Citation Nr: 21015592 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 13-31 228 DATE: March 17, 2021 ORDER Entitlement to service connection for two lipomas—one on the upper chest and the other on the upper right shoulder—is granted. Entitlement to service connection for headaches, secondary to service-connected hypertension, is granted. REMANDED Entitlement to service connection for a thoracolumbar spine disability, to include as secondary to residuals of service-connected hysterectomy, is remanded. FINDINGS OF FACT 1. Lipomas on the Veteran’s upper right chest and upper right shoulder developed during, or are the result of, active service. 2. The Veteran’s headaches are proximately due to her service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection for lipomas are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for headaches are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1978 to May 1992. The Veteran testified before the undersigned Veterans Law Judge in an April 2015 hearing. A transcript of that hearing is of record. The Veteran’s appeal returns to the Board of Veterans’ Appeals (the Board) from a June 2019 decision wherein the Board remanded the issues of her entitlement to service connection for lipomas, headaches, and a thoracolumbar spine disability to the Agency of Original Jurisdiction (AOJ) to afford the Veteran new VA examinations. The Veteran received those examinations in July 2019 and December 2019. The Veteran also received addendum opinions for lipomas and a thoracolumbar spine disorder in July 2020. For the reasons discussed below, the July 2019 VA examination, December 2019 VA examination, and July 2020 addendum opinion assessing the thoracolumbar spine disorder are inadequate, and that claim must be remanded. The Board is granting the Veteran’s claims for service connection for lipomas and headaches; therefore, any duty to assist issues with respect to these two issues are moot.   Service Connection 1. Entitlement to Service Connection for Lipomas on Upper Chest and Upper Right Shoulder, Initially Claimed as Bilateral Arm Pain In her April 2015 hearing testimony, the Veteran stated that her claim for bilateral arm pain was for lipomas on her upper right shoulder and upper right chest. She contended in an October 2012 letter, her April 2015 hearing testimony, and in an October 2016 VA examination that her lipomas onset during active service and were due to firearms training and carrying a rucksack. 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 first two elements of service connection are met here. February 2021 VA treatment records note a diagnosis for lipomas on her right upper chest and right upper shoulder. It notes further that surgical removal may not be appropriate due to the Veteran’s risk of developing keloids. A July 2020 VA examination report includes a summary of the Veteran’s medical history for lipomas on the upper back and chest. The first requirement of service connection is met. With respect to the second element of service connection, the Veteran’s October 2012 statement notes her carrying of a firearm and rucksack during active service. Her April 2015 hearing testimony similarly attribute her lipomas to carrying arms and rucksacks during active service. The second element of service connection is established. Thus, the question for the Board is whether the lipomas are etiologically related to the Veteran’s active service. The cause of lipomas is unknown. In a November 2016 opinion, the examiner responsible for the October 2016 VA examination observed that lipomas are benign neoplasms of unknown etiology. A December 2019 VA examination similarly includes the observation that the etiology of lipomas is unclear. To the extent the causes are known, traumas have been identified as a possible cause of lipomas. A July 2020 VA addendum opinion summarized medical literature discussing the onset of posttraumatic lipomas. According to the medical literature, the mean onset for lipomas was within 2 years of the trauma, with onset in some cases occurring five years after the trauma. The Veteran attributes her lipomas to “trauma” from firearms training and carrying a rucksack during active service. Given the medical uncertainty regarding the etiology of lipomas, and the known role that trauma plays in lipoma formation, the Board resolves reasonable doubt in the Veteran’s favor and concludes that her lipomas are due to her active service. The Board notes that the examiner responsible for the December 2019 VA examination concluded that the events described by the Veteran were not significant enough to constitute trauma and were mere discomforts. The examiner did not provide a basis for this assessment, however. In addition, the Board finds the Veteran’s description of what she experienced during active service to be more probative than the examiner’s assessment of the severity of those experiences. The Board also notes conflicting evidence regarding when the lipomas formed. An October 2016 VA examination places the onset of lipomas on the right upper chest and right upper shoulder in 1980, which was during the Veteran’s active service. This was based on the Veteran’s report during the examination. A July 2020 VA examination includes the examiner’s conclusion that the lipomas did not onset until 2012. The examiner conducted a comprehensive review of the Veteran’s service treatment records and post-service treatment records and did not identify treatment records for lipomas until 2012. The examiner also noted that the Veteran’s May 1992 separation examination did not identify any lipomas. The balance of the evidence with respect to the onset of the lipomas is in equipoise. Thus, given the uncertainty regarding the etiology for lipomas and the timing of onset, the Board resolves all reasonable doubt in the Veteran’s favor and concludes that lipomas are etiologically related to her active service. Entitlement to service connection for two lipomas—one on the upper right chest and one on the upper right shoulder—is granted. 2. Entitlement to Service Connection for Headaches, Secondary to Service-Connected Hypertension The Veteran contends that she experiences headaches due to her service-connected hypertension. An October 2016 VA examination includes a diagnosis for hypertensive-related headaches. The first element of secondary service connection is satisfied. 38 C.F.R. § 3.310(b); Wallin v. West, 11 Vet. App. 509, 511 (1998); Allen v. Brown, 7 Vet. App. 439, 447-48 (1995). A November 2020 rating decision granted entitlement to service connection for hypertension, satisfying the second element of secondary service connection. With respect to the third element requiring an etiological relationship between headaches and the service-connected hypertension, an October 2016 VA examination report includes the examiner’s conclusion that the Veteran’s headaches were due to poorly controlled hypertension. The third element of secondary service connection is satisfied. In light of the foregoing, entitlement to service connection for headaches, secondary to service-connected hypertension, is granted. REASONS FOR REMAND 1. Entitlement to Service Connection for a Thoracolumbar Spine Disorder Compliance with a remand is not discretionary, and failure to comply with the terms of a remand requires another remand to remedy the non-compliance. A remand is necessary here to comply with the Board’s June 2019 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). In addition, once VA has afforded a veteran an examination, it must ensure that it is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The December 2019 VA examination is inadequate because the examiner did not provide an adequate rationale. The examiner concluded that the Veteran’s thoracolumbar spine disorder was less likely than not due to active service. In the rationale, the examiner noted that pregnancy can result in transient back pain. The examiner also noted that carrying heavy loads is a risk factor for developing arthritis. The examiner added that the Veteran’s service treatment records did not include complaints of low back pain, which he reasoned would be necessary to establish a relationship between the Veteran’s active service and her current disorder. However, the examiner’s rationale failed to consider the Veteran’s reports in her medical history of back pain during active service and treatment for back pain with Tylox. The Veteran also stated that her back pain persisted following active service. The examiner’s failure to consider these reports of in-service treatment for low back pain and persistent back pain following active service undermines the examiner’s rationale, and the Board concludes that the December 2019 VA examination is inadequate. Like the December 2019 VA examination, the July 2020 VA addendum opinion is inadequate. The examiner responsible for the addendum opinion did not consider the Veteran’s reports of back pain during her in-service pregnancy. Because of that omission, the addendum opinion did not comply with the Board’s remand directives and is, therefore, inadequate. Reference is also made to the Veteran’s February 2012 statement that there is a relationship between headache pain and back pain. In light of the Board’s grant of service connection for headaches, secondary to service-connected hypertension, an examiner should consider whether her back pain is etiologically related to her service-connected headaches. In light of the foregoing, a remand is needed to afford the Veteran an adequate examination that complies with the Board’s remand directives and addresses all of her contentions. This matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination for her thoracolumbar spine disorder. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) Is the thoracolumbar spine disorder at least as likely as not related to service, including the Veteran’s pregnancy and complaints of low back pain treated with Tylox? (b.) Is a thoracolumbar spine disorder (i) proximately due to a service connected disability, to include hysterectomy residuals or headaches; or (ii) did it undergo any incremental increase in disability, regardless of its permanence, due to a service connected disability, to include hysterectomy residuals or headaches? The term “incremental increase in disability” means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any “incremental increase in disability” need not be permanent. Provide a rationale to support the opinion(s). MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Douglas M. Humphrey, 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.