Citation Nr: 21040280 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 16-60 178 DATE: July 3, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to environmental hazard, is remanded. Entitlement to service connection for a left knee disorder, to include arthritis, is remanded. Entitlement to service connection for a right knee disorder, to include arthritis, is remanded. Entitlement to service connection for a low back disorder, to include spinal cord with cyst, is remanded. Entitlement to service connection for a left ankle disorder, to include chronic pain, is remanded. Entitlement to service connection for a right ankle disorder, to include chronic pain, is remanded. Entitlement to service connection for a left foot disorder, to include chronic pain, is remanded. Entitlement to service connection for a right foot disorder, to include chronic pain, is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1986 to December 1991, to include service in Southwest Asia theater. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in March 2020. A transcript of that hearing has been associated with the claims file. These issues were remanded by the Board in a May 2020 decision for further development. The issues have since returned to the Board for appellate review. Remand is necessary to obtain a new addendum medical opinion. When VA undertakes to obtain an opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is considered adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The October 2020 VA examiner opined for each disorder below that the Veteran's disorder is less likely than not caused by service. The examiner reasoned in each case that there is "insufficient data available to support any positive causal relationship between any current" knee condition and any knee issues or event in service. The examiner stated there is "insufficient diagnostic information" to support causality. Also, the examiner stated there are "insufficient diagnoses found in service that are at least as likely as not of sufficient severity to lead to any chronicity which can support a causal relationship. To opine causality without definitive objective measures would be to render an opinion based merely on speculation." The opinions are identical in wording but for the identification of the disability in question. Based on this repeated opinion, the medical evidence, and lay evidence provided, it is clear the examiner did not review or discuss the evidence. Therefore, the VA examinations and opinions are inadequate as the examiner did not refer to the available evidence or the Veteran's statements. As a result, new VA medical opinions are required. The Veteran's military personnel record states that from September 1990 to April 1991, he was assigned to duty in an imminent danger pay area. In an August 2011 VA treatment record, the medical provider noted the Veteran was diagnosed with posttraumatic stress disorder (PTSD) and depression resulting from combat in Desert Storm. At the August 2011 appointment, the Veteran described incidents from service. First, he stated that while riding in a convoy, he was driving behind a five-ton truck. The convoy made contact with rebel troops and the truck in front of him stopped abruptly. He stated he crashed into the truck and hit his head into the steering wheel and dashboard and possibly lost consciousness. He stated he recalls another soldier trying to wake him up. He stated he does not remember what happened in the crash and immediately after. He stated he did not receive medical treatment. Second, he recalls a report of an air strike coming for his location at the communication center. He heard a plane flying overhead and hearing a huge blast. He attempted to dive out of the confined space of the communication center, and he "slammed into something." At the March 2020 Board hearing, the Veteran testified that he did not seek treatment for the back injury, bilateral knee, bilateral ankle or bilateral foot problems because the nearest treatment was in Bahrain, several hundred miles away. Board Hearing Transcript (T.) at 10. The Veteran stated he sought treatment when he returned to the United States. T. at 13. 1. Entitlement to service connection for hypertension, to include as due to exposure to environmental hazards, is remanded. Here, in addition to above, the November 1991 service treatment record (STR) separation examination refers to blood pressure readings of 132/96 and 128/82. Post-service private treatment records from 1994 onward contain blood pressure readings. The post-service private treatment records show blood pressure in May 1994 is 108/80; July 1994 is 100/80; August 1994 is 114/78; September 1994 is 142/98; October 1995 is 132/80; and in 1996 is 100/78. The October 2020 examiner did not refer to any of these readings. Further, the Veteran reported at his March 2020 Board hearing that he began to experience high blood pressure when he was stationed at Fort Bragg in 1987 to 1988. T. at 28. He also stated that, while serving in Southwest Asia, he was exposed to the environmental hazards of burn pits that may also be the cause of his hypertension. The examiner did not discuss or consider these statements or theory of entitlement. 2. Entitlement to service connection for a left knee disorder, to include arthritis, is remanded. 3. Entitlement to service connection for a right knee disorder, to include arthritis, is remanded. Here, the October 2020 VA knee examiner indicated the Veteran has degenerative arthritis of the bilateral knees. The examiner stated that according to the Veteran, the bilateral knee arthritis began in 1987. In addition to the above rationale, the October 2020 examiner stated the November 1991 STR separation examination noted the Veteran's lower extremities to be normal. In a May 2010 private treatment letter, the medical provider stated that the Veteran underwent knee reconstruction in 2004. However, the examiner did not refer to the Veteran's statements regarding how the knee injury occurred, his reported continuity of symptoms from his time in service to the present, and the current diagnosis. 4. Entitlement to service connection for a low back disorder, to include spinal cord with cyst, is remanded. Here, the October 2020 VA back examiner indicated the Veteran has a lumbosacral strain that began, per the Veteran, in 1989. In addition to above, the examiner stated the November 1991 STR separation examination indicated the Veteran's spine is normal. In a May 2010 private treatment letter, the medical provider listed that the Veteran underwent a lumbar fusion in 1998. However, the October 2020 VA examiner did not refer to the Veteran's statements regarding how the back injury occurred, his reported continuity of symptoms from his time in service to the present, and the 1998 back surgery after separation from service. 5. Entitlement to service connection for a left ankle disorder, to include chronic pain, is remanded. 6. Entitlement to service connection for a right ankle disorder, to include chronic pain, is remanded. Here, the October 2020 VA ankle examiner indicated the Veteran has a diagnosis of bilateral ankle strain that began, per the Veteran, in 1987. The October 2020 VA examiner did not refer to the Veteran's statements regarding how the bilateral ankle injury occurred, his reported continuity of symptoms from his time in service to the present, and current symptoms. 7. Entitlement to service connection for a left foot disorder, to include chronic pain, is remanded. 8. Entitlement to service connection for a right foot disorder, to include chronic pain, is remanded. Here, the October 2020 VA foot examiner indicated the Veteran has a diagnosis of plantar fasciitis that began, per the Veteran, in 1987. In addition to the above opinion, the examiner noted that the November 1991 STR separation examination indicates the Veteran's feet are normal. However, the October 2020 VA examiner did not refer to the Veteran's statements regarding how the injury occurred, his reported continuity of symptoms from his time in service to the present, and current symptoms. 9. Entitlement to service connection for headaches is remanded. Here, the October 2020 VA headache examiner indicated the Veteran has tension headaches that began, per the Veteran, in approximately 1988. At the March 2020 Board hearing, the Veteran testified that he also sustained another head injury when he was driving a five-ton truck and had to stop quickly. T. at 42. Upon stopping, the Veteran stated that when he jammed his brakes, he hit his head on the steering wheel. Id. However, the October 2020 VA examiner did not refer to the Veteran's statements of how the injury occurred, his reported continuity of symptoms from his time in service to the present, and current symptoms. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician, not the October 2020 VA examiner, to determine the nature and etiology of the Veteran's hypertension. The examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including during service around 1987 and 1988. The examiner must address the Veteran's lay statements and contentions as described above, to include the March 2020 Board hearing testimony and the multiple blood pressure readings both during and after service, in the context of any negative opinion. The examiner must also opine as to whether it is at least as likely as not that the Veteran's hypertension was caused or aggravated by exposure to environmental hazards, to include burn pits, during service. 2. Obtain an addendum opinion from an appropriate clinician, not the October 2020 VA examiner, to determine the nature and etiology of the Veteran's bilateral knee disorder. The examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including the fall during service in Southwest Asia theater from September 1990 to April 1991, the convoy accident, or the air strike. The examiner must address the Veteran's lay statements and contentions, to include the March 2020 Board hearing testimony, in the context of any negative opinion. The examiner must also discuss the reported 2004 knee surgery and the Veteran's statements regarding continuity of symptomatology when rendering this opinion. 3. Obtain an addendum opinion from an appropriate clinician, not the October 2020 VA examiner, to determine the nature and etiology of the Veteran's low back disorder. The examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including the fall during service in Southwest Asia theater from September 1990 to April 1991, the convoy accident, or the air strike. The examiner must address the Veteran's lay statements and contentions, to include the March 2020 Board hearing testimony, in the contest of any negative opinion. The examiner must also discuss the reported 1998 lumbar fusion and the Veteran's statements regarding continuity of symptomatology when rendering this opinion 4. Obtain an addendum opinion from an appropriate clinician, not the October 2020 VA examiner, to determine the nature and etiology of the Veteran's bilateral ankle disorder. The examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including the fall during service in Southwest Asia theater from September 1990 to April 1991, the convoy accident, or the air strike. The examiner must address the Veteran's lay statements and contentions regarding continuity of symptomatology, to include the March 2020 Board hearing testimony, in the context of any negative opinion. 5. Obtain an addendum opinion from an appropriate clinician, not the October 2020 VA examiner, to determine the nature and etiology of the Veteran's bilateral foot disorder. The examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including the fall during service in Southwest Asia theater from September 1990 to April 1991, the convoy accident, and the air strike. The examiner must address the Veteran's lay statements and contentions regarding continuity of symptomatology, to include the March 2020 Board hearing testimony, in the context of any negative opinion. 6. Obtain an addendum opinion from an appropriate clinician, not the October 2020 VA examiner, to determine the nature and etiology of the Veteran's headache disorder. The examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including a fall during service and a driving incident in Southwest Asia theater from September 1990 to April 1991 in which the Veteran reported striking his head on the steering wheel when the vehicles in his convoy came to a sudden stop. The examiner must address the Veteran's lay statements and contentions regarding continuity of symptomatology, to include the March 2020 Board hearing testimony, in the context of any negative opinion. A complete rationale must be given for all opinions and conclusions expressed. If any examiner cannot provide an opinion without resort to speculation, he or she should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thompson, 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.