Citation Nr: 21071218 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-58 389 DATE: November 30, 2021 REMANDED Entitlement to service connection for numbness and pain of the right foot, to include gout, is remanded. Entitlement to service connection for numbness and pain of the left foot, to include gout, is remanded. Entitlement to service connection for numbness and pain of the right wrist and right hand, to include gout, is remanded. Entitlement to service connection for numbness and pain of the left wrist and left hand, to include gout, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1988 to August 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision. In March 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. The Veteran's claims for service connection were remanded by the Board in May 2021. Unfortunately, the Veteran's claims must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims, so he is afforded every possible consideration. 1. Entitlement to service connection for numbness and pain of the right foot, to include gout, is remanded. 2. Entitlement to service connection for numbness and pain of the left foot, to include gout, is remanded. 3. Entitlement to service connection for numbness and pain of the right wrist and right hand, to include gout, is remanded. 4. Entitlement to service connection for numbness and pain of the left wrist and left hand, to include gout, is remanded. The above claims for service connection were remanded by the Board in May 2020 to obtain appropriate examinations and medical opinions to determine the nature and etiology of any disabilities manifested by the Veteran's bilateral foot numbness and pain and bilateral hand and wrist numbness pain. Following the remand, the Veteran was afforded a May 2021 VA Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire. The examination report indicates that the Veteran has diagnoses of flat foot, hallux valgus, degenerative arthritis, monoclonal gammopathy with bilateral lower extremity peripheral neuropathy, and myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities. The Veteran was also provided a May 2021 VA Hand and Finger Conditions Disability Benefits Questionnaire. The examination report demonstrates that the Veteran has diagnoses of, in pertinent part, myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities. Lastly, the Veteran was afforded a May 2021 VA Wrist Conditions Disability Benefits Questionnaire. The examination report states that the Veteran has diagnoses of myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities. The Veteran's claims folder contains three corresponding May 2021 VA medical opinions. One May 2021 VA medical opinion states that the Veteran's alcoholic peripheral neuropathy, monoclonal gammopathy peripheral neuropathy, and cocaine induced multiple mononeuropathy claimed as numbness and pain of the right foot, to include gout are less likely than not incurred in or caused by both feet during service. In support, the medical opinion provides that the Veteran's claims folder does not contain any complaints or diagnosis of peripheral neuropathy during or proximate to his active service. The Veteran's medical records indicate that he has a 24-year history of alcohol abuse and a 17-year history of cocaine abuse. Long-term alcohol abuse is a known cause of permanent peripheral neuropathies and long-term cocaine abuse is a known cause of multiple mononeuropathy according to the medical opinion. A review of the Veteran's medical record indicates that he had elevated uric acid (gout) in 2009, which can cause symptoms of neuropathy. However, the medical literature indicates lowering uric acid to within normal range improves neuropathic symptoms and the Veteran has had normal uric acid levels since August 14, 2009. The medical record includes neurology notes from 2011 and 2016 that attribute the Veteran's bilateral lower extremity neuropathy to monoclonal gammopathy peripheral neuropathy. The medical opinion lastly states that the Veteran has myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities that was diagnosed in 2016. May 2021 VA medical opinions also provide that the Veteran's alcoholic peripheral neuropathy, monoclonal gammopathy peripheral neuropathy, and myeloma with bilateral upper and bilateral lower neuropathy, cocaine induced multiple mononeuropathy, bilateral carpal tunnel syndrome onset 2011 confirmed by nerve conduction velocity testing, claimed as numbness and pain of the bilateral wrist and hand, to include gout, is less likely as not incurred in or caused by the numbness in his hands during service. In support, the medical opinion states that there are no complaints or diagnosis of peripheral neuropathy during or proximate to the Veteran's active service. Nerve conduction velocity testing showed bilateral carpal tunnel syndrome in 2011. Again, the Veteran's medical records indicate that he has a 24-year history of alcohol abuse and 17-year history of cocaine abuse. The medical opinion states that long-term alcohol abuse is a known cause of permanent peripheral neuropathies and long-term cocaine abuse is a known cause of multiple mononeuropathy. A review of the Veteran's medical record indicates that he had elevated uric acid (gout) in 2009, which can cause symptoms of neuropathy. However, medical literature demonstrates that lowering uric acid to within normal range improves neuropathic symptoms and the Veteran has normal uric acid levels since August 14, 2009. The Veteran also has myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and bilateral upper extremities diagnosed in 2016. The Veteran's claims folder also contains an additional July 2021 VA medical opinions that states that it is less likely than not that his bilateral flat foot (pes planus), bilateral hallux valgus, and bilateral degenerative arthritis had their onset during his active service and are not related to any incident of service, to include his exposure to cold weather for two weeks and his in-service diagnosis of "frostbite due to prolonged exposure to cold." In support, the medical opinion provides that there is no evidence of complaints or diagnosis of peripheral neuropathy during the Veteran's active service. The Veteran's bilateral pes planus was diagnosed at the time of his enlistment and there is no indication that his bilateral pes planus was aggravated beyond its natural progression during or proximate to his active service. Exposure to cold is not a risk factor for the development of bilateral pes planus, bilateral hallux valgus, or bilateral degenerative arthritis. The Board finds that the above medical opinions are inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The medical opinions are based, in part, upon an absence of contemporaneous documentation of complaints and treatment for peripheral neuropathy. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (holding that the absence of contemporaneous medical records does not, in and of itself, render lay testimony not credible). Further, there is no showing that the examiner considered the Veteran's lay statements regarding the onset of his disability during his active service, the continuity of his symptoms since his active service, and his post-service alcohol use. See Miller v. Wilkie, 32 Vet. App. 249 (2020) (holding that the Board errs when it relies on an examination that fails to consider the veteran's relevant statements and the Board is silent on the credibility of these statements). The medical opinions also do not address the nature and etiology of the Veteran's myeloma. Lastly, the Veteran's claim for service connection for numbness and pain of the left foot, to include gout, was not addressed following the Board's May 2021 remand. Therefore, addendum medical opinions are warranted to address the nature and etiology of the Veteran's disabilities on a direct basis. A separate July 2021 VA medical opinion states that it is less likely than not that the Veteran's bilateral pes planus, bilateral hallux valgus, and bilateral degenerative arthritis, claimed as a disorder manifested by pain and numbness of the feet, to include gout and polyneuropathy were caused by the Veteran's herpes simplex virus type 2, to include Acyclovir, the medication he takes for the condition. The medical opinion states that there is no evidence of complaint or diagnosis of peripheral neuropathy during or proximate to the Veteran's active service. Bilateral pes planus was noted on the October 1987 enlistment examination without complaints of aggravation during or proximate to his active service. The Veteran's diagnosis of herpes simplex virus type 2 that is treated with Acyclovir, is not a risk factor for the development of bilateral pes planus, bilateral hallux valgus, or bilateral degenerative arthritis according to the medical opinion. The Board finds that the above July 2021 VA medical opinion is inadequate as the examiner did not provide any evidence in support of the conclusion that Acyclovir is not a risk factor for the development of bilateral pes planus, bilateral hallux valgus, or bilateral degenerative arthritis. Further, the examiner did not consider whether the Veteran's bilateral pes planus, bilateral hallux valgus, or bilateral degenerative arthritis were aggravated beyond its natural progression by medication used to treat his service-connected herpes simplex virus type 2. 38 C.F.R. § 3.310(b); see El-Amin v. Shinseki, 26 Vet. App. 136 (2012) (a medical opinion addressing secondary service connection must discuss both causation and aggravation). Therefore, addendum medical opinions are necessary to determine the nature and etiology of the Veteran's bilateral pes planus, bilateral hallux valgus, or bilateral degenerative arthritis. The matters are REMANDED for the following action: 1. Undertake efforts to verify the Veteran's current mailing address. As noted in the Veteran's VA treatment records, he reported being unhoused and has recently been residing in hotels. Document all requests for verification and responses in the Veteran's claims folder. 2. Obtain the Veteran's VA treatment records for the period from June 2021 to the present. 3. After the above development is completed, obtain addendum medical opinions from an appropriate clinician to determine the nature and etiology of the Veteran's bilateral lower extremity disabilities, including flat foot, hallux valgus, degenerative arthritis, monoclonal gammopathy with bilateral lower extremity peripheral neuropathy, and myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities. The clinician must review the claims file. The clinician must: (a.) Opine as to whether it is at least as likely as not (50 percent or greater probability) that any current bilateral lower extremity disability had its clinical onset during active service or is related to any in service disease, event, or injury, to include the Veteran's exposure to cold weather for two weeks and his in-service diagnosis of "frostbite due to prolonged exposure to cold." See December 1989 Service Treatment Record. (b.) Opine as to whether it is at least as likely as not (50 percent or greater probability) that any current bilateral lower extremity disability was caused by the Veteran's service-connected herpes simplex II and/or related treatment, including Acyclovir. (c.) Opine as to whether it is at least as likely as not (50 percent or greater probability) that any current bilateral lower extremity disability was caused by the Veteran's service-connected herpes simplex II and/or related treatment, including Acyclovir. (d.) Opine as to whether it is at least as likely as not (50 percent or greater probability) that any current bilateral lower extremity disability was aggravated (i.e., worsened) by the Veteran's service-connected herpes simplex II and/or related treatment, including Acyclovir. NOTE: With respect to the question concerning aggravation, the clinician is advised that aggravation does not require that there be "permanent worsening" of the nonservice-connected disability. In providing these opinions, the clinician should consider: i. The Veteran's statements regarding onset and continuity of symptomatology of his claimed disabilities, i.e., since the in-service incident. See e.g., August 2016 Written Statement, March 2021 Board Hearing Transcript; and ii. Public Health information on Cold Injuries from the United States Department of Veterans Affairs submitted by the Veteran in July 2016 advising that cold injuries may result in long-term health problems, including neurologic injury with symptoms such as bouts of pain in the extremities, hot or cold tingling sensations, and numbness; and iii. The journal article submitted in March 2021 titled "Chronic non-freezing cold injury results in neuropathic pain due to sensory neuropathy"; and iv. The Veteran's assertion that he did not use alcohol while he was imprisoned for approximately 11 years post service. The complete rationale for all opinions expressed must be set forth in the examination report. 4. Obtain addendum medical opinions from an appropriate clinician to determine the nature and etiology of the Veteran's bilateral upper extremity disabilities, including myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities. The clinician must review the claims file. The clinician must: (a.) Opine as to whether it is at least as likely as not (50 percent or greater probability) that any current bilateral upper extremity disability had its clinical onset during active service or is related to any in service disease, event, or injury, to include the Veteran's exposure to cold weather for two weeks and his in-service diagnosis of "frostbite due to prolonged exposure to cold." See December 1989 Service Treatment Record. If it is determined that any bilateral lower extremity disability is related to service or to the Veteran's service-connected herpes simplex II, then the clinician must: (b.) Opine as to whether it is at least as likely as not (50 percent or greater probability) that any bilateral upper extremity disability, including myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities was caused by his now service-connected bilateral lower extremity disability. (c.) Opine as to whether it is at least as likely as not (50 percent or greater probability) that any bilateral upper extremity disability, including myeloma based on bone marrow biopsy with peripheral neuropathy to bilateral lower and upper extremities was aggravated (i.e., worsened) by his now service-connected bilateral lower extremity disability. NOTE: With respect to the question concerning aggravation, the clinician is advised that aggravation does not require that there be "permanent worsening" of the nonservice-connected disability. In providing these opinions, the clinician should consider: i. The Veteran's statements regarding onset and continuity of symptomatology of his claimed disabilities, i.e., since the in-service incident. See e.g., August 2016 Written Statement, March 2021 Board Hearing Transcript; and ii. Public Health information on Cold Injuries from the United States Department of Veterans Affairs submitted by the Veteran in July 2016 advising that cold injuries may result in long-term health problems, including neurologic injury with symptoms such as bouts of pain in the extremities, hot or cold tingling sensations, and numbness; and iii. The journal article submitted in March 2021 titled "Chronic non-freezing cold injury results in neuropathic pain due to sensory neuropathy"; and iv. The Veteran's assertion that he did not use alcohol while he was imprisoned for approximately 11 years post service. The complete rationale for all opinions expressed must be set forth in the examination report. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mussey, Sean 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.