Citation Nr: 21075064 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 16-28 070 DATE: December 17, 2021 REMANDED Entitlement to service connection for a right-hand disability, also claimed as palmar fasciitis, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 2002 to September 2002, and from January 2004 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board finds that for the two reasons discussed below, remand is warranted to fulfill the VA's duties to notify and assist. Entitlement to service connection for a right-hand disability, also claimed as palmar fasciitis is remanded. First, as a preliminary matter, the Board notes that on his September 2015 formal claim for entitlement to service connection, the Veteran cited to receiving treatment at Cleveland VA medical center (VAMC) from January 1, 2007 to current. A negative response for the period of January 1, 2007 to February 18, 2016 was associated with the claims file in February 2016. Then in an April 2016 notification letter informing the Veteran of the April 2016 rating decision, the RO informed the Veteran of the negative response for outpatient treatment records, from Cleveland VAMC from January 1, 2007 to date. However, the Board finds that such notification is not in accordance with 38 C.F.R. § 3.159(e), and as such proper notification was not properly afforded the Veteran. In addition, the Veteran's complete service record does not appear to be of record. Hence, remand is warranted to afford the Veteran proper notification. Second, the matter has previously appeared before the Board in June 2020 and May 2021. The Board notes, that a November 2014 private favorable opinion providing diagnoses of palmar fasciitis right hand and pain right elbow, attached with x-ray evidence, is associated with the claims file, however, the rationale is illegible. Accordingly, in the June 2020 Board remand, the Board directed that a VA examination be obtained to determine the nature and possible relationship to service of any identified right-hand disability. The Board specifically directed that in answering this question, the examiner was to address any statements from the Veteran regarding his in-service duties and possible injuries he suffered therein. The Board further stated that though his service treatment records contain no evidence of such injuries, rather than making findings as to the Veteran's credibility (a task reserved for the Board), the examiner should state whether any identified disability is consistent with the history described by the Veteran. Such examination was obtained in November 2020 of which the Veteran was diagnosed with two right hand conditions: 1) Dupuytren's contracture, right- January 2015; and 2) palmar fasciitis, right -2014. However, the examiner provided a negative nexus opinion, but only discussed why she concluded that the palmar fasciitis condition was not related to service. As such, in the May 2021 Board remand, the Board directed the RO to obtain an addendum opinion which clarifies whether the Veteran's has both conditions and if the Veteran was found to also have Dupuytren's contracture, provide an opinion as to the nature and etiology of the condition. This time, in June 2021 addendum opinion, a separate VA examiner essentially found that the Veteran had neither condition, and found no relation to service. Paramount, the examiner went on to further state that "The VA was correct in deeming the 2014 private opinion as invalid, based on the diagnosis of PF alone, as well as the premise of repetitive injury, as no documented injury is noted, and it is clear he accepted the veteran's history without documentation." Further, the examiner stated, "It is unlikely an individual could have managed for 10 years without seeking care for a condition involving the hands, arising in service." The Board finds that the June 2021 addendum opinion inherently inadequate. First, on its face, the, opinion is inadequate because the examiner himself, addressed the credibility of the Veteran's statements, when a) such is the Board's duty as factfinder and b) is the direct opposite of what the Board directed in the June 2020 remand when the Board directed that the examiner to not make a finding as to the Veteran's credibility. It is the Board's duty as factfinder to assess the credibility and probative weight of evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Second, based on the examiner's explanation, the Board is unable to determine whether the examiner found that the Veteran had any hand disability, other than Dupuytren's contracture or palmar fasciitis. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Although the examiner stated that the Veteran does not have and never has had documented palmar fasciitis/ Dupuytren's contracture and that the previous diagnoses were made in error, the examiner acknowledge physical/functional loss in his right hand to include minimal loss of extension for two fingers documented in previous examinations. The Board is unable to determine whether this means the lack of actual contracture means there can be no diagnosis of either Dupuytren's contracture or palmar fasciitis, or if there may exist some other disability. To this end, the Board notes that pain that causes functional loss by constitute as a disability for purposes of establishing service connection. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). As such, an additional opinion is required to address what disability the Veteran's suffers, and whether such is related to his active service. The matters are REMANDED for the following action: 1. Obtain any outstanding VA medical center treatment records and associate those records with the claims file. If any available records, notably from the Cleveland VA medical center, from January 1, 2007 to current, as noted by the Veteran in the September 2015 claim for benefits are unavailable, provide the Veteran notification in accordance with 38 C.F.R. § 3.159(e). 2. Obtain the Veteran's complete service record and associate those records with the claims file. After the above development is complete, forward the claims file to an appropriate clinician to obtain an addendum opinion. A copy of this REMAND must be provided to and reviewed by the examiner along with the claims file. If upon review of the record, the examiner determine that a VA examination is necessary, schedule the Veteran for an appropriate examination to determine the nature and possible relationship to service of any identified right-hand disability. The examiner is specifically asked to answer the following: (a) Whether the Veteran has a diagnosis of Dupuytren's contracture, palmer fasciitis or any other right-hand disability; (b) Whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed disability, to include a diagnosis of Dupuytren's contracture and/or palmar fasciitis, had its initial onset in service, within a year of service discharge, or is etiologically related to active service. In answering this question, the examiner is to address the complete medical evidence of record, to include all previous diagnoses, opinions, and examinations, to explicitly include the November to December 2014 private treatment record, x-rays and opinion and any statements from the Veteran regarding his in-service duties and possible injuries he suffered therein. Though his service treatment records contain no evidence of such injuries, rather than making findings as to the Veteran's credibility (a task reserved for the Board), the examiner should state whether any identified disability is consistent with the history described by the Veteran. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Alli, 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.