93 Decision Citation: BVA 93-06836 Y93 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 91-14 435 ) DATE ) ) ) Sitting at San Diego, California THE ISSUE Entitlement to service connection for Ehlers-Danlos syndrome, claimed as a bilateral knee disorder. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Raymond F. Ferner, Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from decisions of the Department of Veterans Affairs (VA) Regional Office in San Diego, California (RO). The veteran had active service from June 1978 to December 1980. An April 1990 rating decision denied the benefits sought on appeal. A notice of disagreement was received and a statement of the case was issued in October 1990. A VA Form 1-9 (Appeal to Board of Veterans' Appeals) was received in November 1990 with a request for a hearing before a travel section of the BVA. A supplemental statement of the case was issued in January 1991. The RO certified the appeal in February 1991. A hearing was held on February 27, 1991, before a Board travel section. The case was received at the BVA in March 1991. The case was referred to the veteran's representative at the Paralyzed Veterans of America, Inc., and additional written argument was presented to the Board in April 1991. By a decision dated in October 1991, the Board remanded this case for further development. The RO accomplished that development by promulgating a rating decision in May 1992 and issuing a supplemental statement of the case in June 1992 which continued to deny the benefits sought on appeal. The RO recertified the appeal and the case was again received at the BVA in September 1992. The veteran's representative presented further written argument to the Board in October 1992. REMAND The veteran essentially contends that she has Ehlers-Danlos syndrome, "a congenital hereditary syndrome characterized by hyperextensibility of the joints and hyperelasticity and fragility of the skin with poor healing of wounds," Dorland's Illustrated Medical Dictionary at 1291 (26th ed. 1981), which chronically worsened or increased in severity during service. However, following an evaluation by O. W. Jones, M.D., in which the veteran related that she began to experience knee pain during service in connection with her performance as a corpsman when she repeatedly had to negotiate up and down five flights of stairs, Dr. Jones indicated that: "It is conceivable that excessive stress of the joints of an individual with underlying Ehlers-Danlos syndrome could produce a complicated clinical picture [the veteran] has experienced during recent years [,]" but a service physician treating the veteran as a dependent in April 1990 was of the opinion that it was clearly aggravated during service. We believe that a further examination of the veteran to clarify the two opinions would be useful. The veteran has also submitted a copy of a voucher for payment of a claim filed under the Federal Tort Claims Act. The claim was described as: "Medical Malpractice and/or delay of treatment to knee." She testified that it was predicated on treatment she received during and following her active duty. Transcript at 6-7. However, that voucher does not specify when the medical malpractice and/or delay of treatment occurred, but there is an indication that there are additional "attachments for further explanation in detail." We believe that those records are pertinent and probative, and should be obtained. Therefore, in order to give the veteran every consideration with respect to the present appeal, it is the opinion of the Board that further development of the case is desirable. Accordingly, this case is REMANDED for the following actions: 1. Pursuant to 38 U.S.C.A. § 5106 (West 1991), the RO should obtain and associate with the claims file a description of the particulars of the veteran's claim which was settled in May 1989 from the Department of the Navy, Naval Legal Service Office, Post Office Box 215, Naval Station San Diego, California, or other such repository of those records. The information sought pertains to the dates of the medical malpractice and/or delay of treatment and the nature of the Government's liability. 2. The RO should refer the veteran's claims file, or all pertinent medical records, to the chief of orthopedics at a convenient or appropriate VA medical center for review of the pertinent evidence. That physician, or one designated the responsibility, should review the evidence, particularly records of treatment the veteran received for her knee during service in September 1979 and post service medical records, and offer comments and discussion regarding the following: (1) Did the treatment the veteran receive for her knees during service represent a manifestation of Ehlers-Danlos syndrome, and if so, and in the alternative assuming it was a manifestation, (2) did that manifestation represent (a) a chronic worsening of the syndrome, (b) the natural progress of the syndrome, or (c) an acute exacerbation. As previously mentioned, and since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 (1992), all pertinent medical records in the veteran's claims file or, in the alternative, the claims file, must be made available to the examiner for review. When the development requested has been completed, the case should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the veteran and her representative should be furnished a supplemental statement of the case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional development, and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. No action is required of the veteran unless she is notified. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 C. D. ROMO H. M. MC ALLISTER, M.D. FRANCIS F. TALBOT Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (l992).