Citation Nr: 1633617 Decision Date: 08/25/16 Archive Date: 08/31/16 DOCKET NO. 14-13 556 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for residuals of a head injury. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for residuals of a right hand injury. 5. Entitlement to service connection for residuals of a right ankle sprain. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Costello, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1976 to February 1982. These appeals come to the Board of Veterans' Appeals (Board) from a September 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2016, the Veteran appeared and provided testimony before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is associated with the claims file. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran is seeking service connection for residuals of a head injury, bilateral hearing loss, tinnitus, residuals of a right hand injury, and residuals of a right ankle sprain. During his March 2016 Board hearing he states he has been receiving treatment at the VA since 2003 and in the last two years was told by VA physicians that he had right hand arthritis and right ankle arthritis that was caused by service. However, only VA treatment records from November 2003 and from January 2011 to August 2012 are associated with the record. Considering this fact, it is essential that all VA treatment records from November 2003 to January 2011 and since August 2012 to the present be obtained. Second, the Veteran asserts he was granted disability benefits from the Social Security Administration (SSA) in 2003. However, there is no documentation in the claims folder that the Veteran applied for SSA disability benefits or is receiving SSA disability benefits. Such records, if they exist, could have a dispositive effect on the Board's decision. VA must make reasonable attempts to obtain relevant records held by a government agency. 38 C.F.R. § 3.159(c)(2). Therefore, the RO should make reasonable attempts to obtain the SSA records. Third, the Veteran's service treatment records reflect that in February 1980 he was seen for an injury to his right third finger. He was assessed with a soft tissue injury. Also, in February 1980 he injured his right leg between his ankle and knee after falling on ice. The record notes he had an ankle sprain. Additionally, a September 1981 record notes he went to the emergency room with complaints of an injury to his right shin after falling in a grease pit one day earlier. Assessment was contusion to the right ankle. A January 2011 VA treatment record notes the Veteran had osteoarthritis and carpal tunnel syndrome in his right hand. (See Virtual VA, Capri, 1/4/11, pg. 70). Also, the Veteran submitted a March 2016 VA treatment record that notes a 2013 x-ray of the Veteran's right wrist revealed "[a]dvanced degenerative arthrosis of the right wrist with scapholunate dissociation." In light of the above, only after all the above VA treatment records and SSA records are obtained, afford the Veteran a VA examination of his right hand to determine the nature and etiology of any diagnosed right hand disability, to include arthritis and carpal tunnel syndrome. Also, if the VA treatment records or SSA records show any evidence of a current right ankle disability, to include right ankle arthritis, afford the Veteran a VA examination of his right ankle to assess the nature and etiology of any diagnosed right ankle disability. Accordingly, the case is REMANDED for the following action: 1. Obtain all the Veteran's VA treatment records from November 2003 to January 2011 and from August 2012 to the present from the Clarksburg, Beckley, and Summersville VA, well as any associated outpatient clinics. 2. Also, attempt to obtain any records from the Social Security Administration. Reasonable efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The unavailability of such records must be documented for the record, and the Veteran must be notified of the efforts expended. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(2). 3. Only AFTER obtaining as much of the above noted VA treatment records and SSA records as are available, then schedule the Veteran for an appropriate VA examination to determine the nature, extent, onset, and etiology of his claimed residuals of a right hand injury and a right ankle sprain. The claims folder should be provided to the examiner for review of pertinent documents therein in connection with the examination, and the examination report should reflect that such a review was conducted. The examiner shall address whether it is at least as likely as not (50 percent or better probability) that the Veteran's currently diagnosed right hand or right ankle disability, to include his diagnosed arthritis and carpal tunnel syndrome, was incurred in or a result of a disease or injury sustained during active duty service. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. 4. After completing the above and any other development deemed necessary, readjudicate the remanded issue. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for 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). _________________________________________________ MICHELLE L. KANE 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).