Citation Nr: 21032743 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 11-31 286 DATE: May 27, 2021 ORDER Entitlement to service connection for a right ulnar nerve disorder is granted. Entitlement to service connection for residuals from excision of a tumor from the right elbow is granted. Entitlement to service connection for a right elbow disorder, other than right ulnar nerve disorder and tumor excision residuals, is denied. Entitlement to service connection for a left arm disorder, other than a left forearm disorder, to include as secondary to a claimed back disorder, is denied. Entitlement to service connection for a back disorder is denied. Entitlement to service connection for a right leg disorder, other than a right knee disorder, to include as secondary to a claimed back disorder, is denied. Entitlement to service connection for a left leg disorder, other than a left knee disorder, to include as secondary to a claimed back disorder, is denied. REMANDED Entitlement to service connection for a right arm disorder, to include as secondary to a claimed back disorder, is remanded. FINDINGS OF FACT 1. The Veteran had less than 90 days of active duty service. 2. The Veteran's right ulnar nerve disorder clearly and unmistakably pre-existed his enlistment into service and was aggravated by his active duty service. 3. The Veteran has residuals from excision of a tumor from the right elbow that resulted from his service-connected right hand ulnar nerve disability. 4. The Veteran has no right elbow disorder that is distinct from his service-connected right ulnar nerve disorder. 5. The Veteran has left carpal tunnel syndrome that was not incurred during service and did not result from an in-service injury, illness, or event. 6. The Veteran had thoracolumbar spine degenerative arthritis that was not incurred during service and did not result from an in-service injury, illness, or event. 7. The Veteran has a right lower extremity radiculopathy that resulted from his non-service-connected thoracolumbar spine degenerative arthritis. 8. The Veteran has a left lower extremity radiculopathy that resulted from his non-service-connected thoracolumbar spine degenerative arthritis. CONCLUSIONS OF LAW 1. The criteria for service connection for a right ulnar nerve disorder are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for residuals from excision of a tumor from the right elbow are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 3. The criteria for service connection for a right elbow disorder, other than right ulnar nerve disorder and residuals of a tumor excision, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 4. The criteria for service connection for a left arm disorder, other than a left forearm disorder, to include as secondary to a claimed back disorder, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 5. The criteria for service connection for a back disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 6. The criteria for service connection for a right leg disorder, other than a right knee disorder, to include as secondary to a claimed back disorder, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 7. The criteria for service connection for a left leg disorder, other than a left knee disorder, to include as secondary to a claimed back disorder, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from February through April of 1970. The issues on appeal arise from the Veteran's September 2009 claim and a rating decision issued by the agency of original jurisdiction (AOJ) in March 2010. A Board hearing was held in June 2015. A transcript is of record. A February 2017 letter notified the Veteran that the Veterans Law Judge who presided over the hearing was no longer employed at the Board and the Veteran was given the option to request a new hearing before a sitting Board member. The Veteran has not requested a new hearing. This matter has been remanded previously by the Board on multiple occasions. The development ordered in the previous remands have been completed. The matter now returns to the Board for review. Service Connection Generally, service connection will be granted if the evidence shows that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection requires an evidentiary showing of three essential elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Service connection for certain listed chronic diseases, which include arthritis and organic diseases of the nervous system, may be awarded on a presumptive basis and will be presumed to have been incurred during active service, even though there is no evidence of the disability during service if such disability becomes manifest to a compensable degree within one year of separation from active duty. That presumption may not be applied in this case, however, because the Veteran had less than 90 days of active duty service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a)(1), 3.309(a). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Also, a disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for a right ulnar nerve disorder. The Veteran asserts in his September 2009 claim that he is entitled to service connection for a right hand disorder. This issue has a long and eventful procedural history. The Veteran filed an initial claim for service connection for a right hand disorder in May 1970; however, that claim was denied by the AOJ in a June 1970 rating decision. In November 1972, the Veteran filed a petition to reopen his claim. That petition was denied by the AOJ in an August 1974 rating decision. As mentioned above, a new claim for service connection for a right hand disorder was received by VA in September 2009. That claim was accepted by VA as a renewed petition to reopen the Veteran's claim based on new and material evidence under 38 C.F.R. § 3.156(a). In a November 2015 decision/remand, the Board determined that new and material evidence was received and reopened the Veteran's claim for service connection for a right hand disorder, recharacterized as a right hand ulnar nerve disorder. As the question of whether new and material evidence was received has already been adjudicated fully and favorably, the issue remaining on appeal is simply whether service connection is warranted by the evidence. Subject to the above, the Board notes also that the claims file appears to indicate that the Veteran's service department records were added to the record at various times during the time period from 2011 through 2017, well after the AOJ's earlier decisions in June 1970 and August 1974. However, a plain reading of the AOJ's initial denial in June 1970 and its October 1974 denial of the Veteran's initial petition to reopen reflects that the Veteran's service department records were available to the AOJ at that time, and indeed, facts obtained from its review of the service department records served as part of the basis for the AOJ's denials. Under the circumstances, the Board concludes that VA has correctly construed the Veteran's September 2009 claim as a renewed petition to reopen his previously denied claims under 38 C.F.R. § 3.156(a) and sees no basis for treating the issue on appeal as reconsideration of the Veteran's original May 1970 claim under 38 C.F.R. § 3.156(c). Turning to the merits of the issue at hand, the Board determined in the prior November 2015 decision/remand that the Veteran's February 1970 enlistment examination noted no ulnar nerve disorder or other neurological defects. Hence, the Veteran must be presumed as having been sound at the time of his enlistment. 38 U.S.C. § 1111. That presumption can be rebutted only by evidence showing that: 1) the Veteran's disorder clearly and unmistakably pre-existed his enlistment into service, and 2) the pre-existing disorder was clearly and unmistakably not aggravated by the Veteran's active duty service. 38 U.S.C. § 1111; Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). Addressing the first leg of the test outlined above, the Board finds that the evidence does show clearly and unmistakably that the Veteran had a right ulnar nerve disorder that pre-existed his enlistment into service. In that regard, the Veteran's service department records show that the Veteran sought medical evaluation and treatment on the first day of his basic training for reported inability to fully extend the fourth and fifth fingers on his right hand. During a Medical Board examination conducted that same day, the Veteran related to attending medical staff that he had sustained a puncture wound on his right elbow in 1966, four years before he enlisted, and that he had subsequently experienced numbness and tingling in his right forearm and hand. Although the record contains no treatment records relating to the pre-service injury in 1966, it is notable that the Veteran continued to maintain suffering the pre-service injury during post-service VA treatment in 1972. Indeed, more recent medical opinions rendered in February 2016, September 2017, and August 2020 concur that the Veteran clearly and unmistakably had a pre-existing right ulnar nerve injury. Given the chronology reported by the Veteran during in-service treatment, Medical Board findings, and the opinions described above, the Board concludes that it is clear and unmistakable that the Veteran had a pre-existing right ulnar nerve injury that caused numbness, tingling, and inability to extend his right fourth and fifth fingers. Subject to the above, the Board finds also that the evidence does not show clearly and unmistakably that the Veteran's pre-existing right ulnar nerve disorder was not aggravated by his active duty service. As mentioned, the Veteran's right ulnar nerve disorder was asymptomatic at the time of his enlistment. A physical examination conducted as part of the Veteran's February 1970 enlistment examination revealed no neurological defects or abnormalities in the Veteran's upper extremities. In the prior September 2019 remand, the Board determined also that the Veteran was credibly reporting that he fell from monkey bars and landed on his right elbow during service, apparently on his first day of basic training. The Medical Board examination, which was apparently conducted on the same day as the Veteran's fall, revealed for the first time moderate weakness of the deep extensors in the right fourth and fifth fingers, atrophy in the right hand, and moderate weakness in the right thumb. Mild hypesthesia and hypalgesia over the right ulnar nerve were also observed at that time. Attending medical staff rendered a diagnosis for partial deficit of the ulnar nerve. Overall, the service treatment records suggest strongly that the Veteran's pre-existing right ulnar nerve disorder, which was asymptomatic when the Veteran enlisted, was aggravated, and became symptomatic during service. In conjunction with the same, subsequent post-service treatment records document ongoing and chronic muscle atrophy with continued loss of sensation and motor strength in the right hand. In December 1972, the Veteran underwent right ulnar nerve transposition surgery. Records for subsequent VA treatment received by the Veteran through the present and examinations conducted in January 2016 and September 2017 all document that the Veteran continues to lack the ability to fully extend his right fourth and fifth fingers due to ulnar palsy. Medical opinions rendered in February 2016 and August 2020 both express that the Veteran's pre-existing right ulnar nerve disorder was not aggravated during service. The February 2016 opinion appears to be based without elaboration or explanation on the belief that "there is no evidence of any event during active duty service that suggests aggravation." The February 2016 opinion overlooks the Veteran's reported fall from monkey bars, and, fails to explain how the Veteran's right ulnar nerve disorder was asymptomatic during his enlistment examination but symptomatic a month later during his Medical Board examination. In the absence of such discussion, the February 2016 opinion is incomplete and not entitled significant probative weight. Similarly, the August 2020 negative aggravation opinion is conclusive and supported by little explanation or rationale. Again, the reviewing clinician stated only, "there is no documentation in the claims file to support that the Veteran's pre-existing right arm condition was aggravated beyond its normal progression due to a fall from the monkey bars." Nonetheless, the reviewing clinician again failed to acknowledge the fact that the Veteran's disorder was asymptomatic during his February 1970 enlistment examination but symptomatic during the March 1970 Medical Board examination. For this reason, the August 2020 opinion is also entitled little probative weight. Finding that the Veteran has credibly reported that he incurred an injury to his right elbow and arm in a fall from monkey bars during service, the Board is persuaded by the information contained in the service treatment records and concludes that the Veteran's pre-existing right ulnar nerve disorder was aggravated during his active duty service. The Veteran is entitled to service connection for a right hand ulnar nerve disorder. To that extent, this appeal is granted. 2. Entitlement to service connection for residuals from excision of a tumor from the right elbow. The Veteran contends that he underwent surgery shortly after his separation from service to remove a benign tumor from his right elbow. He claims entitlement to service connection for residuals resulting from the procedure to remove the tumor. During a February 2016 examination, the examiner noted that in December 1972 the Veteran underwent transposition ulnar nerve surgery which revealed a large neuroma and scarring that was likely incurred at the time of the pre-service laceration injury. Accordingly, the examiner essentially opines that the neuroma that necessitated the Veteran's excision procedure in December 1972 is associated with the Veteran's service-connected right ulnar nerve disorder. The Veteran is entitled to service connection for residuals from excision of a tumor from the right elbow. To that extent also, this appeal is granted. 3. Entitlement to service connection for a right elbow disorder, other than ulnar nerve disorder and residuals from excision of a tumor from the right elbow. The Veteran also claims entitlement to service connection for a right elbow disorder. Notably, the Veteran does not identify a specific diagnosis or disorder in support of his claim. Pursuant to the analysis above, service connection is granted for the Veteran for right hand ulnar disorder and residuals from excision of a tumor from his right elbow. As such, the Board's analysis in relation to the Veteran's right elbow will focus upon possible service connection for disorders shown in the record other than right hand ulnar disorder and residuals associated with excision of the tumor from the Veteran's right elbow. As discussed above, the service treatment records document observed weakness in the Veteran's fourth and fifth fingers, right hand atrophy, weakness, hypesthesia, and hypalgesia in the right hand which were associated with the Veteran's right ulnar nerve disorder. A musculoskeletal examination and examinations of the Veteran's upper extremities, conducted as part of the Veteran's enlistment examination and Medical Board examination, revealed no other abnormalities. Similarly, post-service treatment records indicate no subjective complaints by the Veteran related specifically to his right elbow. The records document no objective findings or treatment related to any right elbow disorders. Examinations of the Veteran's right upper extremity conducted in February 2016 and February 2020 revealed no right elbow abnormalities. As mentioned, the Veteran has not pointed to any specific right elbow disorders or diagnoses in support of his claim, and indeed, the evidence overall does not indicate that a right elbow disorder that is distinct from the Veteran's right ulnar disorder and residuals from excision of the tumor in 1972. The Veteran is not entitled to service connection for a right elbow disorder other than ulnar nerve disorder and residuals from excision of a tumor from the right elbow. To that extent, this appeal is denied. 4. Entitlement to service connection for a back disorder. The Veteran claims entitlement to service connection for a back disorder which he also attributes to an in-service fall from monkey bars. He testified during his June 2015 Board hearing that the monkey bars broke suddenly and that the soldier who was on the bars behind him also fell and landed across the Veteran's back. Although the evidence shows that the Veteran has thoracolumbar spine arthritis that was first diagnosed in an October 2009 lumbar spine MRI, the preponderance of the evidence shows that the Veteran's back disorder was not incurred during service and that it did not result from an in-service injury, illness, or event. The service treatment records are entirely silent for any subjective complaints for any back pain or other symptoms, and, reflect no objective findings related to the Veteran's back or spine. Indeed, the Veteran reported during a September 2017 spine examination that his back problems began in approximately 2000, decades after his period of active duty service. Essentially consistent with the reported history, VA treatment records first document subjective complaints of back pain in 2002, although the Veteran did not begin seeking comprehensive evaluation and workup for his back pain until 2008. As mentioned above, an October 2009 MRI study revealed findings that were consistent with mild arthritis with no nerve impingement or narrowing of the spinal canal. Records for subsequent VA treatment received by the Veteran through the present document ongoing treatment for the Veteran's back; however, express no opinions as to the cause or etiology of the Veteran's spine degeneration. The September 2017 spine examination expresses the opinion that the degenerative disorder in the Veteran's spine was less likely as not incurred during service or caused by an in-service injury, illness, or event. As rationale, the examiner explained that mild pain during motion, such as that shown during the examination, generally results from overuse over the years. A February 2020 examination concurred with earlier diagnoses for degenerative arthritis in the Veteran's spine and agreed with the negative September 2017 opinion and rationale. Although the Board remains mindful of the Veteran's theory that the degenerative condition in his spine was caused by his in-service fall, the Board is unable to assign significant weight to that assertion. The question as to whether such an etiological relationship exists is a complex one, particularly given the Veteran's own history that his back first became symptomatic in 2000 and various intervening events which include a 30-year career as a heavy equipment mechanic, as reported in his September 2009 claim and during his spine examinations. The Veteran is simply not competent to provide a probative etiology opinion for his back disorder. In contrast, the negative opinions given during the Veteran's spine examinations appear to be based upon a complete review of the Veteran's medical history, objective findings from the examinations, and application of accepted medical principles. Those opinions are not rebutted by contrary medical opinions in the record, and moreover, are consistent with the other evidence. As noted, MRI studies conducted in 2009 showed findings that were consistent with mild arthritis with no neurological involvement, which appears to be consistent with recent onset rather than initial onset decades earlier. As also noted, the Veteran has reported that he worked for approximately 30 years as a heavy diesel equipment mechanic, and certainly, repetitive physical stress and strain are likely incidental to such work. Indeed, the negative spine opinions in the record appear to suggest plausibly that the Veteran's spine degeneration is more likely attributable to such strain. The Board is persuaded by these negative opinions. The Veteran is not entitled to service connection for a back disorder. To that extent, this appeal is denied. 5. Entitlement to service connection for a left arm disorder, other than a left forearm disorder, to include as secondary to a claimed back disorder. The Veteran also asserts that he is entitled to service connection for a left arm disorder. To that end, he states in his September 2009 claim and during a September 2017 examination that he has had left elbow problems that began during service in March 1970. Again, in his Board hearing, he suggests that his claimed disorder may have resulted from his in-service fall from monkey bars. As an alternate theory, the Veteran testified also that he has been advised by treating physicians that he has a current left arm disorder that may be related to the degenerative condition in his back. Pursuant to the above analysis, there is no basis for awarding to the Veteran service connection for a back disorder. Accordingly, service connection for any left arm disorder cannot be granted to the Veteran pursuant to 38 C.F.R. § 3.310 based on the theory that it is secondary to or caused by the Veteran's back disorder. Subject to the same, the evidence shows that the Veteran began demonstrating neurological symptoms in his left arm in 2008 which were later diagnosed in March 2009 as carpal tunnel syndrome and treated by left carpal tunnel release performed in October 2009. Still, the preponderance of the evidence shows that the Veteran's left carpal tunnel disorder was not incurred during service, and, that it did not result from an in-service injury, illness, or event. Contrary to the Veteran's assertion that he began experiencing left arm problems during service, the service treatment records document no subjective complaints related to the left arm and no objective findings of any left arm abnormalities. Significantly, a Medical Board examination conducted in March 1970 revealed no abnormalities in the Veteran's left upper extremity, and indeed, no subjective complaints related to the left arm were noted. Post-service treatment records note for the first time left arm-related complaints during VA treatment in 2008, when the Veteran began reporting tingling and decreased grip strength. A neurological workup and March 2009 nerve conduction study revealed findings that were consistent with left median and ulnar neuropathies which were diagnosed as carpal tunnel syndrome. The Veteran underwent a left carpal tunnel release in October 2009. Although subsequent treatment records make sporadic mention of ongoing left arm pain, the records express no opinion concerning the cause or etiology of the Veteran's carpal tunnel syndrome. A September 2017 examination revealed no abnormalities in the Veteran's left upper extremity. In relation to the Veteran's left carpal tunnel syndrome, the examiner opined that it is less likely than not that the Veteran's carpal tunnel was incurred during service or caused by an in-service injury, illness, or event. As rationale, the examiner noted the same medical history outlined above and concluded that the history showed the onset of the Veteran's carpal tunnel disorder in 2009. An August 2018 medical record review and opinion concurred. As rationale, the reviewing clinician explained that carpal tunnel syndrome is an extremely common disorder involving the median nerve, which is prone to compression, entrapment, or irritation. She observed that that the majority of carpal tunnel cases are idiopathic but may involve common risk factors such as occupational or overuse injuries (such as likely repetitive strain from the Veteran's long occupational history as a heavy diesel equipment mechanic), trauma, and systemic medical conditions. Although the reviewing clinician acknowledged the Veteran's theory that the carpal tunnel disorder may have resulted from his in-service fall, and also, acknowledged again that direct trauma can cause carpal tunnel syndrome, she observed that the initial onset of the Veteran's carpal tunnel symptoms occurred nearly 40 years after the in-service fall. Given the period between the proposed injury and the approximate date of onset, the reviewing clinician concluded that a relationship between the Veteran's left carpal tunnel and the in-service injury was unlikely. The August 2018 clinician's opinion is supported also by concurring medical opinions given in February 2020 and August 2020, which are based on similar rationale. Under the same analysis as that undertaken above in relation to the back issue, the Veteran is not competent to provide a probative opinion relating his left carpal tunnel syndrome to his in-service fall. Moreover, while the Board acknowledges the Veteran's in-service fall(s), the Board also notes that the Veteran did not report any problems related to his left arm during his Medical Board examination, which was conducted contemporaneously to his in-service fall. In conjunction, the post-service treatment records document left arm complaints no earlier than 2008, despite that the Veteran had been receiving VA treatment for various conditions since 1972. For these reasons, the Board does not assign significant weight to the Veteran's assertion that he has had left arm problems dating back to his period of service. The Board is persuaded instead by the negative opinions contained in the record. Those opinions are not rebutted by contrary medical opinion and are supported by reasoned rationale that is supported by the other evidence. For these reasons, those opinions are entitled significant probative weight. The Veteran is not entitled to service connection for a left arm disorder. To that extent, this appeal is denied. 6. Entitlement to service connection for right and left leg disorders, other than right and left knee disorders, to include as secondary to a claimed back disorder. The Veteran also claims entitlement to service connection for disorders in his right and left lower extremities. Although he does not specify a particular diagnosis or disorder in support of his claims, he indicated in his Board hearing testimony that he believed that his claimed bilateral leg disorders were caused by his back disorder. The Board observes that the Veteran's claims for service connection for right and left knee disorders, which were initially part of this appeal, were denied by the Board in the previous September 2019 decision/remand. As such, the Board's analysis in relation to the Veteran's claimed left disorders will focus upon possible service connection for disorders shown in the record other than those relating to the Veteran's knees. The service treatment records, to include the March 1970 Medical Board examination, are entirely silent for any subjective complaints or objective findings related to the Veteran's lower extremities. Indeed, the Veteran does not appear to raise the assertion that the claimed disorders in his legs had their onset during service outside of the fall from "monkey" bars. The post-service treatment records show that the Veteran first began reporting numbness and tingling in his feet during VA treatment in November 2008, decades after his separation from service and contemporaneously with evaluation and workup for the degenerative condition in his thoracolumbar spine. Although the VA treatment records indicate that the Veteran has not undergone any formal medical workup related to the symptoms in his legs, a February 2020 examination revealed pain, paresthesias, and decreased sensation that was diagnosed as radiculopathies involving the sciatic nerves in both lower extremities. During a November 2020 neurological examination, the Veteran reported that he began having aching in his legs and a burning sensation in his feet approximately eight to ten years ago. The examination noted findings like those observed during the earlier February examination and confirmed the earlier diagnosis for bilateral lower extremity radiculopathies. The examiner concluded that the radiculopathies resulted from nerve irritation caused by the degeneration in the Veteran's thoracolumbar spine. The diagnoses expressed in the February 2020 and November 2020 examinations are not contradicted by any medical evidence in the record, and indeed, the November 2020 examiner's etiology opinion is not rebutted by any contrary opinions, to include the Veteran's own expressed theory and belief that the conditions in his legs are attributable to his back disorder. As such, those findings and the November 2020 examiner's opinion is persuasive. The preponderance of the evidence shows that the Veteran has radiculopathies in his lower extremities that are caused by degeneration in his thoracolumbar spine, but no other disorder. Again, pursuant to the analysis provided above, service connection for a back disorder is denied. Accordingly, service connection for any disorders in the Veteran's legs cannot be granted based on the theory that it is secondary to or caused by the Veteran's back disorder. 38 C.F.R. § 3.310. As the evidence indicates no other basis for which service connection can be granted for the radiculopathies in the Veteran's lower extremities, the Veteran is not entitled to service connection for right and left leg disorders. To that extent also, this appeal is denied. REASONS FOR REMAND Relative to the issue concerning the Veteran's entitlement to service connection for a right arm disorder, the post-service treatment records show that the Veteran began complaining of numbness and tingling that radiated down his arm during VA treatment in September 2008. Subsequent workup, to include a March 2009 nerve conduction study, indicated a bilateral median neuropathy that was consistent with carpal tunnel syndrome. By the Board's analysis above, service connection is in effect for the Veteran for a longstanding right ulnar nerve disorder that was likely aggravated during the Veteran's active duty service and for residuals associated with removal of a tumor from the Veteran's right elbow. The evidence appears to raise the question of whether the Veteran's right carpal tunnel syndrome has been caused and/or aggravated by the Veteran's right ulnar nerve disorder and any residuals associated with the tumor removal from the Veteran's right elbow. To date, VA has yet to obtain a medical opinion that directly addresses that question. As such, the Veteran should be afforded a full examination for his right carpal tunnel to determine whether such an etiological relationship exists. The matters are REMANDED for the following action: 1. The Veteran should be asked whether he has additional evidence pertaining to his right arm condition. Records for VA treatment received by the Veteran since July 2020 and any relevant private treatment identified by the Veteran and not already of record should be obtained. If the records are not available, such unavailability should be documented in the record. The Veteran should be notified of unsuccessful efforts in order to allow them the opportunity to obtain and submit those records for VA review. 2. After the development ordered in Paragraph 1 is complete, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's right arm condition (other than a right ulnar nerve disorder and/or tumor excision residuals). The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination must include a notation that this record review took place. The examiner should identify all right arm disorders present, other than the Veteran's right ulnar nerve disability and tumor excision residuals. For each identified disorder, the examiner is asked to respond to the following inquiries: A. Is it at least as likely as not that the disorder was incurred as a result of the Veteran's active duty service? B. Is it at least as likely as not that the disorder was caused by the Veteran's service-connected right ulnar nerve disorder? C. Is it at least as likely as not that the disorder has been aggravated by the Veteran's service-connected right ulnar nerve disorder? D. Is it at least as likely as not that the disorder was caused by service-connected residuals from excision of a tumor from the Veteran's right elbow? E. Is it at least as likely as not that the disorder has been aggravated by service-connected residuals from excision of a tumor from the Veteran's right elbow? The examiner must provide a complete rationale for all opinions expressed. 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 as to 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. After completion of the above development, the issue on appeal should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a SSOC and be given an opportunity to respond. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Lee 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.