Citation Nr: 0816830 Decision Date: 05/22/08 Archive Date: 06/04/08 DOCKET NO. 05-33 286 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a bilateral wrist disorder. 2. Entitlement to service connection for high blood pressure. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to service connection for a gastrointestinal disorder, claimed as gastritis. 5. Entitlement to service connection for a skin disorder, claimed as pseudofolliculitis barbae. 6. Entitlement to service connection for an acquired psychiatric disorder, claimed as post-traumatic stress disorder (PTSD). 7. Entitlement to an initial rating in excess of 20 percent for right knee chondromalacia patella with patellofemoral pain syndrome. 8. Entitlement to an initial rating in excess of 20 percent for left knee chondromalacia patella with patellofemoral pain syndrome. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD D. Vella Camilleri, Associate Counsel INTRODUCTION The veteran served on active duty from March 2002 to July 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico, which granted service connection for right and left knee chondromalacia patella with patellofemoral pain syndrome but denied the remaining claims. The issues of entitlement to service connection for a low back disorder, digestive disorder, skin disorder, and an acquired psychiatric disorder, and the claims for entitlement to initial ratings in excess of 20 percent for right and left knee chondromalacia patella with patellofemoral pain syndrome, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT There is no competent medical evidence of record showing that the veteran currently has a bilateral wrist disorder or high blood pressure. CONCLUSION OF LAW The criteria for service connection for a bilateral wrist disorder and high blood pressure have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). REASONS AND BASES FOR FINDING AND CONCLUSION To establish service connection for a claimed disability, the evidence must demonstrate that a disease or injury resulting in current disability was incurred during active service or, if pre-existing, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2007). Service connection may also be granted for any injury or disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2007). For certain chronic disorders, such as hypertension, service connection may be granted on a presumptive basis if the disease is manifested to a compensable degree within one year following service discharge. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The veteran's service medical records are devoid of reference to complaint of, or treatment for, high blood pressure or problems with his left wrist. In July 2003, the veteran was seen on three occasions with complaint of right wrist pain after rolling onto his wrist while playing football. A provisional diagnosis of right wrist injury/sprain, rule out fracture (r/o fx) was made; there was no obvious fracture seen. See medical records. During a March 2004 medical board examination, the veteran denied painful wrist; arthritis, rheumatism or bursitis; and high or low blood pressure. He did report impaired use of arms, legs, hands or feet; swollen or painful joint(s); and bone, joint, or other deformity. These references, however, were made in relation to the veteran's knees. See report of medical history. Clinical evaluation of the veteran's vascular system and upper extremities at the time of his discharge was normal and there was no reference to wrist problems or high blood pressure. See April 2004 report of medical examination. The claims folder does not contain any post-service medical evidence, though the veteran was afforded several VA compensation and pension (C&P) examinations in March 2005. During a joints examination, the veteran reported a right wrist fracture in 2003 but denied having any problems with his left wrist. He indicated that his right wrist felt "out of place" when lifting, pushing, pulling or carrying. The Board notes that the veteran's right wrist was not evaluated, as the examiner found that the veteran's claim for service connection was limited to his left wrist. The examiner reported a negative musculoskeletal left wrist joint examination. During a general medical examination, the veteran again reported suffering a fracture of his right wrist in 2003. He also indicated having an episode of arterial hypertension, but had not been treated since four months prior. Cardiovascular examination revealed regular heart rhythm with no murmur or extra or abnormal sounds. The examiner reported that the veteran had normal blood pressure, pulses and peripheral circulation. The examiner also reported that x- ray of the bilateral wrists showed normal density, bones, soft tissue and articular spaces; the bony structure was unremarkable. In pertinent part, the veteran was diagnosed with right wrist arthralgia, post-strain status. No diagnosis was made in reference to the left wrist. The evidence of record does not support the veteran's claims for service connection for a left wrist disorder or high blood pressure. The application of 38 C.F.R. § 3.303 has an explicit condition that the veteran must have a current disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires evidence of a relationship between a current disability and events in service or an injury or disease incurred therein). As there is no competent medical evidence of record showing that the veteran has a left wrist disorder or high blood pressure, service connection is not warranted and the claims must be denied. Nor does the evidence of record support the claim for service connection for a right wrist disorder. While the Board acknowledges that the veteran received in-service treatment related to his right wrist and has been diagnosed with right wrist arthralgia, post-strain status, x-rays taken in March 2005 were normal. The Board also notes that arthralgia is defined as pain in a joint. See DeLuca v. Brown, 6 Vet. App. 321, 322 (1993) (citing Dorland's Illustrated Medical Dictionary 147 (27th ed. 1988)). Pain alone, without a diagnosed or identifiable underlying condition, is not a disability for which service connection may be granted. See Sanchez- Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez- Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Even assuming that arthralgia could be considered a disability, there is no medical evidence of record establishing that the veteran's right wrist arthralgia is related to active service. For these reasons, service connection for a right wrist disorder is not warranted and the claim must be denied. VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Proper notice must also ask the claimant to provide any evidence in his or her possession that pertains to the claim. Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Prior to the issuance of the April 2005 rating decision that is the subject of the appeal concerning entitlement to service connection for high blood pressure and a bilateral wrist disorder, the veteran was advised of the evidence necessary to substantiate a claim for service connection and of his and VA's respective duties in obtaining evidence. He was also advised to send any evidence in his possession that pertains to his claims. See October 2004 letter. Accordingly, the duty to notify has been fulfilled concerning these claims. The Board acknowledges that the veteran was not provided notice of the appropriate disability rating and effective date of any grant of service connection. There is no prejudice in proceeding with the issuance of a final decision, however, as his claims are being denied. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA also has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2007). This duty is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The veteran has not provided any information regarding post- service treatment, either private or VA, related to his wrists or for high blood pressure. In the absence of any such information, the RO could not obtain any post-service medical evidence. In light of the determination made in the Wood case, and as the veteran's service medical records have been associated with the claims folder and he was afforded several appropriate VA examinations in connection with his claims, the Board finds that the duty to assist has also been met. For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or assistance is necessary, and deciding the appeal at this time is not prejudicial to the veteran. ORDER Service connection for a bilateral wrist disorder is denied. Service connection for high blood pressure is denied. REMAND Unfortunately, a remand is required in regards to the remaining claims. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the veteran's claims so that he is afforded every possible consideration. Such development would ensure that his due process rights, including those associated with 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002), and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2007), are met. The veteran seeks entitlement to service connection for a low back disorder, a gastrointestinal disorder (claimed as gastritis), a skin disorder (claimed as folliculitis barbae), and an acquired psychiatric disorder (claimed as PTSD). The veteran's service medical records reveal that he was found to have pseudofolliculitis barbae (PFB) on his chin and neck in July 2002. See SF600 form/personal data report; see also October 2002 SF600 form/personal data report (assessment of mild PFB). In October 2002, an assessment of suspect gastric ulcer versus GERD (gastroesophageal reflux disease) was made and an upper gastrointestinal series (UGI) was ordered. See SF600 form/personal data report. The UGI contained an impression of altered contour of the stomach with antral mucosal thickening and funnel-shaped narrowing; along with duodenal mucosal thickening, these findings are suggestive of gastroduodenitis; other less likely considerations include lymphoma and, even less likely given the age, carcinoma of the stomach. See October 2002 record from Winn Army Community Hospital. In November 2002, the veteran was seen with complaint of back pain. He reported that his job required lifting, twisting his back while lifting or lowering, and use of vibrating equipment or tools. See Medical Record - Low Back Pain. Lastly, the veteran was assessed with depression and anxiety in January and December 2003, respectively. See records from Dr. L.E. Rosa. As noted above, the RO afforded the veteran several VA C&P examinations in March 2003. In pertinent part, the veteran has been diagnosed with neuropsychiatric condition; adjustment reaction with anxious mood; chronic low back pain, post-strain syndrome; lumbar paravertebral myositis; muscle spasms by x-rays of the lumbar spine; folliculitis barbae, in remission; and hyperacidity with GERD. See VA C&P general medical, initial evaluation for PTSD, and spine examination reports. None of the examiners, however, provided opinions regarding the etiology of these diagnosed conditions. See id. In light of the foregoing, the Board finds that the RO should return the claims folder to the examiners who conducted the above-referenced examinations for an opinion regarding the etiology of the veteran's diagnosed conditions. This is especially important given the in-service treatment the veteran obtained related to his back and skin, the treatment he received in relation to gastrointestinal complaints, and the records associated with psychological treatment. While the Board acknowledges that the veteran did not exhibit chronic conditions during service, the fact that he filed his claims for service connection very shortly after his discharge from service supports this determination. See August 2004 VA Forms 21-526 and 21-4138. The Board notes that although the veteran has not reported receiving any VA treatment, it appears that he is receiving treatment at a Psychiatric Intervention Center (PIC). See March 2005 VA C&P initial evaluation for PTSD examination report (examiner reports veteran had his first psychiatric visit to the PIC a few days prior to the examination). In addition, it was later reported during the examination that the PIC requested a consult to the PCT Clinic. Records associated with this treatment, however, have not been associated with the claims folder. On remand, the RO/AMC should obtain all records related to any psychiatric treatment the veteran has obtained from VA. The veteran also seeks initial ratings in excess of 20 percent for service-connected right and left knee chondromalacia patella with patellofemoral pain syndrome. The VA C&P joints examination conducted in March 2005 in conjunction with his initial claim for service connection is now over three years old. The Board finds that fundamental fairness to the veteran warrants a more contemporaneous VA examination for the purpose of assessing the current severity of his service-connected knee disabilities. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993) (when a veteran claims that his condition is worse than when originally rated, and the available evidence is too old for an adequate evaluation of the veteran's current condition, the VA's duty to assist includes providing a new examination). This is also important given the fact that the claims folder is devoid of any treatment records related to the veteran's bilateral knee disability. Lastly, the RO/AMC should also obtain copies of the March 2005 x-rays taken of the veteran's knees and lumbar spine. These x-ray reports have not been associated with the claims folder, but have been referenced by several examiners. See March 2005 VA C&P spine and joints examination reports. The veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158 and 3.655 (2007). Accordingly, the case is REMANDED for the following action: 1. Send the veteran a notice letter under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), that includes an explanation as to the information or evidence needed to establish a disability rating and effective date for the claims on appeal, as outlined in Dingess v. Nicholson, 19 Vet. App. 473 (2006). 2. Obtain all records related to any psychiatric treatment the veteran has obtained from a VA PIC. 3. Obtain copies of the March 2005 x-ray reports related to the veteran's knees and lumbar spine. 4. Return the claims file and a copy of this remand to the VA examiner who conducted the March 2005 general medical examination for an opinion regarding the etiology of the veteran's folliculitis barbae and hyperacidity with GERD. The examiner is asked to state whether it is at least as likely as not (50 percent or greater probability) that any current skin and/or digestive disorder had it onset during service or is related to service. The examiner should provide a rationale for the opinion. If the VA examiner is not available, or if the requested opinion cannot be given without further examination of the veteran, a new VA examination should be scheduled. 5. Return the claims file and a copy of this remand to the VA examiner who conducted the March 2005 initial evaluation for PTSD examination for an opinion regarding the etiology of the veteran's adjustment reaction with anxious mood. The examiner is asked to state whether it is at least as likely as not (50 percent or greater probability) that any psychological disorder had it onset during service or is related to service. The examiner should provide a rationale for the opinion. If the VA examiner is not available, or if the requested opinion cannot be given without further examination of the veteran, a new VA examination should be scheduled. 6. Return the claims file and a copy of this remand to the VA examiner who conducted the March 2005 spine examination for an opinion regarding the etiology of the veteran's lumbar paravertebral myositis; muscle spasms by x-rays of the lumbar spine. The examiner is asked to state whether it is at least as likely as not (50 percent or greater probability) that any current back disorder had it onset during service or is related to service. The examiner should provide a rationale for the opinion. If the VA examiner is not available, or if the requested opinion cannot be given without further examination of the veteran, a new VA examination should be scheduled. 7. Schedule the veteran for a VA joints examination for the purpose of ascertaining the current severity of his knee disabilities. The claims folder, to include a copy of this remand and any additional evidence secured, must be made available to and reviewed by the examiner in conjunction with the examination. The examination report must reflect that the claims folder was reviewed. All necessary tests, including x-rays if indicated, should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner should identify all residuals attributable to the veteran's service-connected right and left knee chondromalacia patella with patellofemoral pain syndrome. The examiner should report the range of motion measurements for each knee in degrees. Whether there is any pain, weakened movement, excess fatigability or incoordination on movement should be noted, and whether there is likely to be additional range of motion loss due to any of the following should be addressed: (1) pain on use, including during flare- ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. The examiner is asked to describe whether pain significantly limits functional ability during flare-ups or when the knees are used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report. The examiner should state whether there is any evidence of ankylosis or recurrent subluxation or lateral instability of the knees, and if so, to what extent. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 8. Thereafter, readjudicate the claims. If the benefits sought on appeal remain denied, the veteran and his representative should be furnished a supplemental statement of the case and be afforded an opportunity to respond. The case should then be returned to the Board for further appellate review, if in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the U.S. Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs