Citation Nr: 21071235 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-05 792A DATE: November 30, 2021 ORDER The petition to reopen the previously-denied claim for service connection for arthritis of the hips, legs, and knees is granted. REMANDED Entitlement to an initial rating in excess of 10 percent for service-connected coronary artery disease (CAD) is remanded. Entitlement to service connection for arthritis of the hips, legs, and knees (also claimed as rheumatoid arthritis and generalized arthritis) is remanded. Entitlement to service connection for arthritis in the bilateral feet, to include as secondary to arthritis of the hips, legs, and knees (also claimed as rheumatoid arthritis and generalized arthritis), is remanded. Entitlement to service connection for arthritis in the bilateral hands, to include as secondary to arthritis of the hips, legs, and knees (also claimed as rheumatoid arthritis and generalized arthritis), is remanded. Entitlement to service connection for arthritis in the left wrist, to include as secondary to arthritis of the hips, legs, and knees (also claimed as rheumatoid arthritis and generalized arthritis), is remanded. Entitlement to service connection for arthritis in the lumbar spine, to include as secondary to arthritis of the hips, legs, and knees (also claimed as rheumatoid arthritis and generalized arthritis), is remanded. FINDING OF FACT 1. In a July 1991 rating decision, the agency of original jurisdiction (AOJ) denied the Veteran's claim for service connection for arthritis of the hips, legs, and knees; he did not initiate an appeal of that decision. 2. Additional evidence associated with the claims file since the July 1991 rating decision is not cumulative or redundant of the evidence of record at the time of the prior denial, it relates to unestablished facts necessary to substantiate the claim for service connection for arthritis of the hips, legs, and knees, and it raises a reasonable possibility of substantiating the claim. CONCLUSION OF LAW 1. The July 1991 rating decision that denied the Veteran's claim for service connection for arthritis of the hips, legs, and knees is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.1103. 2. As evidence received since the July 1991 rating decision is new and material, the criteria for reopening the claim for service connection for arthritis of the hips, legs, and knees are met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1965 to January 1991. In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. Petition to Reopen The AOJ originally denied the Veteran's claim for service connection for arthritis of the hips, legs, and knees in a July 1991 rating decision because the presence of a current disability had not been established. The Veteran did not initiate an appeal of that decision. As such, the July 1991 rating decision is final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Newly received evidence includes medical records showing diagnoses of rheumatoid arthritis, generalized arthritis, reactive arthritis, and pauciarticular undifferentiated arthritis. Also, a January 2014 VA examination report noted a diagnosis of rheumatoid arthritis affecting the spine, sacroiliac joints, shoulders, wrists, hands/fingers, and hips. The Board finds that the evidence received constitutes new and material evidence under the provisions of 38 C.F.R. § 3.156, and his claim is reopened. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for service-connected CAD The most recent VA examination to assess the nature and severity of the Veteran's service-connected CAD occurred in September 2014. Subsequently, during his July 2021 hearing before the undersigned Veterans Law Judge, he indicated that his symptoms may have progressed. See July 2021 Hearing Transcript, pp. 18-19. In order to ascertain the current nature and severity of the Veteran's service-connected CAD, the Board finds that a more contemporaneous examination is needed. 2. Service Connection Claims The Veteran claims entitlement to service connection for rheumatoid arthritis and/or generalized arthritis of various joints that he claims had its onset during his active duty. For example, in June 2014, the Veteran's wife opined that his rheumatoid arthritis/reactive arthritis may be related to his contraction of gonorrhea during his active duty. Further, she argued that the Veteran's diagnosis and treatment for onychomycosis during service was further evidence that his rheumatoid arthritis manifested during his active duty. In support of this, she submitted an article titled "Reactive Arthritis (Reiter Syndrome) Mimicking Onychomycosis." During his July 2021 hearing before the undersigned Veterans Law Judge, the Veteran argued that his currently-diagnosed rheumatoid arthritis and/or generalized arthritis of various joints was directly related to the osteoarthritis noted on his October 1990 Report of Medical History. He also argued that his rheumatoid arthritis and/or generalized arthritis had slowly progressed throughout his body, and that it now affected his back, his feet, his hands and fingers, his wrists, his knees, and his hips. The Veteran also attributes his current disabilities to his in-service diagnosis of and treatment for joint problems in his knees, feet, and hips, as well as the wear and tear associated with his service. See June 2014 Letter from Veteran's Wife. In reviewing the Veteran's service treatment records, a June 1970 service treatment record indicates that he sustained a right-hand injury. A January 1976 service treatment record noted his report of recurrent pain in the bone of his great right toe. X-rays did not reveal arthritic changes, and he was assessed with a normal joint. A January 1983 service treatment record noted the Veteran's report of pain in his upper legs and hips for three years. A February 1983 service treatment record noted a diagnosis of degenerative joint disease in the left hip. A March 1983 record noted that he was seen for a follow-up to rule out arthritis in the bilateral hips. After noting that examination revealed right hip pain and bilateral hip tenderness, the Veteran was diagnosed with rule out arthritis of the right hip. He was seen in September 1983 seeking medication to treat the arthritis in his hip joint. A November 1985 Report of Medical History noted the Veteran's report of arthritis, rheumatism, or bursitis, and the treatment provider noted that he experienced hip pain. A June 1987 service treatment record noted his report of a swollen and panful left knee for the past four weeks. He was diagnosed with left knee pain. An October 1990 Report of Medical History noted the Veteran's report of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and foot trouble, and the treatment provider noted that he had osteoarthritis (although the joint(s) affected was not clearly identified). The treatment provider also noted that the Veteran had to have his toenails removed four times. Post-service treatment records show numerous diagnoses pertaining to the Veteran's various joints. For example, a March 1991 VA examination report noted his report of a sore lower back. A September 2001 treatment record noted his diagnosis of osteoarthritis of the lumbar spine. A May 2003 treatment record noted a probable loose body in the left knee. A July 2008 radiology report indicated a diagnosis of pauciarticular arthritis. An October 2008 treatment record noted that the Veteran experienced joint pain in his fingers. A December 2008 treatment record noted a suggestion of rheumatoid arthritis of the left wrist. An April 2011 treatment record noted a diagnosis of inflammatory arthritis of the proximal and distal interphalangeal joint of the right and left fingers. A February 2012 treatment record notes a diagnosis of rheumatoid arthritis. The Veteran underwent VA examinations in January 2014. For the non-degenerative arthritis examination, the examiner noted the diagnoses of rheumatoid arthritis and degenerative joint disease with intervertebral disc syndrome of the thoracolumbar spine. The joints involved included the Veteran's thoracolumbar spine, the sacroiliac joints, the bilateral shoulders, the bilateral wrists, the bilateral hands and fingers, and the bilateral hips. During the lumbar spine examination, he reported that his lumbar spine symptoms began in August 1986. Ultimately, the examiner opined that the Veteran's lumbar spine disability was less likely than not directly related to his military service. The examiner reasoned that the service treatment records showed no complaints or treatment associated with the lumbar spine. Instead, the examiner noted that spine degenerative was mostly caused by ageing, and there was no indication of any condition in the service treatment record that would cause degeneration. The examiner also opined that the Veteran's hip problems and rheumatoid arthritis were less likely than not directly related to his military service. The examiner reasoned that, while the service treatment records showed complaints and treatment for his bilateral hips, X-rays were negative, and there were no complaints or treatment associated with rheumatoid arthritis. Given the conflicting medical evidence of record and the new testimony provided by the Veteran before the Board, there remain open medical questions that should be addressed by a medical professional before the Board can issue an informed decision. On remand, a medical opinion addressing the etiology of the Veteran's disabilities should be obtained, which takes into account all the in-service and post-service medical histories, as well as the Veteran's contentions. On remand, the AOJ should also associate with the record any outstanding VA treatment records that are not currently associated with the claims file. Additionally, the Veteran should be given the opportunity to identify any outstanding pertinent evidence. The matters are REMANDED for the following action: 1. Associate with the Veteran's claims file any VA treatment records dated from March 10, 2015, to the present. 2. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file, to include any records from the Brooke Army Medical Center. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. Schedule the Veteran for an appropriate examination to determine the current nature and severity of his service-connected CAD. The entire record must be made available to and be reviewed by the examiner, and the examination report should note that review. Any indicated evaluations, studies, and tests should be conducted. The examiner should identify the nature and severity of all current manifestations of his service-connected CAD. All examination findings/testing results, along with a complete, clearly-stated rationale for any opinion offered, must be provided. 4. Schedule the Veteran for appropriate examinations by competent medical professionals to determine whether his currently-diagnosed rheumatoid arthritis/generalized arthritis/reactive arthritis and any currently-diagnosed disabilities of the lumbar spine, bilateral hands, bilateral feet, bilateral hips, bilateral knees, and/or left wrist had their onset during, or are otherwise related to his military service. The record must be made available to the examiner. The examiner should take a history from the Veteran as to the progression of his claimed disabilities. Following a review of the entire record, to include the Veteran's lay statements concerning onset of symptoms, the examiner(s) should address the following questions: (a) Clarify the Veteran's diagnoses related to his claimed rheumatoid arthritis/generalized arthritis/reactive arthritis and/or any currently-diagnosed disabilities of the lumbar spine, bilateral hands, bilateral feet, bilateral hips, bilateral knees, and/or left wrist. By way of history, a September 2001 treatment record noted osteoarthritis of the lumbar spine; a July 2008 radiology report indicated a diagnosis of pauciarticular arthritis; a December 2008 treatment record noted a suggestion of rheumatoid arthritis of the left wrist; an April 2011 treatment record noted a diagnosis of inflammatory arthritis of the proximal and distal interphalangeal joint of the right and left fingers; and a February 2012 treatment record noted a diagnosis of rheumatoid arthritis. (b) For each identified arthritis, is it at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset during the Veteran's active duty service, or manifested within one year following his separation from service in January 1991? In providing a response, please consider and discuss a February 1983 service treatment record noted a diagnosis of degenerative joint disease in the left hip; and an October 1990 Report of Medical History noted that he had osteoarthritis (although the joint(s) affected was not clearly identified). Please also respond to the Veteran's contention that his diagnosis and treatment for onychomycosis during service was evidence that his rheumatoid arthritis manifested during his active duty. In support of this, the Veteran submitted an article in June 2014 titled "Reactive Arthritis (Reiter Syndrome) Mimicking Onychomycosis." (c) With regard to any identified rheumatoid arthritis/generalized arthritis/reactive arthritis and/or any currently-diagnosed disabilities of the lumbar spine, bilateral hands, bilateral feet, bilateral hips, bilateral knees, and/or left wrist that is not believed to have in-service onset, is it at least as likely as not (i.e., a 50 percent or greater probability) that such is otherwise related to his period active service? In providing a response, the examiner should consider and comment on the Veteran's contention that his rheumatoid arthritis/reactive arthritis may be related to his contraction of gonorrhea during his active duty. The Veteran also argues that his currently-diagnosed rheumatoid arthritis and/or generalized arthritis of various joints was directly related to the osteoarthritis noted on his October 1990 Report of Medical History. He also argued that his rheumatoid arthritis and/or generalized arthritis had slowly progressed throughout his body, and that it now affected his back, his feet, his hands and fingers, his wrists, his knees, and his hips. The Veteran also attributes his current disabilities to his in-service diagnosis of and treatment for joint problems in his knees, feet, and hip, as well as the wear and tear associated with his military service. See June 2014 Letter from Veteran's Wife. To assist in review, the Board highlights the following service treatment records: a June 1970 service treatment record indicating that the Veteran sustained a right-hand injury; a January 1976 service treatment record noting the Veteran's report of recurrent pain in the bone of his great right toe; a February 1983 service treatment record noting a diagnosis of degenerative joint disease in the left hip; a November 1985 Report of Medical History noted the Veteran's report of arthritis, rheumatism, or bursitis, and the treatment provider noted that he experienced hip pain; a June 1987 service treatment record noted the Veteran's report of a swollen and panful left knee for the past four weeks; and an October 1990 Report of Medical History noted the Veteran's report of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and foot trouble, and the treatment provider noted that he had osteoarthritis (although the joint affected by the osteoarthritis was not clearly identified). The treatment provider also noted that the Veteran had to have his toenails removed four times. Finally, the examiner should note that the Veteran reported low back pain during his March 1991 VA examination, approximately two months after his discharge from active duty, and he reported that his low back pain started in 1986 during the January 2014 VA examination. (d) If any identified rheumatoid arthritis/generalized arthritis/reactive arthritis is deemed to be related to the Veteran's military service, is it at least as likely as not (i.e., a 50 percent or greater probability) that any currently-diagnosed disabilities of the lumbar spine, bilateral hands, bilateral feet, bilateral hips, bilateral knees, and/or left wrist are caused and/or aggravated by any identified rheumatoid arthritis/generalized arthritis/reactive arthritis? The Board emphasizes that causation and aggravation are two separate inquiries, and both must be answered. A complete rationale must be provided for any opinion provided, and must be reflect consideration of all pertinent lay and medical evidence. 5. Thereafter, and after any further development deemed necessary, the issues on appeal should be readjudicated. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Springer, 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.