Citation Nr: 21008756 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 17-57 477 DATE: February 18, 2021 REMANDED The issue of service connection for peripheral neuropathy of the left lower extremity is remanded. The issue of service connection for peripheral neuropathy of the right lower extremity is remanded. The issue of service connection for peripheral neuropathy of the left upper extremity is remanded. The issue of service connection for peripheral neuropathy of the right upper extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1977 to July 1983. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2015 rating decision. In January 2020, the Veteran testified at a Board videoconference hearing; a transcript of the hearing is associated with the electronic claims file. In April 2020, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. 1. The issue of service connection for peripheral neuropathy of the left lower extremity is remanded. 2. The issue of service connection for peripheral neuropathy of the right lower extremity is remanded. 3. The issue of service connection for peripheral neuropathy of the left upper extremity is remanded. 4. The issue of service connection for peripheral neuropathy of the right upper extremity is remanded. The Veteran contends that bilateral numbness in his hands began in service after a motor vehicle accident in which he sustained a cervical strain or shortly after completing his tour in Germany (July 1982 to July 1983) and separation from service. He reports that the numbness in his hands progressed to his bilateral lower extremities after service. The Veteran’s service treatment records show that in January 1979, he was involved in a motor vehicle accident and complained of left shoulder pain. The impression was slight contusion left deltoid. He presented to the emergency room the next day with complaints of neck pain with movement after being in an accident the day before in which the quarter-ton vehicle he was driving flipped over. The assessment included rule out cervical spine fracture at C3; he was admitted for orthopedic evaluation. Tomograms of the cervical spine were “conclusive in proving that no fracture exists in the cervical vertebrae. Both thin and thick section films are completely normal in C3 and C4 as well as in all the remaining cervical vertebrae.” Later in January, he reported he had been hospitalized after a Jeep accident and released with a soft collar and had a recent onset of neck pain. The assessment was muscle pain secondary to soft collar. In February 1979, he again complained of neck pain after wearing the soft collar for several weeks. During a physical therapy consultation the next day, he complained of posterior cervical pain and weakness with generalized bilateral upper extremity numbness. The impression was resolving posterior cervical strain. In October 1979, the Veteran complained of ingrown toenails on both feet. The examiner removed the ingrown part of the toenails of both great toes. Other service treatment records reflect complaints of muscle pain in the Veteran’s legs after walking and playing basketball and complaints of knee pain that increased with squats or using stairs (December 1980, diagnosed as chondromalacia patellae), after three injuries in a two-week period) (November 1981, assessed as knee sprain), and generalized knee pain that increased at night and with pressure (December 1981, assessed as chondromalacia). In July 1983, the Veteran waived his right to undergo a separation medical examination. The Veteran established medical care at the Columbia, South Carolina VA Medical Center (VAMC) and Community Based Outpatient Clinic (CBOC) in March 2005. He described having constant burning pain and numbness in the heel and ball of both feet that was worse at night and previously taking Neurontin, Ultracet, and Trileptal. The assessment was peripheral neuropathy; the physician prescribed Nortriptyline and ordered a neurology consultation. An April 2005 primary care note includes the report of a September 2002 motor nerve conduction study from Neurology Associates of South Carolina. The conclusion of the study was reported as electrophysical findings consistent with sensorimotor demyelinating polyneuropathy; lack of symmetry on conduction block suggests an inherited disorder; blood DNA testing for Charcot-Marie-Tooth disease recommended. For clarity, Charcot-Marie-Tooth disease is “a group of hereditary conditions characterized by chronic motor and sensory polyneuropathy…, divided into two major types on the basis of nerve conduction velocities….” Dorland’s Illustrated Medical Dictionary 530 (32d ed. 2012). Both types “are characterized by progressive symmetric distal muscle weakness and atrophy starting in the feet and legs, gait disturbance, and absent stretch reflexes.” Id. In addition, the “most common initial presentation of [Charcot-Marie-Tooth disease] is distal weakness and atrophy manifesting with foot drop and pes cavus. Sensory symptoms are often present but tend to be ess prominent. Later in the course, foot deformities such as hammertoes ensue, along with hand weakness and atrophy.” See Peter B. Kang, MD, FAAP, FAAN, “Charcot-Marie-Tooth Disease: Genetics, Clinical Features, and Diagnosis,” UpToDate Online (Feb. 6, 2020), https://www.uptodate.com/contents/charcot-marie-tooth-disease-genetics-clinical-features-and-diagnosis (last visited Feb. 16, 2021). In May 2005, the Veteran presented for a VA neurology consultation to evaluated his peripheral neuropathy involving the bilateral upper and lower extremities. He reported having been seen by a private neurologist on several occasions. He reported that he noticed numbness in his hands when driving and at night in the 1980s and was diagnosed with carpal tunnel syndrome by nerve conduction studies at a New Jersey VA clinic. He stated that he began having burning and sensitivity in his feet approximately five years earlier (2000) and saw a private neurologist in Orangeburg, South Carolina. The VA neurologist reviewed the results of the September 2002 study. The Veteran indicated that the question of Charcot-Marie-Tooth disease had been raised, but although some of his ten sibling had high-arched feet, none had neuropathic symptoms. During an August 2005 follow-up visit, the neurologist remarked that the private electromyograms from 2002 demonstrated severe neuropathy “to the extent that any possible carpal tunnel syndrome in addition to the neuropathy would not be distinguishable.” The impression was severe neuropathy, possibly Charcot-Marie-Tooth; carpal tunnel. Subsequent VA treatment records reflect ongoing treatment for severe distal neuropathy of the upper and lower extremities, believed to be Charcot-Marie-Tooth disease (also identified as hereditary motor and sensory neuropathy (HMSN)) from a degree of probably to somewhat unlikely. In June 2020, the Veteran was afforded a fee-basis examination to obtain a medical opinion regarding the etiology of his peripheral neuropathy. The examiner opined that it was less likely as not that the peripheral neuropathy of each upper and lower extremity was incurred in or cause by service because the record did not show complaints of neuropathy in service or during the presumptive period (within one year of separation from service), and the record did not show a continuity of symptoms from active service to the present. Unfortunately, the appeal must be remanded again to attempt to obtain outstanding VA treatment records because they may support the Veteran’s reports of a continuity of symptomatology of pain and numbness in his extremities since military service. The narrative section of the April 2020 Board Remand noted the Veteran’s report that he had received treatment at the Bronx VAMC beginning in 1984 or 1985. Those records were not obtained or requested. Treatment records from the Columbia VAMC also indicate that he had been treated at the East Orange VAMC in New Jersey and did not move to South Carolina until 1998. The AOJ should attempt to obtain the outstanding VA treatment records and give the Veteran another opportunity to submit any treatment records from private neurologists that may be pertinent to his claim. If additional treatment records are obtained, the AOJ should request a supplemental medical opinion. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain the following treatment records: a) All records from the Bronx, New York VA Medical Center since establishing care around 1984 or 1985. b) All records from the New Jersey VA Healthcare System since establishing care, apparently sometime in the 1980s. c) All private treatment records from Neurology Associates of South Carolina. d) Any other private or VA treatment records the Veteran identifies that are pertinent to his claims. 2. If additional treatment records are obtained, provide the Veteran’s electronic claims file to a VA or fee-basis neurologist to obtain a supplemental medical opinion. Following a review of the claims file, the reviewing examiner should provide a medical opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that peripheral neuropathy of each upper and lower extremity, which may be a hereditary motor and sensory neuropathy (HMSN) such as Charcot-Marie-Tooth disease, began during military service, manifested to a compensable degree within one year of separation from service, or is otherwise related to disease or injury during military service. A medical rationale must be provided for all opinions expressed. In providing the requested opinion, the reviewing examiner should consider the Veteran’s complaint of weakness and numbness in his bilateral upper extremities in February 1979 after sustaining a cervical spine strain one month earlier in a motor vehicle accident; his treatment of ingrown toenails on both feet in October 1979; and other complaints during service regarding muscle pain with walking, squatting, and using stairs and knee pain after several apparent knee injuries within a two-week period in November 1981. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Kirscher Strauss 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.