Citation Nr: 21073853 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 17-20 684 DATE: December 10, 2021 REMANDED Entitlement to service connection for a right upper extremity disability is remanded. Entitlement to service connection for a right lower extremity disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1957 to March 1959. The Veteran's guardian, his wife, appeals an April 2016 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to service connection for tuberculosis meningitis, right upper and lower extremity hemiparesis, an eye disability, and a certificate of eligibility for an automobile allowance and specially adapted equipment. A Board of Veterans' Appeals (Board) hearing was held in August 2018. A transcript is of record. In December 2018, the Board granted service connection for tuberculosis meningitis and remanded the remaining issues for further development as the Veteran claimed the remaining issues were secondary to his tuberculosis meningitis. A November 2020 Board decision recharacterized the pertinent issues as entitlement to service connection for right upper and lower extremity disabilities and remanded the claims again for further development. Subsequent to this development, the AOJ granted service connection for an eye condition and entitlement to an automobile allowance and specially adapted equipment. See March 2021 and September 2021 rating decisions. This is considered a full grant of the benefits sought and the issues of entitlement to service connection for an eye condition and eligibility for an automobile allowance and specially adapted equipment are no longer on appeal. See Grantham v. Brown, 114 F.3d 1156 (1997). The other two issues have been developed and are back before the Board. The Board apologizes for additional delay, but a remand is required to obtain adequate opinions. Most recently, the November 2020 Board remand requested a clinician review the record and provide an opinion addressing the nature and etiology of any right upper and/or lower extremity disability from the date of claim in October 2015 to the present. In September 2021, numerous examinations were conducted, and the examiner provided negative nexus opinions with the rationale that the Veteran did not have any right-sided extremity disability as the examinations were all normal and he "could not find [the conditions] in records." For his right lower extremity, January 2019 VA treatment records note complaints of chronic pain in the Veteran's right thigh and the September 2021 VA examiner noted the Veteran had pain on passive flexion and extension in his right hip. Finally, a May 2021 addendum opinion provided by an examiner who conducted January 2020 VA examinations noted "right lower extremity findings are related to [the Veteran's service-connected] deep vein thrombosis. This is due to being bed ridden and lack of mobility...." Although this May 2021 addendum opinion did not provide a diagnosis, the record reflects a right lower extremity condition during the appeal period. Additionally, as discussed below, the Veteran's records contain evidence of a right upper extremity disability during the appeal period. As the September 2021 VA examiner did not consider any of the pertinent evidence of record, the medical opinions are inadequate and a remand is required. Right Upper Extremity Disability In January 2020, a VA examiner conducted a shoulder and arm examination and noted the Veteran had "abnormal findings" in his right shoulder, to include right shoulder pain that "precluded him from any range of motion testing or any assessments related to repetitive motion or flare-ups." Unfortunately, the examiner stated the Veteran's right upper extremity was unrelated to his claim and, therefore, "not fully evaluated." See January 2020 VA examination report. A diagnosis was not provided. A November 2020 Board Remand noted this assumption by the examiner was inaccurate as the Veteran's appeal included entitlement to service connection for a right upper extremity disability, and remanded for an opinion to address the nature and etiology of any right upper extremity condition from the date of claim in October 2015 to the present. The same VA examiner provided an addendum opinion in January 2021 noting the Veteran did not have any right upper extremity hemiparesis, but failed to address any other potential disability. In May 2021, a second addendum opinion was provided by the same VA examiner, who stated the Veteran's "right shoulder strain is at least as likely as not related" to his service-connected left upper extremity hemiparesis, "due to compensatory overuse of his right shoulder as a consequence of his lack of use of the left side." Unfortunately, it is unclear where this diagnosis of a right shoulder strain originated as it is not noted in any examination or medical record. For example, October 2018 St. Francis treatment records note the Veteran has right shoulder pain and bursitis that is treated with therapeutic injections and July and August 2015 VA treatment records note a history of a right shoulder rotator cuff tear and right-hand weakness, respectively. However, there is no evidence the Veteran had a right shoulder strain during the appeal period. As such, the Board needs further clarification on the issue. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matters are REMANDED for the following action: 1. Obtain all outstanding and updated relevant VA and/or private treatment records and associate the same with the claims file. 2. Thereafter, obtain an opinion from an appropriately qualified clinician to determine the nature and etiology of any right upper extremity disability and/or right lower extremity disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the reviewing clinician. It is up to the discretion of the reviewing clinician whether a new examination is necessary to provide an adequate opinion. Following review of the record and examination of the Veteran, the reviewing clinician should answer the following: (a). Identify with specificity all right upper extremity and right lower extremity disabilities that are current or existed at any time since October 2015. The reviewing clinician should consider the following evidence (i). July 2015 VA treatment records noting history of a right shoulder rotator cuff tear; (ii). August 2015 VA treatment records noting weakness of the right leg and hand; (iii). October 2018 St. Francis treatment records noting treatment of right shoulder bursitis, pain, and tenderness with therapeutic injections; (iv) January 2019 VA treatment records noting chronic right thigh pain; (v). January 2020 VA examination report noting the Veteran could not move his right shoulder due to pain; (vi). May 2021 addendum medical opinion noting right shoulder strain; and (vii). September 2021 VA examination report noting pain on passive flexion and extension of the right hip. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the reviewing clinician should consider them a "disability" for the purpose of providing the requested opinions below. (b). For each right upper extremity and right lower extremity disability the reviewing clinician should opine whether it is at least as likely as not that the disability was incurred in or is otherwise related to the Veteran's military service? The reviewing clinician should consider the Veteran's right foot and right leg complaints in his service treatment records. The reviewing clinician should also consider the Veteran's tuberculosis exposure/infection during his active duty service. (c). For each right upper extremity and right lower extremity disability the reviewing clinician should opine whether it is at least as likely as not that the disability was (1.) caused OR (2.) aggravated by his service-connected disabilities, to include tuberculosis meningitis with resulting strokes, left upper and lower extremity hemiparesis, left shoulder instability, and bilateral lower extremity deep vein thrombosis? The reviewing clinician should address the contentions that the Veteran overuses his right side due to limitations caused by his service-connected left upper and left lower extremity hemiparesis. A full and complete 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. (Continued on the next page) 3. Thereafter, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and his representative with a Supplemental Statement of the Case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bona, 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.