Citation Nr: 21042230 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 15-46 852 DATE: July 12, 2021 REMANDED Entitlement to service connection for a disability manifested by pain of the lower extremities (claimed as joint pain), to include left thigh pain is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1970 to January 1972, including service in the Republic of Vietnam. This matter comes before the Board of Veterans Appeals (Board) on appeal from a January 2014 decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in September 2018, August 2020, and March 2021. While the Board regrets the delay in resolving the Veteran's case, a fourth remand is unfortunately required. When a case is remanded, a veteran is entitled to substantial compliance with all remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). If the RO does not substantially comply with the Board's remand instructions, the Board is legally bound to continue remanding until the mistake is corrected. See id. Additionally, VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). In March 2021, the Board remanded to obtain a new VA examination, based on a finding that the October 2020 VA examination was inadequate and did not comply with prior remand instructions. Specifically, the October 2020 VA examiner did not actually address the etiology of the Veteran's leg pain, stating only that "there is no objective evidence to support a specific current or previous diagnosis." This was in spite of the Board's previous determination that the Veteran's reported leg paindocumented in his medical treatment records over the course of several yearsitself constituted a disability for VA purposes, regardless of whether the Veteran had a specific diagnosed condition in his legs. See Saunders v. Wilkie, 886 F.3d 1356, 1365 (Fed. Cir. 2018). The prior remands were ordered for similar reasons. In April 2021, a new VA examination was obtained. The examiner gave the following opinion on the issues of direct service connection, secondary service connection, and aggravation: Treated/resolved left thigh pulled muscle 1970/1971 with no evidence of recurrence / chronicity / progression / sequalae / residuals. No current diagnosis. Age appropriate ROM, no functional loss, normal for veteran. Less likely than not from service. NO evidence of any aggravation beyond natural progression / unrelated to degenerative arthritis spine. While this opinion is not quite as barren as that of the October 2020 VA examiner, the Board nonetheless finds it inadequate. The April 2021 medical opinion offers no reasoning at all for its conclusion that the Veteran's leg pain is "unrelated to [his] degenerative arthritis." There is again an emphasis on the lack of current diagnosis, despite the Board's repeated instructions that the Veteran's pain alone has been determined to constitute a disability for VA purposes, and that the lack of a specific diagnosis does not free the examiner of their responsibility toto the best of their abilitydetermine the likely cause of the Veteran's pain. The April 2021 opinion also fails to consider multiple pieces of relevant evidence. The opinion does not address documentation of ongoing complaints of (and treatment for) leg cramps in the Veteran's VA medical recordsincluding an emergency department visit in April 2019, where he claimed his cramps had worsened for the past four days. The opinion also does not address the Veteran's February 2017 hearing testimony, wherein he claims that his leg pain has been continuous since service. The Board cannot base a decision on a conclusory opinion that ignores the Veteran's lay testimony and does not consider his full medical history. A new examination is required. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate physician, who has not already provided an opinion in this case, regarding the nature and etiology of the Veteran's lower extremity pain. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's lower extremity pain had its onset during active service? The opinion should specifically address the Veteran's February 2017 hearing testimony, and complaints of left thigh pain documented in his service treatment records in in March and April 1971. (b) Is it at least as likely as not that the Veteran's lower extremity pain was caused or aggravated by an event, injury, or disease that happened during active service? The opinion should specifically address the Veteran's March 1971 thigh injury, and his conceded exposure to herbicide agents during service. (c) Is it at least as likely as not that the Veteran's lower extremity pain was caused or aggravated by a service-connected disability, including degenerative arthritis of the spine? (d) If the Veteran's lower extremity pain is unrelated to his military service or any service-connected disability, what is its likely etiology? In evaluating the Veteran's leg pain, the examiner should consider his full medical history, including treatment for chronic leg cramps documented in his VA treatment records. A complete and fully explanatory rationale must be provided for any opinion offered, citing any record evidence or medical literature relied upon. If an opinion cannot be rendered without resorting to speculation, the examiner must explain why. 2. The Agency of Original Jurisdiction must review the examination report to ensure that the requested opinions comply with the above remand directives. If an opinion is deficient in any manner, the Agency of Original Jurisdiction must undertake corrective action before returning the case to the Board. Signature on the next page DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sundquist, Shermila 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.