Citation Nr: 21008000 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 15-16 195 DATE: February 11, 2021 REMANDED The issue of entitlement to service connection for carpal tunnel syndrome right hand is remanded. The issue of entitlement to service connection for carpal tunnel syndrome left hand is remanded. The issue of entitlement to service connection for primary vitiligo is remanded. The issue of entitlement to an initial evaluation in excess of 10 percent disabling for service-connected degenerative arthritis left knee limitation of flexion is remanded. The issue of entitlement to an initial evaluation in excess of 10 percent disabling for service-connected degenerative arthritis left knee limitation of extension is remanded. REASONS FOR REMAND The record shows periods of active service from January 2004 to September 2007, from April to September 2009, and in September 2012. In November 2017, the Veteran testified under oath at a travel board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In August 2018, the Board remanded these issues for additional development. For the reasons outlined below, remand is again needed. In the August 2018, the issue of entitlement to service connection for left hand surface lump was added to the issues on appeal. The issue was added for the sole purpose of remanding for the issuance of a Statement of the Case (SOC). See Manlicon v. West, 12 Vet. App. 238 (1999). The Board notes that since the remand, the issues of entitlement to service connection for: (1) Dupuytren’s contracture (claimed as left hand surface lump); (2) left hand metacarpal degenerative joint disease (index/longer finger) (claimed as left hand surface lump); and (3) left hand metacarpal degenerative joint disease (ringer/little finger) (claimed as left hand surface lump), were granted in an October 2020 rating decision. Accordingly, the issue of entitlement to service connection for left hand surface lump is no longer before the Board. In addition, following the August 2018 Board remand, in an October 2020 rating decision, service connection for degenerative arthritis left knee (limitation of extension) was granted with an evaluation of 10 percent disabling, effective August 21, 2020. The issue has been added to the issues on appeal. The Board acknowledges that in a November 2020 rating decision, the AOJ found a clear and unmistakable error in the continued evaluation of degenerative arthritis left knee limitation of flexion, at 10 percent disabling, and proposed to decrease the evaluation to a noncompensable evaluation. The Board acknowledges the proposed reduction, but notes that it has not been implemented. Accordingly, the issue on appeal remains a 10 percent evaluation. 1. Entitlement to service connection for carpal tunnel syndrome right hand. 2. Entitlement to service connection for carpal tunnel syndrome left hand. The Board finds that additional development is needed prior to final adjudication of the remaining issues on appeal. Regarding the Veteran’s claimed carpal tunnel syndrome, the Board finds that a new VA opinion is needed. The Board acknowledges the July 2020 VA opinion, but finds that the rationale provided in support of the opinion is inadequate. The rationale provided states only: “There is no evidence of CTS in the STRs.” However, at the November 2017 travel board hearing, the Veteran indicated that he had treatment in service. He noted going and getting braces for his hands. He further indicated that the he believes his claimed disability was caused by the maintenance work he performed. The new opinion must address the Veteran’s lay statements regarding his claimed carpal tunnel syndrome. 3. Entitlement to service connection for primary vitiligo. The Board finds that a new VA examination is also needed for the Veteran’s claimed primary vitiligo. Specifically, the Board seeks clarification as to whether the Veteran’s claimed primary vitiligo pre-existed service. The Board acknowledges that the examiner provided a positive nexus opinion addressing direct service connection. However, the examiner also provided an opinion indicating that the Veteran’s primary vitiligo “clearly and unmistakably existed prior to service,” but “was not aggravated beyond its natural progression by an in-service event, injury or illness.” Based on the rationale provided, it is unclear to the Board why the examiner determined that the claimed disability pre-existed service. Accordingly, a new opinion is needed. In addition, the Board notes that at the November 2017 travel board hearing, the Veteran indicated that when he first started his deployments, he went through a series of anthrax vaccinations and right after that, he noticed the pigmentation of his skin. The Board asks that the new VA opinion address the Veteran’s contentions regarding his vaccinations. 4. Entitlement to an initial evaluation in excess of 10 percent disabling for service-connected degenerative arthritis left knee limitation of flexion. 5. Entitlement to an initial evaluation in excess of 10 percent disabling for service-connected degenerative arthritis left knee limitation of extension. Regarding the Veteran’s service-connected degenerative arthritis left knee disability, the Board finds that a new VA examination is needed. The Board acknowledges that the Veteran was examined in August 2020. However, while the examination report notes that the Veteran experiences pain in his left knee in flexion and extension, the examiner did not note where the pain begins in terms of degrees of range of motion. Similarly, pain was noted in the left knee in passive range of motion, in weight-bearing, and nonweight-bearing, but it was not described in degrees of range of motion. The Board notes that in the August 2018 remand, the Board asked specifically that the examiner “provide range of motion testing (ROM) for the left knee for active motion, passive motion, weight-bearing, and nonweight-bearing.” (Emphasis in the original). Accordingly, a new VA examination is needed. See Correia v. McDonald, 28 Vet. App. 158 (2016). The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for the following VA examinations: (a) A VA examination to address the etiology of the Veteran’s claimed right and left hand carpal tunnel syndrome. For each disability diagnosed, the examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran’s active duty service. The examiner is asked to specifically address the lay statements of record, including the Veteran’s indication at the November 2017 travel board hearing that he had treatment in service. He noted going and getting braces for his hands. He further indicated that the he believes his claimed disability was caused by the maintenance work he performed. The new opinion must address the Veteran’s lay statements regarding his claimed carpal tunnel syndrome. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. (b) A VA examination to clarify whether the Veteran’s claimed primary vitiligo pre-existed service. The examiner is asked to address the following: (i) Whether it is at least as likely as not that the disability clearly and unmistakably pre-existed service. (ii) If there is clear and unmistakable evidence that the claimed disability pre-existed service, then the examiner should address whether there is clear and unmistakable evidence that the claimed disability was not permanently aggravated by service. If not, the examiner should then address whether it is at least as likely as not that it was caused by the Veteran’s active duty service. The Board notes that a pre-existing injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 C.F.R. § 3.306 (a). (iii) If it is determined that the claimed disability did not clearly and unmistakably pre-exist service, then the examiner should address whether it is at least as likely as not that it was caused by the Veteran’s active duty service. The examiner is asked to address the Veteran’s contentions that when he first started his deployments, he went through a series of anthrax vaccinations and right after that, he noticed the pigmentation of his skin. The Board asks that the new VA opinion address the Veteran’s contentions regarding his vaccinations. (c) A VA examination to evaluate the current level of severity of his left knee disability. The claim folder and all pertinent treatment records should be made available to the examiner for review, and review of such records should be noted in any subsequent report. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner is asked specifically to provide range of motion testing (ROM) for both knees for active motion, passive motion, weight-bearing, and nonweight-bearing. Full ROM testing must be conducted on the opposite joint unless the opposite joint is damaged, which includes any disorder that would make the joint in question abnormal. If the opposite joint is determined to be damaged, and no ROM on testing is conducted, this must be explained in the report. In addition, for both knees the examiner must discuss pain for ROM movements on active, passive, and repetitive use testing. The examiner is asked to address the following questions: (i) Are any ROM movements painful on active, passive, and repetitive use testing? If yes, identify whether active, passive, and repetitive use. (ii) If yes (there are painful movements), does the pain contribute to functional loss or additional limitation of ROM? Please further describe the functional loss or additional limitation of ROM. (iii) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. In addition, for both knees the examiner must discuss pain when used in weight-bearing or in nonweight-bearing. The examiner is asked to address the following questions: (i) Is there pain when the joint is used in weight-bearing or nonweight-bearing? If yes, identify whether weight-bearing or nonweight-bearing. (ii) If yes (there is pain when used in weight-bearing or nonweight-bearing), does the pain contribute to functional loss or additional limitation of ROM? Please further describe these limitations. (iii) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. For all ranges and planes of motion where pain is noted, the exact point at which pain starts must be clearly noted. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups, as expressed in range of motion. To the extent possible, the examiner should identify any symptoms and functional impairments due to the knee disabilities and discuss the effect of the Veteran’s knee disabilities on any occupational functioning and activities of daily living. The examiner should state whether or not there is any neurologic disability, to include of the lower extremities, that is the result of the knee disabilities. 3. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Foster, 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.