Citation Nr: 21077554 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 17-21 785 DATE: December 30, 2021 REMANDED Entitlement to service connection for polyarticular joint pain, to include a diagnosis of mixed connective tissue disease. Entitlement to service connection for a thoracolumbar spine disability, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for left shin splint, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for right shin splint, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for a left hand disability, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for a right hand disability, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for a left dorsal wrist disability, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for right dorsal wrist disability, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for a left foot disability, to include as a manifestation of mixed connective tissue disease. Entitlement to service connection for a right foot disability, to include as a manifestation of mixed connective tissue disease. REASONS FOR REMAND The Veteran served on active duty from January 2003 to January 2007. This appeal is before the Board of Veterans' Appeals (Board) from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In his April 2017 substantive appeal, the Veteran requested a hearing before the Board via live videoconference, but his representative withdrew this request in a February 2019 statement. In a May 2018 form, the Veteran's representative requested that his appeal be decided under the modernized appeal system as part of the Rapid Appeals Modernization Program (RAMP). In a September 2018 letter, the Veteran was notified that VA could not process his request because he did not have an appeal pending that qualified for processing under RAMP. In this regard, an appeal that has already been activated at the Board is not eligible for RAMP. Therefore, the Board will continue adjudication under the legacy system. In his August 2012 claim, the Veteran initially claimed service connection for separate disabilities of the spine, wrists, hands, feet, and shins. He reported chronic pain in these joints since various dates in service. For the reasons discussed below, the Board finds that remand is required for a VA examination. Service treatment records reflect treatment for diagnosed shin splints in March 2004, April 2004, March 2005, and April 2005. Records further showed a diagnosis of low back pain in February 2006 and a diagnosis of chronic mid-lower back pain in April 2006. No such abnormalities were noted at his August 2006 separation examination, though he reported these conditions as current and chronic in the accompanying report of medical history. Private treatment records include a February 2010 letter in which nerve conduction studies were unable to diagnose a cause of the Veteran's reported pain in his hands and tingling in his fingers. In May 2012, he reported pain his hands, toes, and mid and low back for about 8 years. A May 2012 MRI of the right wrist showed a full thickness ligament tear, and a July 2012 MRI of the left wrist was suspicious for a partial-thickness ligament tear. He underwent right wrist ligament reconstruction in August 2012. In an August 2012 statement, a soldier stationed with the Veteran reported that he had persistent wrist issues in service for which he wore wrist braces. Private treatment records reflect that September 2012 MRIs showed possible stress changes or early osteoarthritis in the bilateral first metatarsal heads, as well as small effusions in the bilateral first metatarsophalangeal joints. In November 2012, his physician began to treat him for arthralgias in multiple sites. He was monitored, but in February 2013 his physician did not see evidence of active rheumatoid arthritis. In April 2013 he exhibited an elevated ribonucleoprotein (RNP) antibody level. He was prescribed hydroxychloroquine and his levels returned to normal by June 2013. The Veteran underwent VA examinations for shin splints and a back disability in July 2013. The examiner found that both disabilities had resolved and that there was no current disability of the back or shins. In a January 2014 statement, the Veteran's private treating physician stated that he was being treated for polyarticular joint pain and reported similar symptoms since 2004. The physician noted that he was recently found to have an elevated RNP antibody level, suggesting he may have an underlying connective tissue disease accounting for his symptoms. In a December 2015 statement, another of the Veteran's private treating physicians stated that he was being treated for connective tissue disease. The physician noted that his symptoms began in 2004 with a 2012 relapse. The physician stated that the polyarticular joint pain is chronic. In a September 2021 filing, the Veteran's representative argued that the Veteran is diagnosed with mixed tissue connectivity, and all his service-connected claims on appeal are symptoms of this disease. The representative attached a print-out from the Mayo Clinic explaining the nature of the diagnosis and listing symptoms, including muscle and joint pain. The Board finds that remand is necessary to provide the Veteran with a VA examination for his claimed mixed connective tissue disease. VA has a duty to provide a medical examination where there is (1) competent evidence of a current disability or symptoms thereof; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability is associated with service; and (4) insufficient competent medical evidence to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). Here, the Veteran was initially provided with examinations of his lower back and shin splints. The examiner addressed these disabilities discretely. After this examination, however, the Veteran submitted evidence of a systemic diagnosis of mixed connective tissue disease as a possible cause of all his musculoskeletal symptoms. Two of his private physicians have diagnosed this disability and given opinions that it is related to service without any detailed rationale. While his service treatment records do not explicitly note symptoms of a mixed connective tissue disease, there is evidence of in-service joint pain, and the Veteran has provided information from the Mayo Clinic indicating that joint pain is a recognized symptom of his diagnosed disability. This constitutes evidence of a current disability, reported in-service symptoms, and an indication of a relationship between the two, and VA therefore has a duty to provide an examination and medical opinion for this diagnosis. Moreover, the Veteran's other claimed disabilities are intertwined with his mixed connective tissue disease claim, as the Veteran now argues, and his treating physicians agree, that they are manifestations of his mixed connective tissue disease. See Ephraim v. Brown, 5 Vet. App. 549, 550 (1993) (inextricably intertwined claims should be remanded together). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature, extent, and etiology of his claimed mixed connective tissue disease, to include pain. The claims file must be reviewed by the examiner. Following a review of the claims file and any clinical examination results, the examiner is to address the following: (a) Identify all disorders of the connective tissue that are currently present, if any, to include connective tissue disease. If the examiner disagrees with a diagnosis already established in the medical records, he or she should so state and explain why. Even if there is no diagnosed disorder, pain resulting in functional impairment may constitute a disability for service connection purposes. If present, describe any functional impairment; if not, state why. (b) Whether it is at least as likely as not (i.e. 50 percent probability or more) that any disorder of the connective tissue manifested during or is otherwise related to the Veteran's active service. Please discuss the January 2014 and December 2015 opinions of the Veteran's private treating physicians. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. All opinions are to be accompanied by a complete, clearly stated rationale. 2. After completing the above, and any other development deemed necessary, readjudicate the appeal. If any benefit sought remains denied, return the appeal to the Board. Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Gallagher, 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.