rationale should be provided for all opinions. The examiner is advised that pain causing functional loss may be considered a disability for VA purposes. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). The clinician is asked to consider and discuss relevant lay and medical evidence, to specifically include: The Veteran's lay contentions that his disabilities are related to his work as a machinist's mate during naval service, ending in November 1993, or are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) as defined by applicable standards The Veteran's post-service employment, to include working as an operating engineer for an energy company, and 17 years as a "maintenance" worker. See CAPRI, April 2021 (MH Outpatient Note p.84); see also VA examination, November 2010. Service medical records, including August 1993 separation examination showing normal spine, neck, upper and lower extremities, and report of medical history in which the Veteran denied swollen or painful joints, recurrent back pain, painful or trick elbow, trick or locked knee, lameness, foot trouble, arthritis, rheumatism, or bursitis, and did not otherwise report back, neck, elbow, knee, ankle, or hand symptoms VA medical records, to include rheumatology consultations in September 2018 (finding, among other things, that the Veteran's hand problem is "mostly activity related") and December 2019 (documenting full range of motion in the hands and knees) The clinician is reminded that the term "at least as likely as not," does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the clinician's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Reed, 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.