11-33 845, 11-33 845

Background

Veteran served active duty Jun–Dec 2004 and Dec 2005–Nov 2006, with Reserve training; appealed denials from VA Regional Office (Dec 2010 & Jul 2011).
Claims on appeal: service connection for upper back rib dislocation (left 4th rib), bilateral knees (patellofemoral pain), left elbow (medial epicondylitis), and bilateral hands (weakness/numbness/tingling).
Veteran attributes rib injury to a March 2006 martial-arts incident and/or sleeping on cots; attributes knees and hands partly to compensatory changes from service‑connected lumbar spine DDD with disc herniation; attributes left elbow to a fall in boot camp.
Multiple VA examinations (2011, 2015, 2016) produced negative or equivocal etiology opinions; examiners often relied on silence in service treatment records (STRs) and lacked full rationale or did not address specific lay contentions and a treating physician’s (Dr. B.H.) July 2015 opinion.
Board found multiple VA opinions inadequate and identified incomplete development (missing records, lack of VCAA notice regarding secondary theories and outstanding VA treatment records) and remanded all claims for targeted addendum opinions and further record development.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Service connection — upper back rib dislocation (left 4th rib)	Rib subluxation from March 2006 martial‑arts incident and/or sleeping on cots in service; symptomatic since service	VA examiner: less likely than not related to service; attributed to automobile mechanic work; STR silence supports negative inference	Remanded: 2015 opinion inadequate (no rationale for negative, did not address Veteran’s specific contentions or whether lumbar disorder causes/aggravates rib). Obtain addendum addressing in‑service events, cot claim, and relationship to lumbar DDD. VCAA notice also required.
Service connection — bilateral knee disorder (patellofemoral pain)	Knees caused by driving/maintaining vehicles in service and/or secondary to service‑connected lumbar spine (compensatory mechanics)	VA examiner: less likely than not related to service or lumbar disorder; cited anatomical separation and lack of in‑service diagnosis/STR complaints	Remanded: examiner failed to address driving/maintenance contention and offered inadequate rationale for rejecting biomechanical secondary theory. Addendum opinion required addressing both bases and VCAA notice.
Service connection — left elbow disorder (medial epicondylitis)	Elbow injury from fall in boot camp/combat training causing prolonged numbness; January 2010 history of elbow pain	2011/2016 VA examiners: either found not related to service or concluded no current chronic disorder; cited lack of chronicity, limited objective findings, and incomplete testing	Remanded: 2016 addendum inadequate because Board treats the July 2011 diagnosis as a current disability for adjudicative purposes; examiner must opine on nexus to boot camp fall and consider the Jan 2010 history and clarify which exam was reviewed. Addendum required.
Service connection — bilateral hand disorder (weakness/numbness/tingling)	Hand weakness/numbness began in service and persists; lay reports and some VA clinic notes suggest nerve damage	VA examiner (Dec 2015): insufficient evidence for a diagnosable bilateral hand condition; did not consider Persian Gulf/ Southwest Asia exposure rules for undiagnosed/medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317	Remanded: examiner failed to address undiagnosed illness/multisymptom illness theory under §3.317 (applicable because of Southwest Asia service). Addendum exam must document symptoms, rule in/out diagnoses, and opine on undiagnosed or medically unexplained chronic multisymptom illness and nexus to service.

Key Cases Cited

Stegall v. West, 11 Vet. App. 268 (Board must ensure compliance with remand directives)
Kutscherousky v. West, 12 Vet. App. 369 (veteran may submit additional evidence after remand; remand is not final Board decision)