Citation Nr: 21008323 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 18-23 269 DATE: February 16, 2021 ORDER Entitlement to service connection for left upper extremity radiculopathy, to include as secondary to cervical spondylosis or to service-connected low back strain, is denied. REMANDED Entitlement to service connection for cervical spondylosis, to include as secondary to service-connected low back strain, is remanded. Entitlement to service connection for a right knee disability, to include as secondary to service-connected low back strain, is remanded. Entitlement to service connection for a left knee disability, to include as secondary to service-connected low back strain, is remanded. Entitlement to service connection for right upper extremity radiculopathy, to include as secondary to cervical spondylosis or to service-connected low back strain, is remanded. Entitlement to service connection for cervicogenic headaches, to include as secondary to cervical spondylosis or service-connected low back strain, is remanded. Entitlement to service connection for right carpal tunnel syndrome, to include as secondary to cervical spondylosis or to service-connected low back strain, is remanded. FINDING OF FACT The evidence does not show a current diagnosis of left upper extremity radiculopathy during the appeal period. CONCLUSION OF LAW The criteria for service connection for left upper extremity radiculopathy, to include as secondary to cervical spondylosis or to service-connected low back strain, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from May 1970 to October 1970. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision of the Department of Veterans Affairs Regional Office (RO). The case was previously before the Board in October 2018. The issues on appeal were previously remanded by the Board. 1. Entitlement to service connection for left upper extremity radiculopathy, to include as secondary to cervical spondylosis or to service-connected low back strain. The Veteran contends that he has left upper extremity radiculopathy. See November 2014 claim. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of left upper extremity radiculopathy and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In an October 2020 opinion, the examiner noted there was no clinical and objective evidence that warrants a left upper radiculopathy diagnosis. The Veteran denied any sign and symptom that correlated with condition. Furthermore, the examiner found no neurological deficit that correlated with the left upper extremity radiculopathy. VA treatment records do not show reports of left upper extremity radiculopathy but instead show reports of pain radiating to right arm and shoulder and tingling sensation in the right upper extremity. While the Veteran believes he has a current diagnosis of left upper extremity radiculopathy, he is not competent to provide a diagnosis in this case. The issue is medically complex. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. REASONS FOR REMAND 1. Entitlement to service connection for cervical spondylosis, to include as secondary to service-connected low back strain, is remanded. In the October 2018 remand, the Board directed the examiner to provide an opinion as to whether the Veteran’s cervical spondylosis was directly due to his military service including the Veteran’s reports of pain in his back and shoulder during service or a fall in the shower. The Board also directed the examiner to opine whether cervical spondylosis was caused or aggravated by his service-connected low back disability. The October 2020 examiner found that there was no treatment diagnosis, or complaint of cervical conditions in the service treatment records. The examiner did not address the Veteran’s report of back pain or a fall in the shower. Although the examiner provided an opinion as to whether his low back disability caused his cervical spondylosis, she did not provide an opinion as not whether the Veteran’s low back aggravated his cervical spondylosis. For these reasons, an addendum opinion is needed. 2. Entitlement to service connection for a right knee disability, to include as secondary to service-connected low back strain, is remanded. 3. Entitlement to service connection for a left knee disability, to include as secondary to service-connected low back strain, is remanded. 4. Entitlement to service connection for right upper extremity radiculopathy, to include as secondary to cervical spondylosis or to service-connected low back strain, is remanded. 5. Entitlement to service connection for cervicogenic headaches, to include as secondary to cervical spondylosis or service-connected low back strain, is remanded. 6. Entitlement to service connection for right carpal tunnel syndrome, to include as secondary to cervical spondylosis or service-connected low back strain, is remanded. The Veteran’s claims for entitlement to service connection for a right knee disability, left knee disability, right upper extremity radiculopathy, cervicogenic headaches and right carpal tunnel syndrome are inextricably intertwined with the Veteran’s claim for service connection for cervical spondylosis. Therefore, a remand of these issues is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s cervical spine disability is at least as likely as not related to service or proximately due to service-connected low back strain or aggravated beyond its natural progression by the service-connected low back strain. The examiner’s attention to directed to the Veteran’s reports of back and shoulder pain during service and a fall in the shower during service. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s right knee disability, left knee disability, right upper extremity radiculopathy, cervicogenic headaches and right carpal tunnel syndrome are at least as likely as not related to or proximately due to or aggravated beyond its natural progression by his cervical spine disability or his service-connected low back strain. 3. Readjudicate the Veteran’s claim, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Tahirih S. Samadani, 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.