Citation Nr: 22019614 Decision Date: 04/02/22 Archive Date: 04/02/22 DOCKET NO. 17-57 544 DATE: April 2, 2022 REMANDED Entitlement to service connection for a right hand disability is remanded. Entitlement to service connection for a left hand disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a left elbow disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1996 to November 1999. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July and October 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. This matter was previously before the Board in September 2019. During the pendency of the appeal, a July 2020 rating decision established service connection for neck and left shoulder disabilities. As those are considered full grants of the benefits sought, those issues are no longer on appeal. 1. Entitlement to service connection for a right hand disability is remanded. 2. Entitlement to service connection for a left hand disability is remanded. The Veteran asserts he has a bilateral hand disability as a result of active service, and specifically, residuals of a frostbite injury in service. In the alternative, it is contended a bilateral hand disability is secondary to service-connected shoulder disabilities. Pursuant to September 2019 Board remand instructions, the Veteran attended a VA hand examination to assess the nature and etiology of the claimed disabilities. The examiner noted that there was no objective evidence of any hand disability during the examination. The associated negative medical opinion was based on that finding. It was nonetheless reported during the examination that the Veteran experienced subjective symptoms of progressively worsening pain with movement, exacerbated in cold weather, and cramping, stiffness, burning, and swelling. Pain alone, even without an underlying pathology or diagnosis, can constitute a disability for VA purposes where that pain results in functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). While the examiner noted that there was no functional impairment, this finding was based on objective symptoms, and not on the subjective symptoms reported by the Veteran. The Veteran submitted treatise evidence discussing the residual effects and pathophysiology of cold injuries in August 2020, and a statement that the current symptoms were due to hypothermia and frostbite in service. It was further noted that the symptoms had been continuous and worsening since. Accordingly, the claims must be remanded for additional VA medical examination. 3. Entitlement to service connection for a right elbow disability is remanded. 4. Entitlement to service connection for a left elbow disability is remanded. The Veteran asserts he has a bilateral elbow disability as a result of active service, or in the alternative, due to service-connected shoulder disabilities. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical opinion or examination is considered adequate where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one. Stefl v. Nicholson, 21 Vet. App. 120 (2007). Pursuant to September 2019 Board remand instructions, the attended a VA elbow examination in February 2020 to assess the nature and etiology of claimed disabilities. The examiner provided a negative etiological opinion, both on a direct and secondary basis. For direct service connection, the examiner stated that the service records were negative for right elbow pain. The Board notes that the absence of documented treatment in service or after is not fatal to a service connection claim, and the absence of evidence in the service medical records is an insufficient basis, by itself, for a negative opinion. Ledford v. Derwinski, 3 Vet. App. 87 (1992). Unfortunately, the absence of documented treatment in service is the exclusive basis for the negative etiological opinion, and therefore that opinion is inadequate for adjudication purposes. For secondary service connection, the examiner reasoned that the elbow and shoulder conditions were not medically related, and the medical literature did not support a medical relationship. It was added that the literature submitted by the Veteran was written by a physical trainer and did not provide evidence to support causality. Nonetheless, as was expressed in August 2020 correspondence, the literature submitted referenced "the kinetic chain" as a widespread concept in rehabilitative medicine which speaks to chain links, including a relationship between the elbow and shoulder. That was discredited by the February 2020 VA examiner simply on the basis that the literature was produced by a physical trainer, rather than addressing the medical concept itself. Accordingly, the elbow claims must be remanded for additional VA medical opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA and private treatment records pertinent to the Veteran's elbow and hand claims. 2. Then, schedule the Veteran for a VA examination to determine the etiology of any bilateral hand disabilities. Any indicated testing should be conducted. The examiner must review the claims file and should note that review in the report. The examiner should identify all current bilateral hand disabilities, including frostbite residuals, that are found one examination or shown during the pendency of the claim. If there is no diagnosis, consideration should be given as to whether there is functional impairment, including based on subjective symptoms, which can be considered a disability. If there is no diagnosis or functional impairment present, it should be explained why that is so. For any identified right or left hand disability, or functional impairment constituting a disability, the examiner should opine whether it is as likely as not that each right or left hand disability had its onset during service, or is otherwise related to service. The examiner should opine whether it is as likely as not that any right or left hand disability is due to, the result of, or caused by service-connected bilateral shoulder and neck disabilities. The examiner should opine whether it is as likely as not that any right or left hand disability has been aggravated (increased in severity beyond the natural progress of the disorder) by service-connected bilateral shoulder and neck disabilities. The examiner should specifically discuss the significance of the kinetic chain theory of causation by the service-connected shoulder disabilities. The examiner should discuss whether any hand disabilities are the result of a frostbite injury. 3. Schedule the Veteran for a VA examination by a medical doctor who has not previously provided an opinion in conjunction with this claim. The examiner must review the claim file and should note that review in the report. The examiner should diagnose all right and left elbow disabilities found on examination or shown during the pendency of the claim. If there is no diagnosis, consideration should be given as to whether there is functional impairment, including based on subjective symptoms, which can be considered a disability. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any right or left elbow disabilities, or functional limitation due to pain, had their onset during service, or are otherwise related to service. The examiner should opine whether it is as likely as not that any right or left elbow disability is due to, the result of, or cause by service-connected bilateral shoulder and neck disabilities. The examiner should opine whether it is as likely as not that any right or left elbow disability has been aggravated (increased in severity beyond the natural progress of the disorder) by service-connected bilateral shoulder and neck disabilities. Consideration should be given to: (1) the service medical record showing the Veteran received for arm and hand pain; (2) the medical literature submitted by the Veteran's representative indicating a possible interrelation between the claimed disabilities and the Veteran's service-connected right shoulder disability. The examiner should specifically discuss the significance of the kinetic chain theory of causation by the service-connected shoulder disabilities. A complete rationale should be provided for any opinion reached Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Comninos, Georgio 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.