Citation Nr: 21074268 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 16-61 864 DATE: December 14, 2021 REMANDED Entitlement to service connection for a bilateral hip disability is remanded. Entitlement to service connection for a bilateral elbow disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1989 to March 1992. These matters come before the Board of Veterans' Appeals (Board) from a December 2012 rating decision. The Veteran testified at a Board hearing in March 2020. The Board remanded these matters in June 2020 and July 2020. 1. Entitlement to service connection for a bilateral hip disability is remanded. The Veteran seeks service connection for a disability originally described as chronic hip pain. The Veteran has submitted testimony and two lay statements indicating that he first experienced hip symptoms in Fall 1992, within one year after separation from service, during a hunting trip. 02/27/2020, Buddy/Lay Statements; 03/03/2020, Hearing Transcript. He testified that his hip symptoms worsened over the years and that he first sought treatment ten to twelve years ago. Private treatment records (received in January 2012) reflect that, in October 2011, the Veteran was diagnosed with left hip mixed-type femoroacetabular impingement with labral tear. Consequently, in December 2011, he underwent a left hip arthroscopy with labral repair, rim trimming, femoral osteoplasty, and iliopsoas release. 01/13/2012, Medical Treatment Record - Non-Government Facility. In a March 2012 statement, the Veteran provided additional information regarding his hip disability. He indicated that his physician expected a total hip replacement to be required in the future, and that he was scheduled to soon undergo surgery of his left hip. He noted that he had no family history for related illnesses and that he had been told that it is extremely rare for someone of his age to have such deterioration of the joints. 03/22/2012, Statement in Support of Claim. A January 2021 VA examination shows a diagnosis of bilateral hip replacement (right hip in 2012, left hip in 2014). In the medical history, the examiner noted that the hip condition began in the fall of 1992, within six months of separation from service, progressively worsening over time. Regarding current symptoms, the examiner described them as constant aching pain in both hips. A physical examination revealed limited range of motion for both hips. Regarding the etiology of the diagnosed hip disability, the examiner opined that it is less likely than not that the disability was caused by service. The examiner's rationale was that there was no record of chronic hip pain in service and that an October 2011 private treatment record indicated that the hip pain had begun five years earlier and was related to the Veteran's work as a mechanic. As explained in the July 2021 Board remand, this opinion is inadequate because it lacks a medical rationale and appears to dismiss the Veteran's assertion that his symptoms began within one year after separation of service. As explained in the Board's prior remands, an April 2021 rating decision granted service connection for widespread musculoskeletal pain and weakness, rated as analogous to fibromyalgia. This grant of service connection encompasses the Veteran's complaints of chronic joint pain in his hips but not other aspects of the claimed hip disability, most notably any loss of range of motion. Accordingly, the Board remanded the Veteran's appeal for consideration of whether the diagnosed bilateral hip disability was caused or aggravated by the service-connected widespread musculoskeletal pain and weakness. An August 2021 VA examination shows a diagnosis of status post total hip arthroplasty with pain residuals, bilaterally. Current symptoms were described as gradually worsening bilateral hip pain. On physical examination, range of motion was described as abnormal for both hips, with pain limiting flexion and extension. Regarding surgery residuals, the Veteran was noted to have moderately severe residuals of weakness, pain, or limitation of motion. Functional impact was described as a limited ability to walk or stand. Regarding the etiology of the Veteran's hip disability, the examiner opined that the diagnosed disability is less likely than not related to service or secondary to a service-connected disability. The examiner indicated that there was insufficient evidence of symptoms during or whing a few years after service, and that there was evidence of the Veteran working in a field that required repetitive motion of the hips. Notwithstanding, the examiner explained that although hip symptoms appear to have begun within a few years of service, "there is no known cause found of labral tears resulting in rapid worsening of arthritis of the hips to service at this time." The examiner also indicated there is no medical etiology relating bilateral labral tears resulting in bilateral hip arthroplasty for worsening osteoarthritis to the Veteran's service-connected widespread musculoskeletal pain and weakness. The August 2021 VA opinion lacks a clear rationale, and for that reason it is inadequate. Significantly, the opinion skirts the question of whether the Veteran's hip problems (to include any diagnosis of arthritis) first manifested in service or within one year after separation from service. Similarly, the examiner did not really provide a rationale for the question of secondary service connection. In September 2021, the August 2021 VA examiner was asked to issue an addendum opinion regarding secondary service connection. Specifically, the examiner was asked to opine whether the claimed hip disability was caused or aggravated by the Veteran's service-connected widespread musculoskeletal pain and weakness. In response, the examiner stated that there is insufficient evidence that the either the Veteran's widespread musculoskeletal pain and weakness, or his fatigue are caused or aggravated by the widespread musculoskeletal pain and weakness or fatigue. This addendum opinion is clearly inadequate, as it fails to reference the hips. As an adequate opinion is not of record, another remand is necessary. 2. Entitlement to service connection for a bilateral elbow disability is remanded. The Veteran seeks service connection for a disability originally described as chronic elbow pain. In an August 2011 statement, he reported a two-year history of chronic joint pain in his elbows. 08/29/2011, Statement in Support of Claim. Private treatment records show that the Veteran underwent surgeries for chronic bilateral lateral epicondylitis, also known as tennis elbow, in February 2012 and June 2012. 09/21/2012, Medical Treatment Record - Non-Government Facility, at 27 & 29. An October 2012 VA examination shows a diagnosis of bilateral tennis elbow. The examiner opined that this diagnosis is related to the Veteran's post-service work as a power plant mechanic and not related to any in-service exposure or condition. As explained in the Board's prior remands, an April 2021 rating decision granted service connection for widespread musculoskeletal pain and weakness, rated as analogous to fibromyalgia. This grant of service connection encompasses the Veteran's complaints of chronic joint pain in his elbows but not other aspects of the claimed elbow disability, most notably any loss of range of motion. Accordingly, the Board remanded the Veteran's appeal for consideration of whether the diagnosed bilateral elbow disability was caused or aggravated by the service-connected widespread musculoskeletal pain and weakness. An August 2021 VA examination shows a diagnosis of status post lateral epicondylar release with pain residuals, bilaterally. Current symptoms were described as constant aching in both elbows. On physical examination, range of motion was described as normal for both elbows, with no indication of functional loss due to pain, with repeated use over time or during flare-ups. The examination was similarly negative for any other elbow abnormalities. Functional impact was described as a limited ability to grip. Regarding the etiology of the Veteran's elbow disability, the examiner opined that the diagnosed disability is less likely than not related to service or secondary to a service-connected disability. The examiner explained that the evidence supports an onset of symptoms in 2011, related to a history of post-service work that required repetitive motion of the elbows. Regarding secondary service connection, the examiner explained that repetitive motion caused epicondylitis whereas "hazardous exposure" did not. Shortly thereafter, the August 2021 VA examiner was asked to issue an addendum opinion regarding secondary service connection. Specifically, the examiner was asked to opine whether the claimed elbow disability was caused or aggravated by the Veteran's service-connected widespread musculoskeletal pain and weakness. In response, the examiner stated that there is insufficient evidence that the either the Veteran's widespread musculoskeletal pain and weakness, or his fatigue are caused or aggravated by the widespread musculoskeletal pain and weakness or fatigue. This opinion is clearly inadequate, as it fails to reference the elbows. As an adequate opinion is not of record, another remand is necessary. 3. Entitlement to service connection for a bilateral knee disability is remanded. The Veteran seeks service connection for a disability originally described as chronic knee pain. In an August 2011 statement, he reported a ten-year history of chronic joint pain in his knees. 08/29/2011, Statement in Support of Claim. Private treatment records from May 2012 show treatment for bilateral knee pain, diagnosed as painful medial pathological plica and chondromalacia patella. 09/21/2012, Medical Treatment Record - Non-Government Facility, at 8. An October 2012 VA examination shows a diagnosis of bilateral knee chondromalacia patellae. The examiner opined that this diagnosis is related to the Veteran's post-service work as a power plant mechanic and not related to any in-service exposure or condition. As explained in the Board's prior remands, an April 2021 rating decision granted service connection for widespread musculoskeletal pain and weakness, rated as analogous to fibromyalgia. This grant of service connection encompasses the Veteran's complaints of chronic joint pain in his elbows but not other aspects of the claimed knee disability, most notably any loss of range of motion. Accordingly, the Board remanded the Veteran's appeal for consideration of whether the diagnosed bilateral knee disability was caused or aggravated by the service-connected widespread musculoskeletal pain and weakness. An August 2021 VA examination shows a diagnosis of chondromalacia patella, bilaterally. Current symptoms were described as pain and popping in both knees, with 1993 as date of onset. On physical examination, range of motion was described as normal for both knees, with no indication of functional loss due to pain, with repeated use over time or during flare-ups. The examination was similarly negative for any other knee abnormalities. Functional impact was described as a limited ability to walk. Regarding the etiology of the Veteran's knee disability, the examiner opined that the diagnosed disability is less likely than not related to service or secondary to a service-connected disability. The examiner indicated that there was insufficient evidence of symptoms during or within a few years after service and that there was evidence of the Veteran working in a field that required repetitive motion of the knees. The examiner further indicates that chondromalacia is not caused or medically related to the Veteran's service-connected widespread musculoskeletal pain and weakness. In this regard, the examiner explained that there is a clear etiology of chondromalacia related to the Veteran's post-service work; therefore, a hazardous exposure would not aggravate a musculoskeletal condition of this type. Shortly thereafter, the August 2021 VA examiner was asked to issue an addendum opinion regarding secondary service connection. Specifically, the examiner was asked to opine whether the claimed knee disability was caused or aggravated by the Veteran's service-connected widespread musculoskeletal pain and weakness. In response, the examiner stated that there is insufficient evidence that the either the Veteran's widespread musculoskeletal pain and weakness, or his fatigue are caused or aggravated by the widespread musculoskeletal pain and weakness or fatigue. This opinion is clearly inadequate, as it fails to reference the elbows. As an adequate opinion is not of record, another remand is necessary. These matters are REMANDED for the following actions: 1. Obtain an addendum opinion regarding the Veteran's bilateral hip, bilateral knee, and bilateral elbow disabilities. The examiner must review the claims file. For the hips, the examiner is asked to provide a response to the following: (a.) Is the Veteran's currently diagnosed hip disability at least as likely as not (probability of approximately 50 percent) related to service? The examiner must consider the Veteran's assertion that he began to experience hip symptoms months after separation from service. To the extent possible, the examiner should elicit a detailed history of symptoms and treatment from the Veteran. (b.) If there is (or has been) a diagnosis of arthritis, is it as likely as not (probability of approximately 50 percent) that symptoms first manifested in service or within one year after separation from service, with continuity of symptoms? (c.) Is it at least as likely as not (probability of approximately 50 percent) that either the service-connected widespread musculoskeletal pain and weakness, or the service-connected fatigue caused the currently diagnosed hip disability? (d.) Is it at least as likely as not (probability of approximately 50 percent) that either the service-connected widespread musculoskeletal pain and weakness, or the service-connected fatigue aggravated, i.e., worsened beyond its natural progression, the currently diagnosed hip disability? For the knees, the examiner is asked to provide a response to the following: (a.) Is the Veteran's bilateral knee disability at least as likely as not (probability of approximately 50 percent) related to service? (b.) Is it at least as likely as not (probability of approximately 50 percent) that either the service-connected widespread musculoskeletal pain and weakness, or the service-connected fatigue caused the currently diagnosed knee disability? (c.) Is it at least as likely as not (probability of approximately 50 percent) that either the service-connected widespread musculoskeletal pain and weakness, or the service-connected fatigue aggravated, i.e., worsened beyond its natural progression, the currently diagnosed knee disability? For the elbows, the examiner is asked to provide a response to the following: (a.) Is the Veteran's bilateral elbow disability at least as likely as not (probability of approximately 50 percent) related to service? (b.) Is it at least as likely as not (probability of approximately 50 percent) that either the service-connected widespread musculoskeletal pain and weakness, or the service-connected fatigue caused the currently diagnosed elbow disability? (c.) Is it at least as likely as not (probability of approximately 50 percent) that either the service-connected widespread musculoskeletal pain and weakness, or the service-connected fatigue aggravated, i.e., worsened beyond its natural progression, the currently diagnosed elbow disability? The examiner is to provide a medical rational for all opinions and should not rely solely on the absence of corroborating evidence to rule out a nexus. In providing the requested opinions, the examiner must consider the Veteran's description of any in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/ current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. López, 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.