Citation Nr: 25005442 Decision Date: 04/22/25 Archive Date: 04/22/25 DOCKET NO. 16-62 976 DATE: April 22, 2025 REMANDED Entitlement to service connection for a nerve disability of the right upper extremity, to include carpal tunnel syndrome (CTS) is remanded. Entitlement to service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1976 to October 1976, August 1977 to August 1979, and from May 1982 to August 1985, with additional periods of Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision. In January 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These claims have been remanded several times, most recently in November 2023. Unfortunately, remand is required because there still has not been substantial compliance with previous remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). After the November 2023 Board remand, service connection was granted for a neck disability, characterized as cervical spine degenerative disc disease with spinal stenosis and aggravated congenital spinal canal narrowing. See August 2024 rating decision. That claim has been granted in full and is not presently before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). 1. Entitlement to service connection for a nerve disability of the right upper extremity, to include CTS. The claim must be remanded to obtain an adequate VA medical opinion. Subsequent to the last Board remand, the Veteran received a new VA medical opinion regarding his claimed nerve disability of the right upper extremity in November 2023. The examiner opined the claimed nerve disability was less likely than not caused by or incurred during the Veteran's active service. As rationale, the examiner indicated the Veteran had no peripheral nerve conditions diagnosed per the April 2022 peripheral nerve conditions disability benefits questionnaire (DBQ). The examiner indicated there are no subjective or objective findings in the DBQ to support a diagnosis of any peripheral nerve conditions. Furthermore, the examiner asserted the Veteran's service treatment records (STRs), private treatment records, and VA medical records are silent for discussion or diagnosis of a peripheral nerve condition. Regarding secondary service connection, the examiner noted that the Veteran's spinal stenosis and congenital spinal canal narrowing could create a peripheral nerve condition in the upper extremities. However, they concluded there was no present nerve disability. The examiner did not render an opinion regarding secondary aggravation. The Board finds the opinion of the November 2023 VA examiner inadequate for adjudication. The examiner concluded there was no evidence of an upper extremity nerve disability in the Veteran's record. However, November 2013 VA treatment records noted mild CTS in 2011 and slightly decreased sensation over the median distribution. August 2020 and September 2023 VA examinations reported the Veteran had a diagnosis of right upper extremity CTS from a May 2011 EMG. The examiner failed to consider and discuss the Veteran's lay statements asserting his condition occurred while on active duty and indicating he did not go to sick call as much as he should have for fear of being accused of malingering. See December 2016 VA Form 9. The examiner also failed to provide an opinion regarding secondary aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Accordingly, remand is required to obtain a medical opinion that considers the evidence of record and addresses whether the claimed condition was aggravated by the Veteran's service-connected neck disability. 2. Entitlement to service connection for a right knee disability. The claim must be remanded for a new VA medical opinion that considers the Veteran's lay statements regarding etiology. Subsequent to the last Board remand, the Veteran received a new VA medical opinion in November 2023. The examiner opined the Veteran's right knee disability was less likely than not incurred in or caused by his service. As rationale, the examiner indicated there were no STRs diagnosing or addressing right knee issues, and that the Veteran's separation exam was negative for evidence of a right knee condition. The examiner further indicated that right knee osteoarthritis occurs as a result of wear and tear and as a natural part of the aging process. The examiner concluded that the diagnosed right knee osteoarthritis was not uncommon at the Veteran's age. Regarding secondary service connection, the examiner indicated that disorders of the neck do not lead to disorders of the knee, and concluded the Veteran's right knee disability was less likely than not proximately due to or the result of his neck condition. The examiner could not determine a baseline level of severity for the right knee condition, noting the medical evidence was not sufficient to support such a determination. The examiner asserted the Veteran's right knee condition was not aggravated by his neck condition, as knee conditions and neck conditions are separate and unrelated. After the August 2024 rating decision awarded entitlement to service connection for a neck condition, VA requested a new medical opinion. A September 2024 VA examiner opined the Veteran's right knee disability was less likely than not proximately due to or the result of his service-connected neck condition and left and right shoulder strains. The examiner concluded that the Veteran's right knee disability and neck disability are not medically related, as the biomechanics of knee movement and spinal function are independent of each other. Regarding the left and right shoulder strains, the examiner concluded that shoulder strains do not impact the mechanics of walking and are "separate entities entirely" from an altered gait and other joint conditions. The examiner applied a similar rationale to conclude the Veteran's right knee disability was not aggravated by his service-connected conditions. The Board finds the opinions of the November 2023 and September 2024 VA examiners inadequate for adjudication. The November 2023 examiner failed to discuss the Veteran's lay statements regarding the etiology of his right knee disability, including an August 2012 Statement in Support of Claim where he indicated lots of heavy physical fitness activities in the military at a young age put a strain on his knees. Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). The November 2023 and September 2024 examiners concluded the Veteran's right knee disability was not aggravated by his service-connected disabilities. However, both examiners relied solely on general medical articles to conclude the disabilities are biomechanically distinct and unrelated. Bailey v. O'Rourke, 30 Vet. App. 54, 60-61 (2018). Accordingly, the claim must be remanded to obtain an adequate VA medical opinion that specifically considers the Veteran's lay statements regarding etiology and the evidence of record. The matters are REMANDED for the following actions: 1. Provide copies of all pertinent records to an appropriate clinician to obtain addendum opinions regarding the nature and etiology of the Veteran's claimed nerve disability of the right upper extremity and right knee disability. If the examiner determines that opinions cannot be provided without examinations, they should be scheduled. After review of the record and any scheduled examinations, the examiner must respond to the following: (a.) Identify all right knee and right upper extremity nerve disabilities, to include CTS. If a diagnosis cannot be provided but the Veteran's nerve disability of the right upper extremity manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinions. In responding to this question, the examiner must specifically consider and discuss November 2023 VA treatment records noting mild CTS in 2011 and slightly decreased sensation over the median distribution and August 2020 and September 2023 VA examinations reporting the Veteran had a diagnosis of right upper extremity CTS from a May 2011 EMG. (b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed nerve disabilities of the right upper extremity or right knee disabilities were incurred in or are otherwise related to the Veteran's active service? In responding to this question, the examiner must specifically discuss the Veteran's lay statements and Board testimony where he indicated frequent heavy physical fitness activities in the military at a young age put a strain on his knees, and asserted he did not go to sick call as much as he should have for fear of being accused of malingering. (c.) If the answer to (b.) is no, is it at least as likely as not that the Veteran's service-connected left and right shoulder strains or cervical spine degenerative disc disease with spinal stenosis caused his right knee disability or nerve disability of the right upper extremity? (d.) If the answer to (c.) is no, the examiner must state the following: (i) whether, but for the Veteran's service-connected left and right shoulder strains or cervical spine degenerative disc disease with spinal stenosis, he would not have had a right knee disability or nerve disability of the right upper extremity; and (ii) whether the right knee disability or nerve disability of the right upper extremity would have been less severe and resulted in less functional impairment but for the service-connected left and right shoulder strains or cervical spine degenerative disc disease with spinal stenosis. If the examiner opines that the right knee disability or nerve disability of the right upper extremity would have resulted in less functional impairment but for his service-connected left and right shoulder strains or cervical spine degenerative disc disease with spinal stenosis, the examiner must attempt to establish a baseline level of severity of the right knee disability or nerve disability of the right upper extremity prior to aggravation by the service-connected left and right shoulder strains or cervical spine degenerative disc disease with spinal stenosis. The examiner is advised that a service-connected disability need only be a contributing cause, not the contributing cause, to establish secondary service connection. A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state why and what, if any, additional evidence would permit such an opinion to be made. 2. Confirm that the VA medical opinions provided comport with this remand, specifically, that the examiner addresses all theories raised as to the etiology of the Veteran's right knee disability and nerve disability of the right upper extremity and discusses the Veteran's lay statements regarding the nature and etiology of these disabilities. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Buchanan, Attorney Advisor 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.