Citation Nr: 21012314 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-56 764 DATE: March 4, 2021 ORDER Entitlement to service connection for bilateral carpal tunnel syndrome (CTS) is granted. REMANDED Entitlement to service connection for arthralgia of multiple joints, including the ankles, hips, knees, elbows, shoulders, is remanded. Entitlement to service connection for low back disability is remanded. Entitlement to service connection for esophageal disability, to include gastroesophageal reflux disease (GERD), is remanded. Entitlement to service connection for cardiac disability, to include cardiomegaly with palpitations/premature ventricular contractions, is remanded. Entitlement to service connection for an acquired psychiatric disability, to include anxiety with insomnia and memory loss is remanded. FINDING OF FACT The Veteran’s current carpal tunnel syndrome is reasonably shown to have been manifest in service and to be related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for bilateral carpal tunnel syndrome have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1995 to February 1999. This matter is on appeal before the Board of Veterans Appeals (Board) from a September 2012 decision of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, a Board hearing was held before the undersigned; a transcript of the hearing is of record 1. Entitlement to service connection for bilateral CTS. The Veteran alleges that his current bilateral carpal tunnel syndrome (CTS) is related to service. The service treatment records show several medical visits for CTS. At an April 24, 1997 medical visit, the Veteran was diagnosed with possible bilateral carpal tunnel syndrome. At a subsequent October 1997 medical visit, the history of possible carpal tunnel syndrome was noted, and the Veteran was diagnosed with carpal tunnel syndrome vs overuse. On his December 1998 report of medical history, the Veteran was noted to be unable to use the required tools to perform his maintenance duties and to have a history of swollen and painful joints. In August 2001, private EMG testing produced a diagnostic impression of mild bilateral CTS. At a July 2012 VA examination, the examining nurse practitioner diagnosed the Veteran with arthralgia of the bilateral hands. The examiner opined that he could not resolve the question of whether the Veteran had current bilateral CTS that was related to service without resort to speculation. In an April 2020 opinion, a treating VA physician indicated that the Veteran had a clinical diagnosis of CTS and noted that the diagnosis was confirmed on diagnostic testing in 2001. The physician noted that he believed it was as likely as not that the CTS diagnosis existed during service. Given that the VA physician found that the Veteran’s current CTS existed during service and given that the July 2012 nurse practitioner could not resolve the likely etiology of the Veteran’s CTS without resort to speculation, the evidence is at least in equipoise as to whether the Veteran’s current CTS is related to service. Accordingly, resolving reasonable doubt in the Veteran’s favor, service connection for CTS is warranted. REASONS FOR REMAND 2. Entitlement to service connection for arthralgia of multiple joints, including the ankles, hips, knees, elbows, shoulders is remanded. Regarding the claim for arthralgias, the service treatment records show that the Veteran was seen by medical personnel on multiple occasions for joint problems. They also show that he was discharged after Medical Board proceedings with a diagnosis of probable seronegative arthropathy. At a July 2012 VA examination, the examining nurse practitioner found that the Veteran had various joint conditions including right shoulder strain, left elbow strain, right hip strain, chondromalacia of the right knee and right ankle strain. The examiner found that it was less likely than not that the Veteran’s claimed chronic arthralgias of the bilateral ankles, hips, knees, elbows and shoulders were incurred in or caused by the joint problems the Veteran experienced in service. The examiner commented that although the diagnosis of probable seronegative arthropathy was found by the Medical Board during service, the post-service medical evidence (i.e. objective medical evidence) was insufficient to provide a nexus between arthralgias currently found and the Veteran’s military service. In a subsequent April 2020 medical opinion, the Veteran’s primary care physician from the Pittsburgh VA Health Care System found the diagnosis of seronegative arthropathy was documented during active duty and that the arthralgic pains that the Veteran was experiencing after service might be associated with the ones the Veteran experienced during service. The physician also noted that the Veteran is confirmed to be HLAB-27 positive and that he had been referred for further rheumatologic work-up and for additional management of his condition. The Board notes that the VA physician indicated that he relied on VA and non-VA records in rendering his opinion. However, there are no VA treatment records associated with the Veteran’s claims file. The July 2012 VA examiner’s opinion was not based on a full review of the pertinent post-service medical evidence, which may include a full rheumatological work-up (referred to by the VA primary care physician). Accordingly, a remand is required so that the Veteran may be afforded an updated VA examination with medical opinion that addresses the likely etiology of the claimed arthralgias. 3. Entitlement to service connection for low back disability is remanded. Regarding the claim for low back disability, the service treatment records show that the Veteran was seen for a low back strain in service. At the July 2012 VA examination, the examining nurse practitioner opined that any current low back disability was less likely than not related to low back strain in service, finding that there was insufficient evidence to provide that the mid-lumbar spine conditions noted during active duty were long-term, chronic conditions. In an April 2020 opinion, the VA primary care physician found that the Veteran’s low back condition could be related to his arthralgia condition and found that it was at least as likely as not that the Veteran’s condition was present during military service. Given that the VA physician found that the Veteran’s back problems could be related to his arthralgia condition, and given that the claim for service connection for arthralgias must be remanded, the claim for service connection for low back disability is inextricably intertwined with the claim for service connection for arthralgias and must also be remanded. On remand, the Veteran should be provided with an updated VA low back examination that includes an opinion concerning the likelihood that current low back disability is related to the diagnosed probable seronegative arthropathy in service. 4. Entitlement to service connection for esophageal disability, to include GERD, is remanded. Regarding the claim for GERD, the service treatment records show that the Veteran was seen by medical personnel for symptoms of GERD and received some treatment with GERD medications. At a July 2012 VA examination, the nurse practitioner indicated that he could not resolve the likelihood that the Veteran’s GERD was related to gastrointestinal symptoms he experienced in service without resort to speculation. The examiner commented that there was no objective evidence to support that the Veteran had had chronic GERD during or after active duty. In an April 2020 opinion, the VA primary care physician indicated that he was not in a position to say if any current GERD is related to service, commenting that the Veteran did have GERD in service and was shown to have mild esophagitis at an esophagogastroduodenoscopy (EGD) in 2017. Given that the Veteran did have GERD symptoms in service; given that the July 2012 examiner could not resolve the likely etiology of any current GERD without resort to speculation; and given that the April 2020 VA primary care physician did not feel appropriately positioned to render an opinion while at the same time noting that the Veteran had been shown to have mild esophagitis during a 2017 endoscopy, a remand is necessary so the Veteran can be afforded a new VA examination to assess the likely etiology of any current GERD/esophageal disability. 5. Entitlement to service connection for cardiovascular disability, to include cardiomegaly with palpitations/premature ventricular contractions, is remanded. Regarding the claim for cardiac disability, the service treatment records indicate that the Veteran was seen by medical personnel for anxiety attacks during service. At the August 2020 hearing, the Veteran testified that he experienced heart palpitations during service, which were attributed to anxiety. However, post-service, it was eventually determined that he had PVCs, for which he subsequently underwent a surgical procedure (i.e. ablation) in 2011. In July 2012, the VA examining nurse practitioner opined that it was less likely than not that the Veteran’s current cardiomegaly was caused by or a result of chest pain and rapid heartbeat (shown in service in December 1998 and diagnosed as an anxiety attack). The examiner commented that there was no objective evidence that the Veteran’s problem had been a chronic condition. In an April 2020 opinion, the VA primary care physician noted that the Veteran had a documented history of palpitations during active duty with symptoms starting about 4 months before separation. Private medical records from December 1999 then showed a history of irregular heartbeats and anxiety attacks. In May 2000, the Veteran was evaluated at Latrobe Hospital with ECG, which showed sinus tachycardia with PVCs. These episodes were further evaluated in the private sector in 2004 when a Holter monitor report showed 7 percent ventricular ectopy. Ultimately, the Veteran underwent an ablation procedure, which improved his symptoms. A repeat event monitor in 2019 showed less than one percent ventricular ectopy and there was no correlation to documented symptoms of ectopy. The examiner found that it was at least as likely as not that the Veteran had some form of heart condition that started during active duty but based on available records related to that time, the physician could not comment on a specific condition. The July 2012 medical opinion is inadequate because the nurse practitioner was not aware that there had been some chronicity shown in relation to cardiac symptomatology soon after service. However, the July 2020 VA physician’s opinion, while indicative of cardiac problems during service, does not clearly indicate whether the Veteran has any current cardiac disability. Accordingly, a remand is required to afford the Veteran an updated VA examination to assess the likely etiology of any current cardiac disability. 6. Entitlement to service connection for an acquired psychiatric disability, to include anxiety with insomnia and memory loss is remanded. Regarding the claim for anxiety with insomnia and memory loss, the service treatment records do show some findings of anxiety. At the July 2012 VA examination, the nurse practitioner did not diagnose any mental disorder. Thus, he found that an opinion concerning the etiology of current mental disorder could not be rendered. In an April 2020 medical opinion, the VA primary care physician found that it was at least as likely as not Veteran had anxiety during service and service-related activities exacerbated anxiety due to disrupted sleep and exacerbation of joint pains. Additionally, the physician noted that the Veteran was diagnosed with anxiety in May 2000 and June 2002 and with agoraphobia by primary care in 2018. The Board notes that the July 2012 VA examiner’s findings are not sufficient given that the Veteran may have a current psychiatric disability, manifested by agoraphobia. Accordingly, a remand is required to obtain VA treatment records pertaining to any diagnosis or treatment of current anxiety disorder, to include agoraphobia and to afford the Veteran an updated VA examination to assess the likely etiology of any current anxiety disorder with any associated insomnia and memory loss. The matters are REMANDED for the following action: 1. Obtain any outstanding records of VA treatment and evaluation for all the Veteran’s claimed disabilities, including records referenced by the Veteran’s VA primary care physician in his April 2020 medical opinions. In particular, obtain records dated from 2017 to the present. 2. Ask the Veteran to submit or identify any outstanding private treatment records pertaining to his claimed disabilities. Obtain any available, outstanding records appropriately identified by the Veteran. 3. After the development in #1 and #2 has been completed, schedule the Veteran for a VA examination by an appropriate medical professional for his claimed arthralgias. The examiner must review the claims file, including the service treatment records, the post-service private medical records, the post-service VA treatment records, the July 2012 VA examination report, the April 2020 VA physician’s opinion and any other evidence considered pertinent. The examiner is asked to provide a response to the following: Are the Veteran’s current arthralgias at least as likely as not related to service, including the probable seronegative arthropathy diagnosed at the time of discharge? The examiner should explain the rationale for the opinion provided. 4. After the development in #1 and #2 has been completed, schedule the Veteran for a VA examination by an appropriate medical professional for his claimed low back disability. The examiner must review the claims file, including the service treatment records, the post-service private medical records, the post-service VA treatment records, the July 2012 VA examination report, the April 2020 VA physician’s opinion and any other evidence considered pertinent. The examiner is asked to provide a response to the following: Is the Veteran’s current low back disability at least as likely as not related to service, including his back strain and/or seronegative arthropathy experienced therein? The examiner should explain the rationale for the opinion provided. 5. After the development in #1 and #2 has been completed, schedule the Veteran for a VA examination by an appropriate medical professional for his claimed GERD/esophageal disability. The examiner must review the claims file, including the service treatment records, the post-service private medical records, the post-service VA treatment records, the July 2012 VA examination report, the April 2020 VA physician’s opinion and any other evidence considered pertinent. The examiner is asked to provide a response to the following: Is any current esophageal disability, including GERD and/or esophagitis at least as likely as not related to service, including the treatment for GERD the Veteran received during service? The examiner should explain the rationale for the opinion provided. 6. After the development in #1 and #2 has been completed, schedule the Veteran for a VA examination by an appropriate medical professional for his claimed cardiac disability. The examiner must review the claims file, including the service treatment records, the post-service private medical records, the post-service VA treatment records, the July 2012 VA examination report, the April 2020 VA physician’s opinion and any other evidence considered pertinent. The examiner is asked to provide a response to the following: A) Does the Veteran have a current cardiac disability, to include cardiomegaly/disability manifested by palpitations and/or premature ventricular contractions? B) Is any such current cardiac disability at least as likely as not related to service, including the cardiac symptoms the Veteran experienced therein? The examiner should explain the rationale for the opinion provided. 7. After the development in #1 and #2 has been completed, schedule the Veteran for a VA examination by an appropriate medical professional for his claimed acquired psychiatric disability. The examiner must review the claims file, including the service treatment records, the post-service private medical records, the post-service VA treatment records, the July 2012 VA examination report, the April 2020 VA physician’s opinion and any other evidence considered pertinent. The examiner is asked to provide a response to the following: A) Does the Veteran have a current psychiatric disability, to include anxiety? B) If any such psychiatric disability is present, is it at least as likely as not related to service, including the anxiety the Veteran experienced therein? C) Does that Veteran have a psychiatric disability that is caused by a service-connected disability? D) Does the Veteran have a psychiatric disability that is aggravated by a service-connected disability? The examiner should explain the rationale for the opinion provided. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dan Brook, 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.