Citation Nr: 22042871 Decision Date: 07/28/22 Archive Date: 07/28/22 DOCKET NO. 12-24 490 DATE: July 28, 2022 REMANDED Service connection for a cervical spine condition is remanded. Service connection for a left eye condition is remanded. Service connection for a left elbow condition is remanded. Service connection for a left hand condition is remanded. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral syndrome is remanded. Entitlement to an initial rating in excess of 10 percent for lumbar back pain prior to April 8, 2021, and in excess of 20 percent thereafter is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1986 to November 1987. This matter comes before the Board of Veterans' Appeals (Board) from September 2009, March 2013, and May 2013 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.800 (c). 1. Service connection for a cervical spine condition is remanded. The Veteran contends that he has a cervical spine disability that either is directly related to active duty service or is secondary to his service-connected left knee disability. Unfortunately, the Board cannot make a fully-informed decision on the issue of service connection for a cervical spine condition because no VA examiner has adequtely opined whether the Veteran's cervical spine condition is secondary to his service-connected left knee disability. In compliance with the Board's August 2018 remand directives, addendum opinions were obtained in February 2019 and February 2022. In providing a negative secondary opinion, the February 2019 VA examiner indicated that the cervical condition has an unrelated etiology and anatomical location to the Veteran's service-connected left knee patellfemoral syndrome. Similarly, the February 2022 VA examiner indicated that, by definition, cervical condition and left knee patellofemoral syndrome are different disease entities with different pathophysiological processes unrelated to each other at different anatomical areas without biomechanical interaction. The February 2022 examiner also noted that there is no clinical and objective evidence to 'support condition' but that 'condition has followed natural progression.' The opinions of record do not appear to adequately consider or address the Veteran's contention that his cervical spine condition is due to or aggravated by falling and injuring himself after his service-connected left knee gave out. Accordingly, on remand, an addendum opinion must be obtained. 2. Service connection for a left eye condition is remanded. The Veteran seeks service connection for a left eye condition. After the August 2018 Board remand, a June 2019 rating decision granted service connection for thrombosis, transient ischemic attack (TIA) or cerebral infarction with stenosis, left, middle cerebral artery (MCA) and internal carotid artery (ICA), and right homonymous hemianopsia. The Veteran now contends any current left eye condition is related to his service-connected thrombosis, TIA, or cerebral infarction with stenosis, left MCA and ICA, and right homonymous hemianopsia. In compliance with the Board's August 2018 remand directives, VA examinations and opinions were obtained in February 2019 and November 2021. Although the examiners provided direct service connection opinions, the Board cannot make a fully-informed decision on the issue of service connection for a left eye condition other than right homonymous hemianopsia because no VA examiner has opined whether the Veteran's age-related senile cataracts are aggravated by his service-connected thrombosis, TIA or cerebral infarction with stenosis, left MCA and ICA, and right homonymous hemianopsia. 38 C.F.R. § 3.310 (b); El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). 3. Service connection for a left elbow condition is remanded. The Veteran contends he incurred a left elbow fracture after active service as a result of falling and injuring himself when his service-connected left knee gave out. See, e.g., February 2022 VA examination. The August 2018 Board remand noted an October 2010 VA examination indicates the Veteran was diagnosed with a left forearm-wrist extensor strain, tendonitis, and lateral and medial epicondylitis (tennis elbow). However, the VA examiner did not provide an opinion on any of these conditions. Thus, this matter was remanded for further development, to include a VA examination and opinion. In compliance with the August 2018 Board remand, a VA examination was obtained in February 2022. The examiner opined that the Veteran left elbow fracture was less likely than not incurred in or caused by a left elbow fracture during service. The examiner noted there is no clinical and objective evidence to support a diagnosis of left elbow fracture such that a diagnosis is not warranted. The examiner noted a June 2010 x-ray was without evidence of a left elbow fracture. The examiner further opined that the Veteran's current medial epicondylitis is less likely than not related to active military service as the condition dates to years after active military service and has followed natural progression. Regarding secondary service connection, the examiner opined that the Veteran's left elbow medial epicondylitis was less likely than not caused by his service-connected left knee patellofemoral syndrome. The examiner noted that his left elbow condition and left knee patellofemoral pain syndrome are different disease entities with different pathophysiological process unrelated to each other, each condition is intrinsic of its anatomical area without biomechanical interaction, and medical literature does not support that left knee patellofemoral pain syndrome is a causal etiology for the onset of left elbow condition. The examiner further opined that the Veteran's left elbow epicondylitis was not at least as likely as not aggravated beyond its natural progression by his left knee disability. The examiner noted that there is no clinical and objective evidence to support the diagnosis and the condition has followed the natural progression. The examiner does not appear to consider or address the Veteran's specific contention that his left elbow condition is due to falling and injuring himself after his service-connected left knee gave out. Accordingly, an addendum opinion must be obtained. 4. Service connection for a left hand condition is remanded. The Veteran contends he incurred a left hand condition after active service as a result of falling and injuring himself when his service-connected left knee gave out. See, e.g., February 2022 VA examination. In compliance with the August 2018 Board remand, a VA examination was obtained in February 2022. The examiner noted a diagnosis of left hand strain. The examiner opined that the Veteran's left hand strain was less likely than not incurred in or caused by a left hand condition during service as there is no clinical and supporting objective evidence and no chronicity of care. Regarding second service connection, the examiner opined that the Veteran's left hand strain was less likely than not caused by his service-connected left knee patellofemoral syndrome because, by definition, left hand strain and left knee patellofemoral pain syndrome are different disease entities with different pathophysiological process unrelated to each other. The examiner also noted each condition is intrinsic of its anatomical area without biomechanical interaction and medical literature does not support that left knee patellofemoral pain syndrome is a causal etiology for the onset of left hand condition. Finally, the examiner opined that the Veteran's left hand strain is less likely than not aggravated beyond its natural progression by his service-connected left knee patellofemoral syndrome as there is no clinical and objective evidence that support that left hand strain was aggravated by service-connected left knee patellofemoral pain syndrome. Unfortunately, the February 2022 examiner does not appear to consider or address the Veteran's specific contention that his left hand condition is due to falling and injuring himself after his service-connected left knee gave out. Accordingly, an addendum opinion must be obtained. 5. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral syndrome is remanded. 6. Entitlement to an initial rating in excess of 10 percent for lumbar back pain prior to April 8, 2021, and in excess of 20 percent thereafter is remanded. The Veteran seeks increased ratings for his service-connected left knee patellofemoral syndrome and lumbar back pain. Additional VA treatment records were associated with the record following transfer of the case to the Board. In May 2022, the Board requested a waiver of initial review by the AOJ; however, a response was not received. Since VA has developed additional relevant evidence concerning both claims since the claims were last adjudicated in the February 2022 supplemental statement of the case (SSOC), remand is required for the issuance of another SSOC. 38 U.S.C. § 7105 (e); 38 C.F.R. § 20.1304 (c). 7. Entitlement to a TDIU is remanded. Because a decision on the remanded issues of entitlement to an increased initial rating for left knee pateollfemoral syndrome and lumbar back pain could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's cervical spine condition, left hand strain, and left elbow disorders (i.e., left forearm-wrist extensor strain, tendonitis, and lateral and medial epicondylitis) are at least as likely as not proximately due to his service-connected left knee disability or aggravated by his service-connected left knee disability. The examiner must provide a rationale. In formation of the opinion and rationale, the examiner must address the Veteran's specific contention that his cervical spine condition, left hand strain, and left elbow disorders were incurred or worsened as a result of falling and injuring himself after his service-connected left knee gave out. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms resulted from a fall when his left knee gave out, this should be noted. Stated another way, does the Veteran's reported injury (falling as a result of his service-connected left knee disability) align with how the cervical spine condition, left hand strain, and left elbow disorders are known to develop, or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left eye cataracts are at least as likely as not aggravated by his service-connected thrombosis, TIA, or cerebral infarction with stenosis, left MCA and ICA, and right homonymous hemianopsia. The examiner must provide a rationale. 3. Issue an SSOC that reflects consideration of the pertinent evidence received after the February 2022 SSOC. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.Aoughsten, Associate 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.