Citation Nr: 22018037 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-27 602 DATE: March 28, 2022 REMANDED Entitlement to service connection for amputation of the right leg is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1976 to March 1977, with additional periods of active duty for training (ACDUTRA) in the Army National Guard. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision. The Board reopened and remanded this matter in August 2021 for further development. 1. Entitlement to service connection for amputation of the right leg is remanded. Initially, at a May 2016 VA treatment record, the Veteran reported that he is currently on Social Security disability. These records are not currently contained in the Veteran's claims file. A remand is required to allow VA to request these records. Further, there has not been substantial compliance with the Board's previous August 2021 remand directives regarding this issue. Another remand is required for a VA medical opinion to be obtained. Stegall v. West, 11 Vet. App. 268, 271 (1998). Pursuant to the Board's remand directives, a VA medical opinion was obtained in October 2021 to determine whether the Veteran's right leg amputation was the result of aggravation caused by his period of ACDUTRA or the nature progression of his pre-existing diagnoses. The VA examiner concluded that aggravation of the Veteran's preexisting disability, manifested by blood clots, during his period of active duty training was clearly and unmistakably due to the natural progress of the disability. However, after discussing that the Veteran had arterial thrombosis and elevated hemoglobin prior to annual training, the examiner stated that that "... his increased level of running and exertion aggravated his right leg condition which led to the need of a below the knee amputation." The Board notes that the examiner's conclusion is inconsistent with her rationale. As such, the opinion is inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Another medical opinion was obtained in December 2021. The VA examiner concluded that there is no doubt that the aggravation of the Veteran's preexisting disability, manifested by arterial blood clots, during his period of active duty was clearly and unmistakably due to the natural progress of the disability. To support this finding, the examiner stated that there is "no support" that the maneuvers performed by the Veteran at his training and associated dehydration were associated temporally with the development of arterial vascular insufficiency. The examiner further stated that were no signs of dehydration or elevated hemoglobin and that such was "falsely interpreted in the records." The examiner concluded that the Veteran "should not have been admitted to the military with this history," and that his "amputation is clearly due to the natural history of arterial insufficiency and arterial clots." The Board also finds the December 2021 opinion to be inadequate to fairly resolve the Veteran's claim. First, the examiner did not provide adequate medical rationale to support his finding of no aggravation. In this regard, the examiner failed to explain the basis of his finding that there is "no support" that the Veteran's annual training was associated temporally with his arterial vascular insufficiency, when, in fact, service treatment records document that the Veteran visited sick call on June 22, 1985, with complaints of right leg pain and swollen toes immediately following a long day of marching and walking and was diagnosed with possible, recurrent thromboembolism. Furthermore, the examiner did not discuss the favorable medical opinions provided by Dr. M.V., as specifically requested by the Board in its remand directives. Finally, the examiner did not provide an explanation for his assertion that contemporaneous reports of dehydration and elevated hemoglobin have been "falsely interpreted in the records." In light of the above, the opinion is not supported by adequate rationale and is therefore inadequate. See Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124. The record still does not contain a medical opinion that is sufficient to fairly decide the Veteran's claim. As such, remand is once again required for an adequate medical opinion to be obtained. See Stegall, 11 Vet. App. at 271. The Board also notes that an opinion has not yet been obtained to address whether the Veteran's right knee injury incurred in the line of duty in August 1980, and the subsequent diagnosis of synovitis and chondromalacia of the patella in January 1983, caused or contributed to the development of the thromboembolism in March 1985, which eventually led to the Veteran's right leg amputation. As such, the opinion obtained on remand must also address this theory of entitlement. Accordingly, the matter is REMANDED for the following actions: 1. Obtain the Veteran's federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 2. Obtain an addendum opinion from a VA physician of appropriate expertise (i.e., a vascular specialist) regarding the etiology of the Veteran's right leg amputation. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a) Is it at least as likely as not that the Veteran's right knee injury incurred in the line of duty in August 1980, and the subsequent diagnosis of synovitis and chondromalacia of the patella in January 1983, caused, aggravated, or contributed to the development of thromboembolism in March 1985? In providing a response to the above, the examiner must specifically discuss the significance of the March 1985 treatment note in which the Veteran underwent urgent exploration of the right popliteal artery and thrombectomy, and it was noted at that time that the Veteran's medical history was significant for a ligament tear and knee joint dislocation on the right side, which "may be related to his present problem." (i) If not, identify all right lower extremity disabilities that preexisted the Veteran's June 1985 period of ACDUTRA. (b) For each identified preexisting disability of the right lower extremity, did the Veteran's disability, which existed prior to service, at least as likely as not increase in severity during the Veteran's period of ACDUTRA in June 1985? (i) If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? In providing the requested opinion(s), the examiner must specifically discuss (a) service treatment records documenting that the Veteran went to sick call with right leg pain and swollen toe on June 22, 1985 after marching and walking all day; and (b) the private medical opinions of record from Dr. M.V., in which it was found that the maneuvers performed by the Veteran at his training and the associated dehydration and elevated hemoglobin were associated temporally with the development of arterial vascular insufficiency, and such insufficiency ultimately led to the need for an amputation of the right leg below the knee. Provide a rationale to support the opinions. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. S. M. Watkins Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, 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.