Citation Nr: 1623497 Decision Date: 06/13/16 Archive Date: 06/29/16 DOCKET NO. 14-24 485 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a left ankle disorder. 2. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from April 1969 to January 1971, with subsequent unverified Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In October 2015, the Veteran testified before the undersigned during a videoconference hearing. A transcript of the hearing is included in the electronic claims file. The psychiatric claim for service connection has been developed as a claim for PTSD. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the claim has been recharacterized to include any psychiatric disorder. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The current service records associated with the claims file appear incomplete. Specifically, the Veteran reports that he had Reserve service for 14 years after active duty, however, there are no service treatment records from this period of service in the file. Additionally, the personnel documents of record largely pertain to the Reserve service; there are nearly no personnel records from the Veteran's period of active duty from 1969-1971. Given his contentions of continuous ankle problems in service, his full personnel records should be obtained in the event a physical profile was ever issued. Moreover, the personnel records may corroborate the stressors he contends are related to his current psychiatric disorder(s). A VA examination is needed to resolve the claim for an acquired psychiatric disorder. In February 2014, the RO determined that a fear-based stressor pursuant to 38 C.F.R. § 3.304(f) was established; no other stressor has been corroborated. On VA examination in March 2014, the examiner determined the Veteran had only an alcohol use disorder. However, in a November 2014 private medical report, the examiner diagnosed PTSD and major depression, and attributed the disorders to the Veteran's having to shoot someone while standing guard in service, as well as his general fear of death in service. However, the private examiner's opinion was founded on a review of limited records, which did not include service records or the VA examination report. Following the addition of any outstanding service or personnel records, a new opinion should be obtained, reconciling these opinions. Additionally, a VA examination has not been conducted for the left ankle claim. Despite the Veteran's hearing testimony about a preexisting left ankle disorder, and the Report of Medical History obtained on entry into service documenting an asymptomatic left ankle status-post fracture, the record, in its current status, does not clearly and unmistakably, i.e., undebatably, establish that a left ankle disorder preexisted service. See 38 C.F.R. § 3.304(b)(1) ("history of preservice existence of conditions recorded at the time of examination does not constitute a notation . . ."). Significantly, in March 1968, an entrance examination was conducted and no abnormality of the left ankle was found by the examining physician, and no notation of any left ankle condition was made. Thereafter, in March 1969 another examination was conducted, also prior to the Veteran's entry into service. On examination, the service physician again found no abnormalities affecting the left ankle, and no notation of a left ankle disorder was made. See VBMS Entry 7/30/13, p. 3/26 & 23/36. Unless additional service or personnel records indicate otherwise, it appears the Veteran was sound on entry. Current service treatment records do not document any complaint, diagnosis, or treatment relating to a left ankle disorder, but the Veteran has provided competent lay contentions of ankle pain and swelling due to running and physical activity in service. A medical opinion should be obtained. Accordingly, the case is REMANDED for the following action: 1. Contact the National Personnel Record Center and/or the appropriate service entity and request that (1) it identify the exact dates for all periods of active duty, active duty for training, and inactive duty for training performed by the Veteran, and (2) forward any and all service treatment records associated with such duty that are not already incorporated in the record. Additionally, request the Veteran's entire personnel file from the National Personnel Records Center, to include for the Veteran's service from April 1969 to January 1971, and associate all such records with the Veteran's electronic claims folder. 2. After all available records have been associated with the claims file/e-folder, afford the Veteran a VA examination to determine the etiology of his acquired psychiatric disorder, including PTSD. The claims folder/e-folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place must be included in the report of the examiner. All examination findings, along with a complete explanation for all opinions expressed, must be set forth in the examination report. (A.) The examiner is requested to first clearly identify all current psychiatric disabilities. If there is disagreement with a prior diagnosis, the examiner must explain why. In doing so, the examiner must address the November 2014 private medical report, the March 2014 VA examination report, and the VA treatment records reflecting diagnoses of PTSD. (B.) For each disorder other than PTSD, the examiner must provide an opinion as to whether the disorder began during active service or is related to any incident of service. (C.) With respect to PTSD, the RO/AMC must provide the examiner with a summary of any verified in-service stressors. The examiner must be instructed that only these events, and any stressors related to fear of hostile military or terrorist activity, may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The examiner must determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If a PTSD diagnosis is deemed appropriate, the examiner must then comment upon the link between the current symptomatology and any verified in-service stressor, including the fear of hostile military or terrorist activity. (D.) The examiner must also provide an opinion as to whether a psychosis manifested within one year of separation from service. All examination findings, along with a complete explanation for all opinions expressed, must be set forth in the examination report. 3. Also after all available records have been associated with the claims file/e-folder, afford the Veteran a VA examination to obtain an opinion as to the etiology of his left ankle disorder. The claims folder/e-folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place must be included in the report of the examiner. After an interview of the Veteran, a physical examination, and all tests and studies required, the VA examiner must offer the following opinions: The examiner must then provide an opinion as to (i.) whether the disorder began during active service or is related to any incident of service, considering the Veteran's contentions of in-service ankle pain and swelling due to running and physical activity, and (ii.) whether arthritis of the left ankle manifested within one year of separation from service. All examination findings, along with a complete explanation for all opinions expressed, must be set forth in the examination report. 4. Conduct any other appropriate development deemed necessary. Thereafter, readjudicate the claims, considering all evidence. If the benefits sought remain denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for a response. The appellant has the right to submit additional evidence and argument on the matter or 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 of Veterans' Appeals or by the United States 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 2014). _________________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2015).