Citation Nr: 21072452 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 15-39 394 DATE: December 3, 2021 REMANDED Entitlement to service connection for right shoulder pain is remanded. Entitlement to service connection for bilateral wrist pain is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1976 to June 1992 and from January 2003 to March 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board last remanded the issues on appeal in July 2021. However, the Board finds that remand is necessary for additional development as discussed below. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for right shoulder pain is remanded. The Veteran seeks service connection for right shoulder pain. See April 2013 statement in support of claim. Specifically, the Veteran, through his representative, contends that his condition is due to exposure to a variety of environmental factors while in the Middle East, including exposure to burn pits, oil well fires, and toxin vapors. See November 2015 Statement of Accredited Representative. The Veteran, through his representative, also contends that the possibility of wearing heavy equipment on a military vehicle and restriction of movement may have caused shoulder pain. See November 2021 Written Brief Presentation. The Veteran's representative also cited a National Institute of Health report in which investigators proposed that loads carried by military personnel may contribute to injury susceptibility, and requested the Board remand to evaluate evidence on the effects of wearing an improvised outer tactical vest (OITV) during combat/training operations on the musculoskeletal system. See "The Influence of Body Armor on Balance and Movement Quality", available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033495/. Id. The Veteran was initially afforded a VA examination in November 2019. When VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For a medical opinion to be adequate, it must be: (1) based upon sufficient facts or data; (2) be the product of reliable principles and methods; and (3) be the result of principles and methods reliably applied to the facts. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). The November 2019 VA examiner noted the Veteran's report that his shoulders began to hurt while serving in Iraq in 2003 when he was under fire and had to dismount a vehicle to take cover. See November 2019 VA examination. The Veteran reported that he jumped off a 5-ton truck, sprained both ankles, and hurt his left shoulder. Id. The Veteran reported that his shoulder continued to bother him in service and the pain got progressively worse. Id. The VA examiner did not diagnose the Veteran with any right shoulder disability. Id. The VA examiner did not provide an etiological opinion for the Veteran's right shoulder pain. Id. As such, the Board finds the November 2019 VA examination inadequate for decision making purposes. See Nieves-Rodriguez, 22 Vet. App. at 302. In the Board's July 2021 remand, the Board directed the RO to obtain an addendum medical opinion to address the nature and etiology of the Veteran's claim right shoulder pain, including whether the Veteran has a current right shoulder disability, and discuss any functional impairment due to pain described by the Veteran. The Board directed the examiner to consider that pain alone resulting in functional impairment, even if there is no identifying underlying diagnosis, can constitute a disability. The Veteran was afforded an addendum VA medical opinion in August 2021. The VA examiner opined that it was less likely than not that the Veteran's claimed right shoulder condition was incurred in or caused by the claimed in-service injury, event, or disease. See August 2021 VA medical opinion. As rationale, the VA examiner determined that there was no chronic diagnosis made for right shoulder pain or a right shoulder condition. Id. The VA examiner noted the symptoms are subjective only. Id. The VA examiner noted the Veteran's service treatment records do not note medical evaluations, treatment, or a diagnosis for right shoulder pain or a right shoulder condition, and there is no objective medical evidence noted in the available medical records showing a link between the Veteran's current reported right shoulder condition and his military service. Id. The VA examiner noted the Veteran is deemed competent to provide a history of his symptoms and considered the Veteran's lay statements; however, the VA examiner noted the Veteran is not capable of diagnosing the medical condition related to those symptoms. Id. The Board finds remand is necessary for further development. The August 2021 VA examiner did not discuss any functional impairment due to pain described by the Veteran as directed by the Board's July 2021 remand directives. As noted, the Veteran previously reported that his shoulder pain continued to bother him while in service, especially carrying his ruck sack, weapons, and other equipment, and that the pain got progressively worse. See November 2019 VA examination. The VA examiner further noted that it was unsafe for the Veteran to perform repetitive overhead tasks and lift/carry objects weighing over 20 pounds. Id. In September 2020, the Veteran requested a brace or support for his shoulders and reported that both of his shoulders hurt overall. See September 2020 VA treatment records. In December 2020, the Veteran reported that his shoulder issues have gotten worse over time. See December 2020 VA treatment records. The Veteran reported that he has limitations that are a barrier to physical activity, to include his shoulder. See April 2021 VA treatment records. The Board notes that while pain alone may not constitute a disability, pain may rise to a level of functional impairment that impacts earning capacity, which would then qualify pain as a disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In this case, there is competent evidence of right shoulder pain, including the Veteran's statements, and therefore potential presence of a disability under Saunders that is related to the Veteran's in-military service. Finally, no VA examiner has reviewed the most recent medical literature reference by the Veteran's representative or addressed his contention about the relationship between wearing an OITV and his claimed right shoulder condition. As such, remand is necessary to obtain an addendum medical opinion. Stegall, 11 Vet. App. at 271. Entitlement to service connection for bilateral wrist pain is remanded. The Veteran seeks service connection for bilateral wrist pain. See April 2013 statement in support of claim. Specifically, the Veteran, through his representative, contends that his condition is due to exposure to a variety of environmental factors while in the Middle East, including exposure to burn pits, oil well fires, and toxin vapors. See November 2015 Statement of Accredited Representative. The Veteran, through his representative, also contends that his bilateral wrist condition is due to years of repetitive motion due to his military occupation specialty (MOS). See June 2021 appellate brief. The Veteran's representative also cited a study that indicates Carpal Tunnel Syndrome is a fairly common condition in working-aged people, sometimes caused by physical occupational activities, such as repeated and forceful movements of the hand and wrists or use of hand-held powered vibratory tools. Id. The Veteran, through his representative, also contends that the possibility of wearing heavy equipment on a military vehicle and restriction of movement may have caused shoulder pain. See November 2021 Written Brief Presentation. The Veteran's representative also cited a National Institute of Health report in which investigators proposed that loads carried by military personnel may contribute to injury susceptibility, and requested the Board remand to evaluate evidence on the effects of wearing an improvised outer tactical vest (OITV) during combat/training operations on the musculoskeletal system. See "The Influence of Body Armor on Balance and Movement Quality", available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033495/. Id. The Veteran was initially afforded a VA examination in November 2019. The VA examiner noted the Veteran's report that his wrists had been bothering him for the past 2 to 3 years with aching. See November 2019 VA examination. The Veteran reported flare ups in cold and damp weather and reported the aching and throbbing gets worse. Id. The VA examiner diagnosed the Veteran with bilateral carpal metacarpal arthritis and bilateral wrist sprain. Id. The VA examiner noted pain and incoordination causes functional loss during flare ups and the range of motion of the Veteran's bilateral wrists are reduced during flare ups. Id. The VA examiner noted there is credible historic evidence provided by the Veteran and clinical evidence that his bilateral wrist conditions were not related to service in Southwest Asia. Id. The VA examiner stated that the Veteran stated that his wrist condition began 3 years prior to this evaluation and there were no interval notes regarding complaints or care. Id. However, the Board previously determined the November 2019 VA examiner's rationalization inadequate since the Veteran contends that his repetitive motions of his hands and wrist during service as a generation equipment repairer caused his bilateral wrist pain. In the Board's July 2021 remand, the Board directed the RO to obtain an addendum medical opinion to address the nature and etiology of the Veteran's claim bilateral wrist pain, including whether the Veteran has a current bilateral wrist disability, and discuss any functional impairment due to pain described by the Veteran. The Board directed the examiner to consider that pain alone resulting in functional impairment, even if there is no identifying underlying diagnosis, can constitute a disability. The Veteran was afforded an addendum medical opinion in August 2021. The VA examiner opined that it was less likely than not that the Veteran's claimed bilateral wrist condition was incurred in or caused by the claimed in-service injury, event, or disease. See August 2021 VA medical opinion. As rationale, the VA examiner determined that there was no chronic diagnosis made for bilateral wrist pain while on active duty. Id. The VA examiner noted the symptoms are subjective only. Id. The VA examiner noted that medical records do not support the November 2019 diagnoses for left wrist arthritis or bilateral wrist strain. Id. The VA examiner noted there is no objective medical evidence noted in the available medical records showing a link between the Veteran's current reported wrist condition and the Veteran's time in service. Id. The VA examiner noted the Veteran is deemed competent to provide a history of his symptoms and considered the Veteran's lay statements; however, the VA examiner noted the Veteran is not capable of diagnosing the medical condition related to those symptoms. Id. The Board finds remand is necessary for further development. First, the August 2021 VA examiner determined there was no chronic bilateral wrist diagnosis, and no medical evidence to support a finding of left wrist arthritis and bilateral wrist sprain. However, the November 2019 VA examiner noted that imaging studies of the wrists had been performed and the results were reviewed with the Veteran. See November 2019 VA examination; November 2019 VA treatment records. Additionally, VA treatment records demonstrate a diagnosis for pain in unspecified wrist and the Veteran was provided with wrist braces. See January 2020 VA treatment records. The August 2021 VA examiner did not address the November 2019 X-ray reports or VA treatment records. Second, the August 2021 VA examiner did not discuss any functional impairment due to pain described by the Veteran as directed by the Board's July 2021 remand directives. As noted, the November 2019 VA examiner noted pain and incoordination causes functional impairment of the Veteran's bilateral wrists that results in reduced range of motion. See November 2019 VA examination. As noted, the VA treatment records demonstrate the Veteran was provided with wrist braces. See January 2020 VA treatment records. Additionally, the VA examiner did not address the Veteran's contention that repetitive motion during service as a generation equipment repairer caused his bilateral wrist pain. The Veteran's DD Form 214 demonstrates the Veteran's MOS as power generation equipment repairer. As such, the Board finds the August 2021 VA medical opinion is inadequate for decision making purposes. See Nieves-Rodriguez, 22 Vet. App. at 302. The Board notes that while pain alone may not constitute a disability, pain may rise to a level of functional impairment that impacts earning capacity, which would then qualify pain as a disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In this case, there is competent evidence of right shoulder pain, including the Veteran's statements, and therefore potential presence of a disability under Saunders that is related to the Veteran's in-military service. Finally, no VA examiner has reviewed the most recent medical literature reference by the Veteran's representative or addressed his contention about the relationship between wearing an OITV and his claimed wrist conditions. As such, remand is necessary to obtain an addendum medical opinion. Stegall, 11 Vet. App. at 271. The matters are REMANDED for the following action: 1. Forward the record and a copy of this Remand to the examiner who provided the August 2021 medical opinion, or, if that examiner is unavailable, to another suitably qualified examiner for completion of an addendum opinion to determine the nature and etiology of the Veteran's right shoulder pain. If the examiner determines that a new examination is necessary to provide the requested opinion, such examination should be scheduled. The examiner should address the following: (a.) Identify any right shoulder disability proximate to, and during the pendency of the claim, by (1) diagnosis or (2) complaints of pain that result in a functional impairment. (b.) The examiner should address whether it is at least as likely as not (i.e., 50 percent probability or greater) that any diagnosed right shoulder condition is etiologically related to the Veteran's service, including exposure to any environmental factors while serving in Southwest Asia, the Veteran's claim that he injured his shoulder in service, and the wear of tactical equipment. A complete rationale should be given for all opinions and conclusions expressed. The examiner must address the Veteran's lay statements regarding experiencing shoulder pain in service that has progressed over time. See November 2019 VA examination. The examiner must address the Veteran's VA treatment records indicating at least some limitation in physical activities due to shoulder pain. See April 2021 VA treatment records. The examiner must also address the National Institute of Health report in which investigators proposed that loads carried by military personnel may contribute to injury susceptibility, as well as the effects of wearing an improvised outer tactical vest (OITV) during combat/training operations on the Veteran's current right shoulder pain. See "The Influence of Body Armor on Balance and Movement Quality", available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033495/. See November 2021 appellate brief. In responding to the above, the examiner should state whether there is any medical reason to accept or reject the proposition that an in-service right shoulder injury, including wear of an OITV, could have led to the current right shoulder pain. Please explain your answer. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. 2. Forward the record and a copy of this Remand to the examiner who provided the August 2021 medical opinion, or, if that examiner is unavailable, to another suitably qualified examiner for completion of an addendum opinion to determine the nature and etiology of the Veteran's bilateral wrist pain. If the examiner determines that a new examination is necessary to provide the requested opinion, such examination should be scheduled. (a.) Identify any bilateral wrist disability proximate to, and during the pendency of the claim, by (1) diagnosis or (2) complaints of pain that result in functional impairment. The VA examiner must address the diagnoses of carpal metacarpal arthritis, bilateral wrist strain, and pain in unspecified wrist. See January 2020 VA treatment records; November 2019 VA examination. If the examiner determines the previous diagnoses provided are incorrect, the examiner must explain with sufficient detail why such diagnoses are incorrect. (b.) The examiner should address whether it is at least as likely as not (i.e., 50 percent probability or greater) that any bilateral wrist condition is etiologically related to the Veteran's service, including exposure to any environmental factors while serving in Southwest Asia, the Veteran's MOS as a power generator equipment repairer, and wear of tactical equipment. A complete rationale should be given for all opinions and conclusions expressed. The examiner must address the Veteran's lay statements and VA treatment records. The examiner must address the cited study provided by the Veteran's representative regarding carpal tunnel syndrome that can be caused by physical occupational activities, such as repeated and forceful movements of the hand and wrist or use of hand-held powered vibratory tools. See June 2021 appellate brief. The examiner must also address the National Institute of Health report in which investigators proposed that loads carried by military personnel may contribute to injury susceptibility, as well as the effects of wearing an improvised outer tactical vest (OITV) during combat/training operations on the Veteran's current bilateral wrist pain. See "The Influence of Body Armor on Balance and Movement Quality", available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033495/. See November 2021 appellate brief. In responding to the above, the examiner should state whether there is any medical reason to accept or reject the proposition that the Veteran's MOS could have led to the current bilateral wrist pain. Please explain your answer. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Carlin 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.