Citation Nr: 21041879 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-41 330 DATE: July 10, 2021 REMANDED Entitlement to service connection for a left knee disability, to include as secondary to service-connected right knee chondromalacia and Osgood-Schlatter's disease (right knee disability). Entitlement to service connection for a heart disability, to include pacemaker implant, claimed as bradycardia, arrhythmia, atrial fibrillation, fatigue and malaise, (heart disability), to include as secondary to medication taken for service-connected posttraumatic stress disorder (PTSD) and as due to a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1987 to February 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. This appeal was remanded by the Board in September 2019 and October 2020. As explained below, appeal is again required in these matters. 1. Entitlement to service connection for a left knee disability, to include as secondary to service-connected right knee disability. The Veteran contends that a left knee injury he sustained on active duty has caused functional loss and impairment since his discharge from active duty service which he treated himself until it became so disabling that he needed to seek professional medical treatment. See Appellate Brief (June 2020). Alternatively, he testified that his service-connected right knee has caused an altered gait resulting in his left knee disability. See Appellate Brief (June 2020); Hearing Transcript (March 2019). The Board finds that an addendum opinion is required to obtain adequate opinions that substantially comply with prior remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. An examiner's opinion regarding secondary service connection must provide separate findings and rationales as to the causation and aggravation prongs which are separate concepts. Atencio v. O'Rourke, 30 Vet. App. 74, 89-91 (2018). A December 2019 VA examination diagnosed left quadricep tendonitis. The examiner opined that the disability did not have onset during service, as there was no continuity of the in-service diagnosis of bursitis after service separation and degenerative joint disease and tendonitis are not known complications of knee bursitis. Regarding secondary service connection, the examiner opined that the disability was not caused by the service-connected right knee disability because the Veteran did not have leg length discrepancy and prolonged duration of limp due to the right knee disability, citing to literature that the affected limb only causes injury to a previously unaffected limb only with discrepancies of 4 to 5 centimeters and significant gait lurches or significant limp of prolonged duration. As to aggravation, the examiner noted "see rationale above." In an October 2020 remand, the Board found the opinion inadequate to decide the appeal. See BVA Decision (October 2020). The Board noted that the opinion did not provide an adequate rationale for secondary service connection, did not provide a separate opinion and explanation for aggravation, and did not consider lay evidence of a limp over many years. The Board thus directed that an addendum opinion be obtained that addressed the following: whether the left knee disability was related to service, to include specific STRs, and whether the disability is caused or aggravated by the right knee disability. See BVA Decision (October 2020). In an October 2020 VA opinion, a VA clinician opined that the left knee disability was not related to service, noting that the STRs did not show chronicity, the Veteran was seen for other complaints at VA beginning in 2001, but did not report left knee symptoms until 2014, the presence of normal x-rays until 2014, and the presence of risk factors such as a high weight and strenuous activity over the last 20 years. See C&P Exam (November 2020). Regarding secondary service connection, the examiner opined that the left knee disability was not caused by the right knee disability, noting that the records did not show a limping gait or nerve or muscle damage associated with the right knee disability, the Veteran was able to walk/hike multiple miles several times a week and work out at the gym several times a week for the past 20 years, and x-rays show equal degenerative joint disease in the right and left knee, which supports that the changes are due to aging, weight, and active lifestyle. Regarding aggravation, the examine there was a lack of objective evidence to establish aggravation and noted as rationale, "[s]ee etiologies above." See C&P Exam (November 2020). The Board finds that the aggravation opinion is inadequate and does not provide substantial compliance with the Board's prior remand because it does not contain an analysis or rationale for the opinion that is separate from the opinion for causation. As noted above, aggravation and causation are separate concepts and require separate findings and explanation. Accordingly, remand is required for an addendum secondary service connection opinion. 2. Entitlement to service connection for a heart disability, to include as secondary to medication taken for service-connected PTSD and as due to a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. The Veteran contends that his heart disability is secondary to medication used to treat his service-connected PTSD or, alternatively, related to his Persian Gulf War service. See Hearing Transcript (March 2019). The Board finds that an addendum opinion is required to obtain adequate opinions that substantially comply with prior remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall, 11 Vet. App. at 271. RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. An examiner's opinion regarding secondary service connection must provide separate findings and rationales as to the causation and aggravation prongs which are separate concepts. Atencio, 30 Vet. App. at 89-91. A December 2019 VA examination and opinion report contained diagnoses of second-degree atrioventricular block/sick sinus syndrome status-post pacemaker, atrial fibrillation, silent myocardial infarction, and cardiomyopathy. See C&P Exam (December 2019). The examiner determined that the sick sinus syndrome encompassed bradycardia, tachycardia, and atrial fibrillation. The examiner then essentially opined that the sick sinus syndrome was the most likely etiology of the heart disability. Regarding Persian Gulf veterans, the examiner opined that the heart disability was not related to such service, noting that cardiomyopathy was a diagnosable chronic multi-symptom illness with a partially explained etiology and was not related to service. See C&P Exam (December 2019). In an October 2020 remand, the Board found the December 2019 opinion inadequate because it did not address whether sick sinus syndrome was etiologically related to service, whether sick sinus syndrome was secondary to PTSD medications, and whether the heart diagnoses other than cardiomyopathy were due to Gulf War service. See BVA Decision (October 2020). The Board thus requested addendum opinions regarding the Veteran's heart disability. First, the Board requested that a clinician provide an opinion regarding whether the etiology and the pathophysiology of each heart diagnosis was inconclusive, partially understood, or fully understood. Next, the Board directed the clinician to provide an opinion regarding whether for each heart diagnosis, it is due to medication prescribed for his service-connected PTSD, and to address the theory that the medications triggered onset of an irregular heartbeat. Finally, the Board requested that the clinician provide an opinion regarding whether each diagnosis was aggravated by the PTSD medications. See BVA Decision (October 2020). An October 2020 VA medical opinion was provided upon an extensive review of the relevant evidence in the claims file and review of noted medical literature. See C&P Exam (November 2020). The clinician answered the first questions, finding that the diagnoses are consistent with a partially-explained etiology, and there was no undiagnosed illness or symptoms due to Southwest Asia service. The examiner then opined that the heart disability (which encompassed each of the diagnoses) was less likely as not due to the PTSD medications. The examiner provided the following explanation with reference to specific medical records: 1) the Veteran had a long history of bradycardia which may be a first manifestation of sinus sick syndrome; 2) the Veteran had a long history of sleep apnea, which often includes severe bradycardia; 3) the medical literature did not support Bupropion as an etiology of sinus sick syndrome, the medication was not discontinued after his heart disability diagnosis, and the records show his heart rate did not decrease suddenly when the medication was initiated; and 4) the Veteran had a family history of heart disease, and other risk factors for cardiomyopathy and atrial fibrillation, including elevated blood pressure, weight, and hyperlipidemia. The examiner then provided an opinion that the PTSD medications did not aggravate the Veteran's heart disability, as there was no objective evidence to support an aggravation and then stated "[s]ee etiologies and rationale above." See C&P Exam (November 2020). The Board finds this opinion inadequate regarding secondary service connection as the examiner did not provide, as expressly requested by the 2020 Board remand, separate explanations for secondary causation and aggravation although they are separate concepts. Accordingly, remand is required for an addendum opinion. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran's left knee disability. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the diagnosed left knee disability. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to whether the Veteran's left knee disability is at least as likely as not aggravated beyond its natural progression by the service-connected right knee disability. Provide a rationale that addresses aggravation as a concept independent from causation. Consider and address the December 2019 VA and October 2020 VA medical opinions. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 2. Obtain an addendum opinion regarding the etiology of the Veteran's heart disability. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the diagnosed heart disability. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to whether the Veteran's heart disability is at least as likely as not aggravated beyond its natural progression by service-connected PTSD medications. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and address the December 2019 VA and October 2020 VA medical opinions. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 3. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.