Citation Nr: 22018265 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-16 682 DATE: March 28, 2022 REMANDED Entitlement to service connection for bilateral carpel tunnel (CTS) is remanded. Entitlement to service connection for a bilateral foot condition is remanded. Entitlement to service connection for a lower back condition, to include as secondary to a bilateral foot condition, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1961 to December 1962. In February 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the Veteran's electronic claims file. In April 2018, June 2020, December 2020, and October 2021, the Board remanded this appeal for further development. Bilateral Carpel Tunnel Syndrome Regrettably, while the Board acknowledges that the claim for entitlement to service connection for bilateral CTS has been remanded three times previously for a VA medical opinion, the Board finds that the March 2021 VA addendum opinion is inadequate as it does not consider the Veteran's lay statements or the Veteran's spouse's statements, as requested by the Board's previous remands. See Stegall v. West, 11 Vet. App. 268 (1998). Here, the Board notes that the Veteran has a diagnosis of bilateral CTS. See November 2019 peripheral nerve examination report. Furthermore, while the Veteran's service treatment records are silent for any complaints, treatment, or diagnoses related to CTS, the Veteran contends that his military occupational specialty (MOS) as radio teletype operator caused his bilateral CTS. Furthermore, the Veteran contends that he began experiencing symptoms of CTS, such as tingling and numbness during his service. See December 2020 lay statement. In a January 2018 statement, the Veteran's spouse also notes that the Veteran complained of symptoms related to CTS since service. See January 2018 statement. In the March 2021 VA addendum opinion, the VA examiner opines that the Veteran's bilateral CTS is less likely than not related to his service. The examiner states that absent documentation of symptoms of CTS during service and over the ensuing years since military service, a connection to service is unlikely. The Board finds that this medical opinion is inadequate because it fails to consider the Veteran's lay statements that he has suffered symptoms of tingling and numbness in his hands since his service and subsequently afterwards. In fact, this opinion does not contain an actual discussion of the Veteran's lay contentions. Furthermore, the Board also previously requested that the examiner consider the Veteran's spouse's statement. However, the VA examiner did not discuss the spouse's statement in this opinion either. Therefore, the Board is not satisfied with the examiner's opinion that does not in any meaningful way discuss the specifics of the Veteran's contentions or the spouse's statement. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). Particularly, as here, the examiner appears to have formulated this opinion due to the lack of symptoms of CTS in service, without acknowledging the Veteran's lay statements that his symptoms began during service. Given such, the Board finds that an addendum opinion is warranted. Bilateral Foot Condition Unfortunately, while the Board recognizes that the Veteran's claim for entitlement to a bilateral foot condition has been remanded three times previously for a medical opinion, the Board finds that the March 2021 and the June 2021 addendum opinions are inadequate, as (1) the VA examiner did not discuss the Veteran's lay reports of ongoing bilateral feet pain and (2) the VA examiner formulated an opinion without review of the entire record. In the March 2021 VA medical opinion, the VA examiner opines that the Veteran's in-service left foot injury was a trauma to left foot with toes fractures "not complex." The VA examiner notes that healing was good. Thus, the VA examiner states that he sees no reason that the Veteran's bilateral pes cavus is related to service and that it is most likely genetic. In the Board's prior remand, the Board specifically requested that the Veteran's lay statements and spouse statements be considered. Here, the Veteran contends that he suffered from foot pain that became unbearable in 1999 and has progressively worsen. See December 2020 statement. The Veteran's spouse contends that after the Veteran's foot injury, and when he returned from service, she noticed that he was having trouble walking. She noted that he favors his right foot and still experiences bilateral foot pain. See January 2018 correspondence. The March 2021 VA addendum opinion does not discuss either the Veteran's lay statements or the Veteran's spouse statements, as specifically requested by the Board's precious remand. As such, the Board finds the March 2021 VA medical opinion inadequate. See Stegall v. West, 11 Vet. App. 268 (1998). In the June 2021 VA medical addendum, the VA examiner noted that only VA treatment records were reviewed. However, the record also contains private medical records related to the Veteran's bilateral foot condition. Specifically, the record contains private medical records from Dr. S.P. (associated with the claims file on September 28, 2019 ), in which Dr. S.P. notes bilateral foot pain. Also, the record contains private medical records from Dr. S.S. (associated with the claims file on March 22, 2019 ), in which Dr. S.S. notes that the Veteran's history of feet issues goes back to his service days in which he had an injury to his left foot and developed pain off and on. Dr. S.S. also notes that the Veteran subsequently started to favor his right foot and now has constant back pain. Moreover, in the June 2021 VA examiner's opinion, the VA examiner states that there is absence of documentation of any evaluation, diagnosis, or treatment of any foot condition, except in the 2019 VA examination report. This premise appears to be a significant factor in the June 2021 opinion. However, as discussed above, the record contains private medical records, which document evaluation, diagnosis, and treatment of the Veteran's bilateral feet. Given such, as the June 2021 VA examiner did not consider the complete record, to include relevant medical records, the Board finds that this opinion is inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Low Back Condition Additionally, as to the claim for entitlement to a low back condition, to include as secondary to his bilateral foot condition, the Board finds this claim is inextricably intertwined with the Veteran's claim for service connection for a bilateral foot condition on appeal. Here, the Veteran presents a theory of entitlement to service connection for his low back condition to include as due to his bilateral foot condition. In this respect, the Veteran contends that because of the pain associated with his feet, and favoring his right foot, he developed back pain. Therefore, the Board will defer adjudication of the lower back claim until the development directed on the bilateral foot claim has been completed. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. With respect to the Veteran's claim for bilateral carpel tunnel syndrome (CTS), request an addendum opinion to determine the nature and etiology of the Veteran's bilateral CTS, from a different VA examiner than the March 2021 examiner, preferably from a neurologist, if available, that upon a review of the record, addresses the following: (a.) If an examination is warranted, obtain the Veteran's detailed lay history, including onset and progression of symptomatology. (b.) Opine as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition had its onset during, or is otherwise related to, the Veteran's active duty service. In formulating this opinion, the VA examiner must address the following: The examiner should discuss the Veteran's lay statements regarding the history and chronicity of symptomatology, to include the Veteran's ongoing reports of neck problems. S/he should outline that history in the report. The examiner should discuss the Veteran's lay statements regarding the history and chronicity of symptomatology, to include: the Veteran's statements of that he felt tingling and numbness during service due to his MOS as a radio teletype operator, as noted in a December 2020 statement and during the February 2018 Board hearing: the Veteran's ongoing reports of issues with these hands. Specifically addressing: a. Are the Veteran's assertions consistent with medical knowledge or implausible; b. Are the Veteran's reports about symptoms or an in-service injury align with how the disease or disability is known to develop. S/he should outline that history in the report. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so must be provided. a) The Veteran's spouses lay statement, in which she notes that for as long as she can remember, the Veteran had issues with his hands, as noted in her January 2018 statement. The examiner is advised of the following: The absence of evidence of treatment for symptoms related to the disability in the Veteran's available service treatment records and post-service records cannot, standing alone, serve as the basis for a negative opinion. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. If the VA examiner relies on medical literature, please apply the medical literature to the specific facts of this case. It is insufficient to make a general statement such as "the medical literature does not support an association the Veteran's claim disability and his service." Rather, the VA examiner must explain why the medical literature does not support such an association. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If utilizing references within the electronic claims file, the examiner should clearly provide an identifier. 2. With respect to the Veteran's claim for bilateral foot condition, request an addendum opinion to determine the nature and etiology of the Veteran's bilateral foot condition, preferably from a podiatrist, if available, that upon a review of the record, addresses the following: (a.) If an examination is warranted, obtain the Veteran's detailed lay history, including onset and progression of symptomatology. (b.) Opine as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition had its onset during, or is otherwise related to, the Veteran's active duty service. In formulating this opinion, the VA examiner must address the following: A) Private medical records from Dr. S.P. and from Dr. S.S., which document diagnosis, treatment, and complaints related to the Veteran's bilateral foot condition and B) In-service left foot injury from December 1962; and C) The examiner should discuss the Veteran's lay statements regarding the history and chronicity of symptomatology, to include: the Veteran's ongoing reports of a bilateral foot pain, attributing his pain to his in-service foot injury. Specifically addressing: a. Are the Veteran's assertions consistent with medical knowledge or implausible; b. Are the Veteran's reports about symptoms or an in-service injury align with how the disease or disability is known to develop. S/he should outline that history in the report. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so must be provided. b) The Veteran's spouse's lay statement, in which she notes the Veteran had difficulty walking since returning from service, as noted in her January 2018 statement. The examiner is advised of the following: The absence of evidence of treatment for symptoms related to the disability in the Veteran's available service treatment records and post-service records cannot, standing alone, serve as the basis for a negative opinion. If the VA examiner relies on medical literature, please apply the medical literature to the specific facts of this case. It is insufficient to make a general statement such as "the medical literature does not support an association the Veteran's claim disability and his service." Rather, the VA examiner must explain why the medical literature does not support such an association. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If utilizing references within the electronic claims file, the examiner should clearly provide an identifier. 3. With respect to the Veteran's claim for a low back condition: if, and only if, a foot condition is found to be related to service, provide the following opinions for each diagnosed lower back condition: (a) Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition is caused by a service-connected disability, to include any foot condition found to be related to service. (b) Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition underwent an incremental increase (aggravated), regardless of permanence, by a service-connected disability, to include any foot condition founds to be related to service. In rendering any opinion, the examiner is instructed to consider and address: The examiner should discuss the Veteran's lay statements regarding the history and chronicity of symptomatology, to include: the Veteran's ongoing reports of back pain due to him favoring his right foot. Specifically addressing: a. Are the Veteran's assertions consistent with medical knowledge or implausible; b. Are the Veteran's reports about symptoms or an in-service injury align with how the disease or disability is known to develop. S/he should outline that history in the report. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so must be provided. The examiner should discuss the Veteran's spouses lay statement that the Veteran experienced back pain throughout their marriage. The examiner is advised of the following: The absence of evidence of treatment for symptoms related to the disability in the Veteran's available service treatment records and post-service records cannot, standing alone, serve as the basis for a negative opinion. If the VA examiner relies on medical literature, please apply the medical literature to the specific facts of this case. It is insufficient to make a general statement such as "the medical literature does not support an association the Veteran's claim disability and his service." Rather, the VA examiner must explain why the medical literature does not support such an association. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If utilizing references within the electronic claims file, the examiner should clearly provide an identifier. Any opinion expressed by the VA examiner must "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). 4. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. (Continued on the next page) IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Abdelbary, 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.