Citation Nr: 21023977 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 19-31 594 DATE: April 21, 2021 ORDER Entitlement to service connection for multiple sclerosis (MS) is granted Entitlement to service connection for left hand numbness, to include as due to MS, is granted. Entitlement to service connection for right hand numbness, to include as due to MS, is granted. Entitlement to service connection for vertigo, to include as due to MS, is granted. REMANDED Entitlement to service connection for stiff body syndrome, include as due to service-connected disabilities, is remanded. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran’s in-service neurological symptoms were early manifestations of the Veteran’s currently diagnosed MS. 2. The evidence is in equipoise as to whether the Veteran’s left hand numbness is secondary to service-connected MS. 3. The evidence is in equipoise as to whether the Veteran’s right hand numbness is secondary to service-connected MS. 4. The evidence is in equipoise as to whether the Veteran’s vertigo is secondary to service-connected MS. CONCLUSIONS OF LAW 1. The criteria for service connection for MS have been met. 38 U.S.C. § 1131 (West 2012); 38 C.F.R. § 3.303. 2. The criteria for service connection for left hand condition have been met. 38 U.S.C. § 1131 (West 2012); 38 C.F.R. §§ 3.303; 3.310. 3. The criteria for service connection for right hand condition have been met. 38 U.S.C. § 1131 (West 2012); 38 C.F.R. §§ 3.303; 3.310. 4. The criteria for service connection for vertigo have been met. 38 U.S.C. § 1131 (West 2012); 38 C.F.R. §§ 3.303; 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1987 to April 1990. In April 2021, the Veteran testified at a video conference Board hearing before the undersigned Veterans Law Judge. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability. Id. Thus, if the Secretary determines that the causal disease or disability is, in fact, connected to service, then the claim for benefits for the condition “reasonably encompasses” a claim for that causal disease or disability, such that no additional filing is necessary to initiate a claim for benefits for the causal disease or disability. DeLisio v. Shinseki, 25 Vet. App. 45 (2011). Multiple Sclerosis The Veteran seeks service connection for MS. The Veteran contends that her symptoms associated with MS began during her service. The Board finds that the record reflects that the Veteran has a current diagnosis of MS. See April 2017 VA examination report. Thus, the first element of service connection is satisfied. The Board notes that the Veteran’s service treatment records document reports of neurological symptoms. Specifically, in a July 1989 service treatment record, the Veteran reported left leg numbness at least once a month. In an October 1989 service treatment record, the Veteran was treated for weakness and leg numbness that occurred three times a month. She was seen during service twice for left extremity numbness and right extremity numbness that was noted as “paresthesia.” Thus, the second element of service connection is satisfied. Therefore, the dispositive issue in this case is with respect to the third element, a causal relationship, i.e., nexus between the claimed in-service symptoms and the current disability. The Board finds that the medical evidence of record is in equipoise as to whether the Veteran’s MS was incurred in active service. Here, in a July 2017 private medical opinion, Dr. M.R.R. noted that the Veteran’s service treatment records reflect early neurological manifestations of MS. Specifically, Dr. M.R.R. noted that in July 1989, there were reports of left leg numbness; in October 1989 reports of weakness and leg numbness and paresthesia; in November 1989 reports of paresthesia with no clear etiology of the lower extremity numbness; in 1991 double and blurred vision with no clear etiology; in September 1992 dizziness (Dr. M.R.R. noted this is a common symptom of MS); and high prolactin (another common symptom of MS). Dr. M.R.R. pointed out that these symptoms were likely the early manifestations of MS as the Veteran has no known degenerative lumbar spine disease to explain months of migrating left then right leg numbness. Dr. M.R.R. further explained that MS symptoms can start before the clinical diagnosis. The date of diagnosis typically depends on the testing ordered and if the care provider considered MS in the differential. If so, then a Central Nervous System imaging would be ordered. Here, there was no Central Nervous System imaging done while the Veteran was in service. Dr. M.R.R. noted that leg numbness lasting a few months in a 20-year-old, especially numbness that moves from left to right leg would need more evaluation than a plain film of the lumbar spine to determine the etiology. Given such, Dr. M.R.R. opined that the leg numbness experienced during the Veteran’s service was due to MS, as she was later found to have multiple cord lesions. Based on the foregoing, the Board finds that Dr. M.R.R.’s medical opinion, which links the Veteran’s MS to her in-service neurological symptoms, supports a finding that the Veteran’s MS is at least as likely as not related to the Veteran’s service. Thus, the third element of service connection is satisfied. The Board acknowledges, when considering all the evidence of record, some of it is favorable and some of it is unfavorable and thus in equipoise. A claim will be denied only if the preponderance of the evidence is against the claim. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107. Resolving reasonable doubt in the Veteran’s favor, entitlement to service connection for MS is warranted. Vertigo and Left and Right-Hand Numbness Here, the Board notes that the Veteran contributes her vertigo and left and right-hand numbness to her MS. With respect to the Veteran’s claims for service connection for vertigo and left and right-hand numbness, the Board finds that the evidence is in equipoise as to whether the Veteran’s vertigo and left and right-hand numbness are secondary to her now service-connected MS. As stated above, the first element of secondary service connection requires evidence of a current disorder. Here, the Veteran’s medical records reflect diagnoses of vertigo and right and left-hand conditions. Thus, the Veteran has satisfied the first element of secondary service connection. The second element of secondary service connection requires evidence of a service-connected disability. By granting service connection for MS in this decision, the Veteran is now service connected for MS. Thus, the Veteran has satisfied the second element of secondary service connection. Lastly, the third element of secondary service connection requires medical nexus evidence establishing a connection between the service-connected disability and the current disorder. Here, a review of the private medical records by Dr. M.R.R. reveals that the Veteran’s vertigo and left and hand numbness are at least as likely as not related to the Veteran’s MS. The private medical records document the Veteran’s symptoms of vertigo and left and right-hand numbness, which are secondary to the Veteran’s MS. Based on the foregoing, the Board finds that the Veteran’s private medical records, which link the Veteran’s vertigo and left and right hand numbness to the Veteran’s MS, support a finding that the Veteran’s vertigo and left and right hand numbness are at least as likely as not proximately due to or a result of her service-connected MS. Thus, the third element of secondary service connection is satisfied. The Board acknowledges, when considering all the evidence of record, some of it is favorable and some of it is unfavorable and thus in equipoise. A claim will be denied only if the preponderance of the evidence is against the claim. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107. Resolving reasonable doubt in the Veteran’s favor, entitlement to service connection for right- and left-hand condition and vertigo is warranted. REASONS FOR REMAND With respect to the Veteran’s claim for service connection for stiff body syndrome, further development is required. Here, during the April 2021 Board hearing, the Veteran testified that her stiff body syndrome is a symptom of her MS. Thus, it is unclear whether the Veteran’s stiff body syndrome is part and parcel of the Veteran’s MS or whether the Veteran’s stiff body syndrome is a separate and distinct diagnosis. As such, a medical opinion is necessary to ascertain whether the Veteran’s stiff body syndrome is a separate and distinct diagnosis. The matters are REMANDED for the following action: 1. Request a medical opinion from a qualified medical professional to ascertain the nature and etiology of the Veteran’s stiff body syndrome. After reviewing the entire record, and any tests or studies deemed necessary, the examiner is asked to address the following: (a) Whether the Veteran has a current diagnosis of stiff body syndrome. If so, then whether the Veteran’s stiff body syndrome is a separate and distinct diagnosis/disability, or whether the symptoms of stiff body syndrome are attributed solely to the Veteran’s service-connected disabilities, to include MS, vertigo, and left and right hand numbness. (b) If it is determined that the Veteran’s stiff body syndrome is a separate and distinct diagnosis, then whether the Veteran’s stiff body syndrome is at least as likely as not related to the Veteran’s service. whether it is at least as likely as not stiff body syndrome is (1) proximately caused by or (2) underwent any incremental increase in disability, regardless of its permanence, due to the Veteran’s service-connected disabilities. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Abdelbary, 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.