Citation Nr: 21076576 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 14-23 368 DATE: December 27, 2021 REMANDED Entitlement to an initial evaluation in excess of 10 percent for ulnar neuropathy of the right upper extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1975 to August 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In August 2017, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. In February 2018 and September 2021, the Board remanded this matter for further development. 1. Entitlement to an increased rating for ulnar neuropathy of the right upper extremity is remanded. The Veteran contends that his right upper extremity ulnar neuropathy is more severe than initially rated. As noted above, the Board remanded this matter in February 2018 and September 2021. The Board directed VA to obtain a VA examination to determine the severity of the Veteran's right upper extremity neuropathy. Specifically, the Board directed that the examiner to address the Veteran's claimed flare-ups in which the Veteran reported increased symptomatology. The September 2021 remand directed VA to obtain an addendum medical opinion to specifically address the Veteran's flare-ups, which were not addressed in a January 2020 VA examination. In September 2021, VA obtained an addendum medical opinion. The examiner, addressing the Veteran's contention regarding flare-ups, stated that flare-ups are not consistent with the concept of persistent neuropathy described by the Veteran in his history in the January 2020 examination. The examiner explained that flare-ups are also not a component of a peripheral nerve examination. The examiner stated that even in the presence of a normal EMG, a diagnosis of ulnar neuropathy was made based upon the Veteran's history and a positive clinical sign of Tinel's sign. The examiner stated the Veteran had a comorbid medical epicondylitis, which pathophysiologically is consistent with "flare-ups" as it is a musculoskeletal condition that can vary based upon usage. The location of the Veteran's epicondylitis is also in the vicinity of the ulnar nerve which can be further irritated (as it was with the Tinel's). The examiner explained that the musculoskeletal issue is what has most correlation with a flare-up while a nerve issue may be residual to those musculoskeletal flare-ups. The Board finds that the September 2021 VA medical opinion is unclear. The September 2021 examiner stated that flare-ups are not a component of the Veteran's nerve disability, but flare-ups of a non-service-connected disability caused the nerve disability. The Board interprets this opinion as indicating that the severity of the Veteran's service-connected nerve disability does increase when his musculoskeletal disability flares. This is akin to a flare-up of the Veteran's service-connected nerve disability. The September 2021 examiner failed to describe the severity of such increases. Further, symptomatology attributed to a nonservice-connected disability cannot be differentiated from symptomatology attributed to a service-connected disability unless medical evidence does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). The Board finds the September 2021 examiner's opinion unclear as to whether the symptoms of the right ulnar neuropathy are distinguishable from the non-service-connected musculoskeletal disability and if they are not distinguishable, whether the flare-ups cause more severe symptoms. The Board finds that a remand is required for the Veteran to undergo a VA examination. Upon examination, the examiner must determine whether the symptoms of the Veteran's service-connected ulnar neuropathy are distinguishable from the noted epicondylitis. If the symptoms are not distinguishable then the examiner must determine the severity of symptoms during a flare-up. Further, if the symptoms are distinguishable, then the examiner must attempt to determine the severity of the Veteran's right ulnar neuropathy during a flare-up, to include any increase in severity due to a flare-up of the Veteran's noted epicondylitis. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right ulnar neuropathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (a.) The examiner must determine whether the symptoms of the epicondylitis (noted in the September 2021 VA opinion) is distinguishable from the Veteran's right ulnar neuropathy. (b.) If the examiner finds the epicondylitis distinguishable from the right ulnar neuropathy, then the examiner must describe any increase severity of the right ulnar neuropathy symptoms during a flare-up of the epicondylitis. i. The examiner must discuss the September 2021 opinion that the neuropathy is a possible residual of a flare-up of the epicondylitis. (c.) If the examiner cannot distinguish the epicondylitis from the right ulnar neuropathy, then the examiner must provide describe the severity of those symptoms during a flare-up. (d.) The examiner must provide a complete medical rationale for all opinions. If it is not possible to provide an opinion on the severity of the symptoms associated with the right ulnar neuropathy to include during a flare-up without speculation, the examiner must state 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 knowledge or training). S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert Batten 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.