Citation Nr: 21074490 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 15-03 482 DATE: December 15, 2021 REMANDED Entitlement to service connection for bilateral Parsonage-Turner syndrome (PTS) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from March 1991 to March 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2012 Department of Veterans Affairs (VA) rating decision. In July 2014, a hearing was held before a Decision Review Officer (DRO) at the Regional Office (RO). In November 2017, a videoconference hearing was held before the undersigned. Transcripts of both hearings are in the Veteran's record. In May 2018, February 2020, and August 2021, the case was remanded for additional development. Entitlement to service connection for bilateral Parsonage-Turner Syndrome The Board is aware that this matter was remanded several times before (and regrets the delay inherent with yet another remand); but because there was not substantial compliance with previous remand instructions, another remand is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In August 2021 the Board found that an April 2021 opinion failed to address the Veteran's primary theory of entitlement, namely that his PTS was caused by immunizations in service, and remanded this matter for an addendum advisory medical opinion. Notably, the April 2021 opinion cited to a recent study which explained that the most common risk factor for the development of PTS is recent viral illness (25% of patients) and the second most common risk factor is recent immunization (15% of patients). That examiner concluded, "Per medical literature it is not possible to correlate the Veteran's diagnosis to his time in service or any exposure he may have had. No nexus has been established[.]" In September 2021(pursuant to the August 2021 remand), another VA (fee basis) provider (nurse practitioner) reviewed the record and provided a negative nexus (to service) opinion. She explained that the cause of PTS is not completely understood, but theories include viruses, infections, trauma to the shoulder, cancerous cells, vaccinations/immunizations, rheumatologic or autoimmune disorders, heroin use, or genetics (hereditary). [The treatise she cited to also noted that 25% of cases occurred after recent viral illness/infection, and that 15% of cases occurred after a vaccination.] She concluded that there is a "multifactorial etiology involved in the development" of PTS and there is a "lack of objective medical evidence noted in the available medical records to confirm or support a conclusion that the Veteran's [PTS] is related to the Veteran's active duty service, including related to inoculations/immunizations therein." The Board finds that further remand for an addendum advisory medical opinion regarding the likely etiology of the Veteran's Parsonage Turner syndrome is necessary. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The September 2021 medical opinion, like the April 2021 opinion, is not fully adequate for rating purposes as it fails to address the Veteran's primary theory of entitlement, namely that his PTS was caused by immunizations in service. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). [While citing to medical literature indicating that recent vaccination was found associated with 15% of PTS patients, it does not explain why this Veteran's PTS is not related to inoculations/immunizations in service.] Furthermore, it is conclusory as it lacks adequate rationale; the examiner did not explain why the Veteran's PTS is less likely than not related to service (versus incurred in military service, or due to an alternative etiology, such as the documented postservice (August 1993) bicycle accident involving right scapula injury)), and does not cite to supporting factual data supporting the conclusion. It also did not identify the etiology that is considered to be more likely (beyond noting it is "multifactorial", without explanation why the vaccination in service is not one of the "multi-factors"), as directed in the August 2021 remand. Stegall, 11 Vet. App. at 271. Accordingly, a remand for a fully adequate (with supporting rationale) addendum advisory medical opinion is necessary. The matter is REMANDED for the following: Return the Veteran's record to the September 2021 consulting clinician for review and an addendum advisory medical opinion regarding the likely etiology of his bilateral Parsonage Turner syndrome, and specifically whether it is related to his active duty service, including as related to inoculations/immunizations therein. [If that provider is unavailable or unable to provide the opinion sought, forward the record to another appropriate clinician for review and the opinion.] The consulting clinician should: (a) Identify the likely etiology of the Veteran's bilateral Parsonage Turner syndrome. Specifically, is it at least as likely as not (a 50% or greater probability) that it is etiologically related to his active service, to include as due to inoculations/immunizations therein? If the response is no, considering that immunizations are a known risk factor for development of the syndrome, identify the clinical data and medical principles supporting that such was not the case in the matter at hand. The provider is advised that an opinion that this Veteran's PTS has a "multifactorial etiology" without identifying the more likely cause/providing supportive rationale will be rejected as inadequate. (b) Further, if the Veteran's bilateral Parsonage Turner syndrome is found to not be etiologically related to his service, identify the etiology for the syndrome that here is considered to be more likely (and explain why it is so). All opinions should include rationale with citing to supporting factual data and medical principles (and if medical principles are invoked, to supporting medical text/treatise), as deemed appropriate. If an opinion cannot be provided without resort to mere speculation, indicate whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner does not have the requisite knowledge or training. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dupont, 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.