Citation Nr: 22016133 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 17-46 658 DATE: March 21, 2022 REMANDED Entitlement to service connection for restless leg syndrome is remanded. Entitlement to service connection for right Achilles tendonitis is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1987 to July 1991; November 2003 to November 2005; October 2008 to March 2009; May 2011 to October 2011; and January 2018 to June 2018, with additional periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) in the Air Force Reserve. This case comes to the Board of Veterans' Appeals (Board) from a September 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office. This case was previously remanded in March 2020. The Board's prior remand requested that medical opinions be obtained which would address whether it was at least as likely as not that the Veteran's restless leg syndrome was caused or aggravated by his service-connected lumbar spine disorder. The examiner was also asked to address whether it was as likely as not that the Veteran's right ankle achilles tendonitis had its onset during or was related to a period of active duty, ACDUTRA, or INACDUTRA, and whether a right ankle disorder had been permanently worsened by his period of active service in 2018. The Board notes that the Veteran has asserted that he ruptured his right ankle during a military test in May 2015 while on active duty, which led to his Achilles tendonitis. The record includes a private record from April 2016 that includes an impression of "Achilles tendinopathy likely representing low-grade partial tear without tenosynovitis or complete tear and retraction." The Veteran attended a VA examination in November 2020. The Veteran reported that while running for a fitness test during Reserve service, he injured his right ankle, and was treated by medical at the time. He said that over the last few years, the pain in his right ankle had worsened, and that it now caused difficulty with walking, standing at attention, running, and stairs. The examiner wrote that the Veteran had a diagnosis of right Achilles tendon rupture and tendonitis from April 2015. Physical examination found normal range of motion, but with repeated use over time, range of motion would decrease by 5 degrees in both dorsiflexion and plantar flexion. The examiner noted that the Veteran regularly wore a brace due to Achilles tendinopathy. The examiner wrote that the Veteran's right ankle disability was less likely than not incurred in or caused by service, because he had no chronic diagnosis for the right ankle, and the objective examination was normal, with subjective symptoms only. The examiner did not answer the Board's question regarding any preexisting right ankle disability had been aggravated by the Veteran's service in 2018. The VA examiner based his opinion entirely on the supposed lack of a current right ankle disability. The Veteran has, however, reported having pain in his right ankle, and it was even found by the examiner that repeated use over time would cause slight decrease in range of motion. The Board therefore finds that the Veteran does have a current ankle disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability.). The Board requests that a VA examiner take this into consideration and provide an adequate nexus opinion regarding the Veteran's right ankle disorder or dysfunction. The Board also notes that this condition, though not noted on an entry examination, clearly and unmistakably preexisted the Veteran's period of service in 2018, and this should be addressed. Regarding the claim for restless leg syndrome, the Veteran attended a VA examination for restless leg syndrome in February 2021. The Veteran reported that he had pain, numbness, tingling, and a feeling like he needed to move his legs. The examiner diagnosed the Veteran with bilateral lower extremity peripheral neuropathy. The examiner found that the Veteran's restless leg syndrome was less likely than not related to service, because the service treatment records were silent for this disorder. The examiner wrote that the condition was less likely than not proximately due to a lumbar spine disability. As rationale, she wrote that restless leg syndrome was difficult to distinguish from sciatica, and there were many medical conditions linked to restless leg syndrome, including iron deficiency, diabetes, kidney disease, Parkinson's disease, and genetics. She wrote that restless leg syndrome was a state of dopamine dysfunction and iron deficiency, and less likely than not aggravated by the spine disorder or femoral nerve impairment. An additional medical opinion was obtained in October 2021. The examiner wrote that the Veteran's disability baseline was not at least as likely as not aggravated beyond the natural progression by his lumbar spine disorder. As rationale, he wrote that restless leg syndrome was a common sleep-related movement disorder characterized by an often unpleasant urge to move the legs that occurred during periods of inactivity. He wrote that the most common conditions associated with restless leg syndrome included iron deficiency, renal failure, neuropathy, spine cord pathology, pregnancy, multiple sclerosis, Parkinson's disease, and essential tremors. He wrote that the spinal cord was implicated after transient or permanent spinal cord lesions. He wrote that it was therefore less likely than not that the restless leg syndrome was aggravated beyond the natural progress by the lumbar condition. The Board also finds these medical opinions to be inadequate to decide the claim for service connection for restless leg syndrome. The October 2021 VA examiner indicated that spinal cord pathology could be a condition associated with restless leg syndrome, but did not actually discuss whether the Veteran's lumbar spine degenerative arthritis could affect his restless leg syndrome, including why it would or would not aggravate such a condition. The February 2021 VA examiner did not actually find a current diagnosis of restless leg syndrome, but instead attributed the Veteran's symptoms to bilateral lower extremity peripheral neuropathy. The Veteran is already service connected for left leg peripheral neuropathy and right leg radiculopathy. The Board requests that an opinion be provided regarding whether the Veteran's reported symptoms are actually a manifestation of these disorders, for which he is already service connected. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The October 2021 VA examiner also wrote that neuropathy was a condition that was commonly associated with restless leg syndrome, so an opinion should also be provided regarding whether the Veteran's restless leg syndrome is secondary to his neuropathy or radiculopathy. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since September 2021. 2. Obtain an addendum medical opinion to address the nature and etiology of any current right ankle disorder, including right Achilles tendonitis. If the examiner finds that an examination must be held prior to providing an opinion, schedule such an examination. The examination may be held via telehealth during social distancing restrictions. The examiner must be provided access to the Veteran's entire claims file. The examiner should then address: a) What are the Veteran's current diagnoses related to his right ankle? Even if no specific diagnosis is found, please discuss the functional impact of the Veteran's pain in his foot and ankle, including his reports of having pain that affects his ability to walk, stand, and run, and the November 2020 examination finding that there would be decreased range of motion with repeated use. The Board notes that when pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability for VA purposes. See Saunders, 886 F.3d 1356. b) For every diagnosis found, or for the Veteran's symptoms related to his right ankle (even in the absence of a diagnosis), is it at least as likely as not that the condition is related to his active military service? The examiner should discuss the Veteran's assertions that he injured his right ankle during a training test that occurred during a period of active duty, ACDUTRA, or INACDUTRA. c) For every diagnosis found, or for the Veteran's symptoms related to his right ankle, was the condition clearly and unmistakably not aggravated (worsened beyond the natural progression) by the Veteran's active duty service from January 2018 to June 2018? A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. 3. Obtain an addendum medical opinion to address the nature and etiology of the Veteran's claimed restless leg syndrome. If the examiner finds that an examination must be held prior to providing an opinion, schedule such an examination. The examination may be held via telehealth during social distancing restrictions. The examiner must be provided access to the Veteran's entire claims file. The examiner should then address: a) Is it at least as likely as not that the Veteran has restless leg syndrome which began during his active duty service or is related to any period of service? b) Is it at least as likely as not that the Veteran's restless leg syndrome was either i) caused or ii) aggravated by his lumbar spine degenerative arthritis, his left leg peripheral neuropathy, or his right leg radiculopathy? Please discuss the Veteran's reports that his restless leg symptoms began after his 2000 laminectomy surgery, and the October 2021 VA examiner's statement that spinal cord pathology and neuropathy are conditions that are commonly associated with restless leg syndrome. c) Did the Veteran's restless leg syndrome clearly and unmistakably preexist his period of service from January 2018 to June 2018? Was the condition clearly and unmistakably not aggravated (worsened beyond the natural progression) during this period of service? A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.