Citation Nr: 21009124 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 16-01 363 DATE: February 19, 2021 REMANDED Service connection for right knee condition, to include as due to an undiagnosed condition/illness or medically unexplained chronic multi-symptom illness (MUCMI) as result of service in the Persian Gulf War, is remanded. Entitlement to service connection for left hand numbness (hereinafter a left-hand condition), to include as due to an undiagnosed condition/illness or medically unexplained chronic multi-symptom illness (MUCMI) as a result of service in the Persian Gulf War, is remanded. Entitlement to service connection for right hand numbness (hereinafter a right-hand condition), to include as due to an undiagnosed condition/illness or medically unexplained chronic multi-symptom illness (MUCMI) as result of service in the Persian Gulf War, is remanded. REASONS FOR REMAND The Veteran had active duty service from December 2003 to March 2005, to include active duty for training (ACDUTRA) from February 1981 to May 1981, and from September 1985 to February 1986, with additional periods of service in the Army National Guard. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). In September 2018, the Board denied, in part, service connection for a right knee condition, an esophageal condition, and bilateral hand conditions. The Veteran appealed the September 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). While the matter was pending before the Court, the Veteran and VA’s General Counsel filed a June 2019 Joint Motion for Partial Remand (JMR). In a June 2019 Order, the Court granted the parties’ Motion, vacated the portions of the September 2018 Board decision that denied service connection for a right knee condition, an esophageal condition, and a bilateral hand condition, in particular noting the Board erred in relying on the May 2014 VA opinion and that neurological symptoms, joint pain, and gastrointestinal issues may constitute signs or symptoms of a MUCMI. The Court vacated the September 2018 Board denial to allow for a VA examination and medical opinion to determine whether the Veteran’s claimed conditions and symptoms would collectively constitute a MUCMI. In December 2019 and September 2020, the Board remanded the matters for further development. These matters return to the Board for appellate consideration. In October 2020, the RO granted service connection for Barrett’s esophagitis with GERD. Because the Veteran was granted service connection for the esophageal condition and he has not disagreed with the effective date, the claim for entitlement to service connection for Barrett’s esophagitis, also claimed as acid reflux, is no longer on appeal. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997).   1. Service connection for right knee condition, to include as due to an undiagnosed condition/illness or medically unexplained chronic multi-symptom illness (MUCMI) as result of service in the Persian Gulf War, is remanded. 2. Entitlement to service connection for left hand numbness (hereinafter a left-hand condition), to include as due to an undiagnosed condition/illness or medically unexplained chronic multi-symptom illness (MUCMI) as result of service in the Persian Gulf War, is remanded. 3. Entitlement to service connection for right hand numbness (hereinafter a right-hand condition), to include as due to an undiagnosed condition/illness or medically unexplained chronic multi-symptom illness (MUCMI) as result of service in the Persian Gulf War, is remanded. Although the Board regrets the delay, a remand is required before the Board can issue an appellate decision. In September 2020, the Board instructed the RO to obtain an addendum opinion from a VA examiner for the claimed right knee and bilateral hand conditions. The examiner was asked to determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s claimed right knee symptoms and bilateral hand numbness, when considered together, are due to a diagnosable but MUCMI or an undiagnosed illness that is defined by a cluster of signs or symptoms due to the Veteran’s Persian Gulf service; in addition; when addressing whether a condition is a diagnosable MUCMI or undiagnosed illness, the examiner was asked to discuss both the etiology AND pathophysiology of the claimed condition with specific emphasis on whether both the etiology and pathophysiology of the condition are understood or at least partially understood in the context of the Veteran’s unique circumstances. Pursuant to the September 2020 Board remand, an October 2020 addendum opinion was obtained. The examiner opined that it is less likely than not the claimed right knee and bilateral hand conditions were incurred in service or caused by an in-service injury or event because there is not enough information gathered from the Veteran, noted on physical examination or cited medical records, to show that the claimed conditions were an ongoing chronic condition during service. The examiner concluded the following: The claimed right knee strain is a diagnosable condition physiologically caused by physical wear and tear of the knee joint by irregular pressure on the joint which stretches (strains) the tendons and ligaments of the knee joint causing symptoms; the claimed bilateral carpal tunnel syndrome is a diagnosable condition physiologically caused by wear and tear and repetitive strenuous movement of the hands, causing tendon sheath tightness on the median nerves of the hands producing symptoms. The Board finds the October 2020 opinion is inadequate. Although the examiner discussed the etiology and pathophysiology of the claimed conditions, the examiner failed to discuss how both the etiology and pathophysiology of the conditions are, understood or at least partially understood, in the context of the Veteran’s unique circumstances. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). In particular, the examiner did not discuss the cited complaints for bilateral hand numbness and tingling in a January 2004 service treatment record and February 2005 post deployment assessment, nor the January 2005 line of duty injury determination. Instead, the examiner simply concluded, in its direct service connection opinion, that there was not enough information gathered from the Veteran, nor physical examinations or medical records, to show that the claimed conditions were ongoing chronic conditions during service. More notably, the Board notes that the December 2019 VA examiner concluded that the right knee strain is likely due to wear and tear on the right knee joint with marches and general physical military duty, causing strain of the right knee structure. Although the October 2020 examiner similarly attributed the etiology of the right knee strain as due to wear and tear, the examiner’s basis for conclusion conflicts with that of the December 2019 examiners’ such that the latter opinion seemed to suggest a causal connection between the right knee wear and tear and physical demands of service. Furthermore, the October 2020 examiner did not consider the Veteran’s lay statements regarding periodic pain in his right knee as a result of wearing gear in excess of 70 pounds and completion of various tasks during his tour in Iraq. See January 2016 Form 9. As such, an addendum opinion should be obtained to determine the nature and etiology of the claimed right knee and bilateral hand conditions. The matters are REMANDED for the following action: Obtain an addendum opinion from the October 2020 VA examiner or another qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must determine whether it is at least as likely as not (50 percent probability or more) the Veteran’s claimed right knee and bilateral hand conditions are related to his active duty service, to include periods of ACDUTRA. The examiner must discuss the cited complaints for bilateral hand numbness and tingling in the January 2004 service treatment record and February 2005 post deployment assessment, as well as, the January 2005 line of duty injury determination. The examiner must also reconcile the discrepancy between the December 2019 VA examiner’s conclusion linking the right knee wear to the physical demands of service, and the October 2020 VA examiner’s conclusion that the right knee wear and tear is not related to service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Asfaw, Associate 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.