Citation Nr: 18154222
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 16-08 152
DATE:	November 29, 2018
REMANDED
Issue of entitlement to service connection for gout of right knee is remanded.
Issue of entitlement to service connection for gout of right foot is remanded.
Issue of entitlement to service connection for gout of left foot is remanded.
REASONS FOR REMAND
The Veteran served on active duty from September 1979 to January 2000.
This appeal to the Board of Veterans’ Appeals (Board) arose from June 2014 and March 2015 rating decisions issued by the Department of Veterans Affairs (VA).  See June 2015 Notice of Disagreement (NOD); February 2016 Statement of the Case (SOC); February 2016 Substantive Appeal (VA Form 9).
1. Issue of entitlement to service connection for gout of right knee is remanded.
The Board cannot make a fully-informed decision on the issue of service connection for gout of right knee because clarification by a VA examiner is needed as to whether it is a current disability.
The Veteran asserts that jumping out of planes and helicopters during service resulted in arthritis, which has turned into gout in his right knee with swelling and severe pain symptoms.  See August 2013 VA 21-4138; February 2016 VA Form 9.  The Veteran relates that his VA and civilian doctors told him his gout attacks are caused by the advance stages of his arthritis.  See November 2014 VA Form 21-4138; February 2016 VA Form 9.
The medical evidence shows the Veteran has a diagnosis for right knee osteoarthritis, but with no specific diagnosis for gout of the right knee.  See September 2011 VA treatment record.  However, private treatment records show that the Veteran has current diagnoses and treatment for reoccurring gout in at least his right and left foot, with uric acid test results ranging from 5.3 during his service to 8.0 in 2015.  See September 1999 Service treatment records; January 2015 to November 2015 Private treatment records by M.R., M.D.  
The Board acknowledges that the April 2014 VA examiner opined that there is evidence of gout of the right foot, but no objective evidence of gout of the right knee.  See April 2014 VA examination.  However, the VA examiner provided no discussion as to what objective evidence supports gout in the right foot, but not in the right knee.
The Board, therefore, finds that a VA examination is needed to clarify whether the evidence supports a current disability of gout of right knee.  If gout of right knee is found as a current disability, then an opinion is needed on whether there is a direct medical link to the Veteran’s service or as secondary to his service connected disabilities, to include right knee degenerative joint disease with retropatellar syndrome.
2. Issue of entitlement to service connection for gout of left and right foot is remanded.
The Board cannot make a fully informed decision on the issue of service connection for gout of the left and right foot because an opinion from a VA examiner is needed on whether there is a direct medical link between the Veteran’s current gout of the left or right foot, and service.
The Veteran asserts that gout developed from his knee arthritis.  See August 2013 VA Form 21-4138.  The Regional Office (RO) then broadened his claim to include claims of service connection for gout of the left and right foot based the Veteran’s subsequent statement that he has gout in his lower foot and toes, and on a private physician statement indicating the Veteran is treated for gout of the right foot.  See November 2014 VA Form 21-4138; March 2015 Rating decision.
The Board finds that there is evidence showing that gout of left foot is a current disability, but no VA examiner has opined on whether there is a direct medical link to service or as secondary to a service connected disability.
Regarding the right foot, the April 2014 VA examiner opined that his gout of the right foot is less likely than not proximately due to the Veteran’s right knee retropatellar femoral pain syndrome.  See April 2014 VA examination.  However, the VA examiner did not opine on whether his current gout of the right foot is aggravated by a service connected disability, nor on whether there is a direct medical link between the Veteran’s gout of the right foot and service.  See id.  In addition, it is unclear if the VA examiner only considered the Veteran’s retropatellar femoral pain syndrome and not the right knee degenerative joint disease diagnosis when evaluating for a secondary service connection.
The Board, therefore, finds an addendum opinion is needed.
The matters are REMANDED for the following action:
1. Obtain an addendum opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s gout of the right knee, right foot, and left foot.  If the medical professional determines that it is necessary, schedule the Veteran for a VA examination regarding the etiology of his gout of the right knee, right foot, or left foot.  The medical professional should respond to the following:
(a) Does the Veteran have a current disability of gout of the right knee?  The examiner should consider and discuss the evidence about the Veteran’s right knee condition, the uric acid testing levels, and that he has a diagnosis for gout in his feet with medication treatment.
(b) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s gout of the right knee (if found as a current disability), right foot, or left foot began in (or is otherwise related to) the Veteran’s military service?  The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms.  A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate.
(c) The examiner should also provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current gout of the right knee (if found as a current disability), right foot, or left foot are proximately due to or the result of his service connected disabilities, including right knee degenerative joint disease with retropatellar syndrome.  If not, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s gout of the right knee (if found as a current disability), right foot, or left foot are aggravated (permanently made worse) by one or more service connected disabilities, to specifically include right knee degenerative joint disease with retropatellar syndrome. The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms, including his assertion that his gout is caused by the advance stage of his arthritis.  A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate
(d) If his gout of the right knee, right foot, or left foot are deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely for each one and explained why that is so.
 
DEBORAH W. SINGLETON
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Lin, Associate Counsel

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