Citation Nr: 21022266 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 18-19 948 DATE: April 15, 2021 REMANDED 1. Entitlement to service connection for a back disability is remanded. 2. Entitlement to service connection for right lumbar radiculopathy is remanded. 3. Entitlement to service connection for left lumbar radiculopathy is remanded. 4. Entitlement to service connection for a right wrist disability is remanded. 5. Entitlement to service connection for a left wrist disability is remanded. 6. Entitlement to service connection for a right upper extremity nerve disability is remanded. 7. Entitlement to service connection for a left upper extremity nerve disability is remanded. 8. Entitlement to service connection for a right elbow disability is remanded. 9. Entitlement to service connection for a left elbow disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1982 to January 1984, and from November 1990 to July 1991, and had additional Reserve service. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision. Unfortunately, the Veteran died in October 2019, during the pendency of this appeal. The Agency of Original Jurisdiction (AOJ) has recognized his widow as the substitute claimant for the purpose of processing this appeal to completion. See February 7, 2020 VA correspondence. In April 2021, a virtual Board hearing was held before the undersigned. 1., 2., 3., 4., 5., 6., 7., 8., 9. Entitlement to service connection for back, right and left lumbar radiculopathy, right and left wrist, right and left upper extremity nerve, and right and left elbow disabilities is remanded. Prior to his death, the Veteran’s primary theory of entitlement was that his claimed disabilities were directly related to his military service in the Gulf War, specifically Operation Desert Storm. See May 2015 Notice of Disagreement. He reported that his joint pain began about six months after separation from service, and progressed over time. Id. He reported that he had a high pain tolerance and did not file a claim until the pain worsened. Id; see also April 2018 VA Form 9. At her April 2021 Board hearing, the appellant testified that the Veteran had ongoing, chronic pain in various joints upon his return from Southwest Asia. She contends he may have had a multi-symptom unexplained musculoskeletal illness, specifically fibromyalgia, which progressed/worsened to the point that it manifested in various diagnosed joint disabilities, such as arthritis. Her representative asserted that the VA examinations of record did not adequately address whether the Veteran had fibromyalgia, considering the evidence regarding ongoing complaints since service. [Review of the Veteran’s service treatment records (STRs) found that on February 1996 examination (for Reserve instructor purposes), he reported a history of “discomfort-stiffness in joints of shoulders, elbows, and knees since returning from tour of duty in Saudi 6/91.” ] Upon review of the record, including the Veteran’s statements and the appellant’s testimony, the Board finds that further development of the medical evidence is necessary. Prior to his death, the Veteran was afforded two VA Gulf War examinations. In March 2014, a VA nurse practitioner opined that the Veteran did not then meet the criteria for fibromyalgia because there were “no tender points specific to fibromyalgia.” She opined that the Veteran’s claimed disabilities are “more likely than not related to arthritis which is a diagnosis with partially explained etiology [his postservice physical employment] and is less likely than not related to his gulf war service.” [She did not diagnose the Veteran’s reported elbow and wrist pain.] In August 2014, another VA examiner (a physician) identified the Veteran’s claimed disabilities as “a disease with a clear and specific etiology and diagnosis,” and opined (without explanation) it is at least as likely as not that “the disability pattern or diagnosed diseases are related to specific exposure events experienced by the Veteran during service in Southwest Asia.” [He did not identify the “exposure events” noted in his statement.] Both opinions lack adequate rationale – they do not fully address all of the Veteran’s claimed disabilities, do not address his February 1996 report of joint pain since service in Southwest Asia, do not cite to supporting factual data specific to this case, and do not specifically address the theory of entitlement raised by the appellant at the April 2021 Board hearing. Remand for another, fully adequate, medical opinion is necessary. The matters are REMANDED for the following: After the April 2021 Board hearing transcript is associated with the record, arrange for the claims file to be forwarded to an appropriate clinician for review and an advisory medical opinion regarding the likely etiology of the Veteran’s back, right and left lumbar radiculopathy, right and left wrist, right and left upper extremity nerve, and right and left elbow disabilities. The entire record (to include this remand, the March and August 2014 VA examination reports, and the appellant’s April 2021 Board hearing testimony and argument regarding the alleged theory of entitlement) must be reviewed by the provider. The consulting provider should respond to the following: (a) Identify (by diagnosis) each back, right and left lower extremity nerve, right and left wrist, right and left upper extremity nerve, and right and left elbow disabilities shown by the record. (b) Identify the likely etiology for each of the disability entities diagnosed in part (a). Specifically, is it at least as likely as not (a 50% or greater probability) that the disabilities were etiologically related to his service, and specifically his service in Southwest Asia? The rationale for the opinion must acknowledge and discuss: (i) The Veteran’s lay reports (prior to his death, as outlined above) that he experienced joint discomfort/stiffness of his shoulders, elbows, and knees since returning from Southwest Asia, and that his reported joint pain began approximately 6 months after he returned from Operation Desert Storm; and, (ii) The theory of entitlement that the Veteran had fibromyalgia as a result of his service in Southwest Asia, and that his reported complaints of migrating joint pain that became noticeable to him in service or shortly thereafter (for which he had a high tolerance, and did not seek treatment until the pain had progressed considerably) were manifestations (or sequelae) of fibromyalgia in the various joints that ultimately progressed to the point of manifesting as the diagnosed disabilities, including arthritis). (c) If the diagnosed disabilities are found to not have been directly related to service, to include as manifestations/sequalae of fibromyalgia related to service in Southwest Asia, identify the etiology/ies that is/are considered more likely (and explain why that is so). The consulting provider should explain the rationale for all opinions, citing to supporting factual data and medical principles, as deemed appropriate. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dupont, 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.