Citation Nr: 21032267 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 15-02 783 DATE: May 26, 2021 REMANDED The claim of entitlement to service connection for arthritis of the left hand with painful and swollen joints is remanded. The claim of entitlement to service connection for arthritis of the right hand with painful and swollen joints is remanded. The claim of entitlement to service connection for a left elbow disability, claimed as arthritis with painful and swollen joints, is remanded. The claim of entitlement to service connection for a right elbow disability, claimed as arthritis with painful and swollen joints, is remanded. The claim of entitlement to service connection for a left hip disability is remanded. The claim of entitlement to service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran had active service from Mach 1969 to September 1991. This matter comes before the Board of Veterans' Appeals (Board) from a May 2014 rating decision by the Agency of Original Jurisdiction (AOJ). A Board hearing was held in May 2018. A transcript is of record. In February 2019, the Board dismissed the Veteran's claims of entitlement to service connection for bilateral hearing loss, allergic rhinitis, and asthma. Claims of entitlement to service connection for gout, left and right knee disabilities, a left knee scar, left and right hip disabilities, arthritis with painful and swollen joints, bladder cancer, a prostate disability, erectile dysfunction, and hypertension were remanded. In July 2020, the AOJ granted service connection for left and right knee disabilities, a left knee scar, gout, and hypertension. As these awards of service connection constitute a full grant of the benefits sought on appeal, these issues are no longer in appellate status. In August 2020, the AOJ granted service connection for bladder cancer status post cystectomy and prostatectomy, and erectile dysfunction. As these awards of service connection constitute a full grant of the benefits sought on appeal, these issues are no longer in appellate status. The Board observes that in December 2020, the AOJ severed service connection for gout. The Veteran has not appealed that decision. Service connection for arthritis of the left hand with painful and swollen joints Service connection for arthritis of the right hand with painful and swollen joints Service connection for a left elbow disability (claimed as arthritis with painful and swollen joints) Service connection for a right elbow disability (claimed as arthritis with painful and swollen joints) In the February 2019 remand, the Board noted that the Veteran related his hand and elbow pain to the cumulative wear and tear from his long career as a Boatswain's Mate. It also acknowledged the Veteran's report of having fallen on a ship, with resulting right elbow and wrist pain. The Board directed that an examination be conducted, and that the examiner should specifically address the Veteran's contention that he had joint pain and swelling caused by cumulative wear and tear during his 20-year Navy career including due to his duties as a Boatswain's Mate. The Board also directed that the examiner consider an October 2016 VA psychiatric consultation report, in which the provider noted the Veteran's report of a fall on a ship and resulting right elbow and wrist pain. On VA hand and finger examination in September 2020, the diagnosis was polyarticular osteoarthrosis. The examiner indicated that imaging revealed arthritis in both hands. She concluded that the diagnosis was not related to service. She indicated that she had reviewed the book-marked evidence and the service treatment records, but was unable to find any documentation that the Veteran had arthritis in the bilateral hands and fingers during service. She did not discuss the Veteran's contentions regarding cumulative wear and tear on his joints during his 20-year career, to include physical activity as a Boatswain's Mate. Moreover, the question is not whether the Veteran had arthritis during service, but whether the current diagnosis of arthritis is related to service. As this examiner did not adequately address the question of whether the claimed disability is related to service, the Board concludes that an additional examination is necessary. On VA elbow and forearm examination in September 2020, the diagnoses were right mild ulnohumeral osteoarthrosis and left triceps tendinopathy. The examiner opined that the Veteran's elbow disability was not related to service. She stated that she had reviewed the book-marked evidence and service treatment records, but was unable to find any documentation indicating arthritis in the bilateral elbows, or treatment during service. While the examiner considered the Veteran's report of a fall during service, she did not discuss his contentions regarding cumulative wear and tear on his joints during his 20-year career, to include physical activity as a Boatswain's Mate. As this examiner did not adequately address the Veteran's competent statements or provide sufficient rationale, the Board concludes that an additional examination is necessary. Service connection for a left hip disability Service connection for a right hip disability In the February 2019 remand, the Board noted that the Veteran related his hip disabilities to the cumulative wear and tear of his long career as a Boatswain's Mate, or as secondary to his bilateral knee disability. It also noted that an August 2008 record from the Naval Medical Center (NMC) San Diego included an assessment of osteoarthritis of the right hip, but that it was unclear whether the diagnosis was confirmed on X-ray. The Board also observed that a June 2012 NMC San Diego record indicated that the Veteran had gait abnormality due to left knee pain. It directed that an examination be conducted, and that the examiner should provide opinions regarding whether the Veteran's claimed hip disabilities were related to service or to his knee disabilities. The Board specified that the examiner should address the Veteran's report of bilateral hip pain and evidence indicating that the Veteran had an altered gait due to knee pain. On VA examination in February 2020, the diagnosis was osteoarthritis of the bilateral hips. The examiner indicated that arthritis was confirmed on imaging. He concluded that the Veteran's hip disability was not related to his left knee disability. Regarding rationale, he stated the following: American Academy of orthopedics list causes of knee arthritis as advanced age, obesity, joint, family history, illness or congenital defect, chronic joint stress, lack of exercise and poor muscle tone. Medical literature does not support an association of gait abnormalities with development of osteoarthritis and lower extremity joints. This generic statement does not adequately address the question of whether the Veteran's bilateral hip arthritis was caused or aggravated by his now service-connected knee disability, to include the documented gait abnormality. Absent a discussion of the medical principles upon which the opinion is based, the Board is unable to make a determination as to whether service connection for the bilateral hip disability is warranted as secondary to the Veteran's service-connected knee disability. The Board also observes that an opinion regarding the question of direct service connection was obtained in August 2020; however, the examiner did not additionally address the question of a relationship between the Veteran's knee disability and his claimed hip disability. Thus, an additional examination is necessary to address the secondary theory of entitlement. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the nature and etiology of his claimed hand and elbow disabilities. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. After the record review and examination of the Veteran, the examiner should identify all relevant diagnoses referable to the Veteran's hands and elbows. The examiner should provide an opinion regarding whether it is at least as likely as not that any such diagnosis was incurred in, or is otherwise related to active service. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. The examiner should specifically address the Veteran's testimony regarding the cumulative wear and tear on his joints throughout his over 20-year career, including due to his duties as a Boatswain's Mate. The examiner should also address the October 2016 VA psychiatry consultation in which the Veteran reported he has pain in his right elbow and wrist related to a fall on a ship. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Schedule the Veteran for a VA examination to determine the etiology of his bilateral hip disability. The claims file must be made available to the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. Following review of the record and examination of the Veteran, the examiner should provide an opinion with respect to whether it is at least as likely as not (50 percent or more probability) that the Veteran's hip disability was caused or aggravated (worsened beyond normal progression) by the Veteran's service-connected bilateral knee disability. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. The examiner should specifically address the Veteran's contention that the pain in his hips is due to his knees, as well as the indication in NMC San Diego treatment notes of an altered gait due to knee pain. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. (Continued on the next page) 3. Then, readjudicate the Veteran's claim. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period within which to respond thereto. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Barone, 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.