Citation Nr: 1642171 Decision Date: 11/02/16 Archive Date: 11/18/16 DOCKET NO. 12-06 626 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for fatigue with joint and muscle pain, to include as claimed due to an undiagnosed illness. 2. Entitlement to service connection for a psychiatric disability, to include anxiety, depression, and post-traumatic stress disorder (PTSD), to include as secondary to service-connected disabilities. 3. Entitlement to an increased rating for a cervical spine disability, in excess of 20 percent prior to July 10, 2012; and in excess of 10 percent as of July 20, 2012. 4. Entitlement to an increased rating in excess of 10 percent for a low back disability. 5. Entitlement to an increased rating in excess of 10 percent for a left shoulder disability. 6. Entitlement to an increased rating in excess of 10 percent for a right shoulder disability. 7. Entitlement to an increased rating in excess of 10 percent for right lateral humeral epicondylitis. 8. Entitlement to an increased rating in excess of 0 percent for right hallux valgus. 9. Entitlement to an increased initial rating in excess of 0 percent for headaches. 10. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran had active service from February 1986 to February 1990 and from April 1991 to May 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In October 2009, the Veteran filed claims for service connection for radiculopathy of the individual upper extremities. After the RO denied these claims in a February 2010 rating decision, the Veteran appealed the denials to the Board. In a December 2015 rating decision, the RO granted service connection for radiculopathy of the upper extremities. Therefore, the appeals on those issues are satisfied and those claims are no longer before the Board. Initially, the Veteran was represented in these matters by an attorney. In August 2016, the Board notified the Veteran that attorney was no longer accredited to represent claimants before VA. The Board advised the Veteran that he could seek other representation or proceed without representation. In August 2016, the Veteran filed a written response, indicating that he wanted to represent himself and proceed with the appeal. REMAND Regarding the claim for service connection for fatigue with joint pain and muscle pain, to include as due to an undiagnosed illness, the Veteran's service treatment records contain notations indicating that the Veteran was feeling tired during service. A remand is necessary to schedule a VA examination to determine the etiology of the claimed disability. Regarding the issue of service connection for a psychiatric disability, in an October 2011 VA psychiatric examination report, a VA examiner diagnosed the Veteran as having an adjustment disorder, secondary to the Veteran's employment situation. The examiner specifically found that the Veteran did not have PTSD or any other psychiatric disabilities related to service. Although the examiner stated that the Veteran's psychiatric disability was less likely than not caused by the Veteran's service-connected disabilities, the examiner did not offer an opinion as to whether the psychiatric disability was aggravated by the service-connected disabilities. Additionally, in a June 2012 private psychological evaluation, submitted by the Veteran, a private examiner diagnosed PTSD. Since June 2012, the Veteran has submitted statements regarding a claimed in-service stressor. The RO did not attempt subsequently to corroborate the Veteran's stressor. A remand is necessary to attempt to verify the Veteran's claimed stressors and to schedule an additional VA psychiatric examination. Regarding the issues of increased ratings for cervical spine, low back, headache, right hallux valgus, left shoulder, right shoulder, and right lateral humeral epicondylitis disabilities, the most recent examination of those disabilities was in July 2012. A remand is necessary to provide more contemporary VA examinations. The claim of entitlement to a TDIU is inextricably intertwined with the other claims on appeal. Therefore, those claims must be readjudicated before the claim for entitlement to a TDIU may be adjudicated. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: 1. Request the Veteran identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who provided treatment for his claimed disabilities. After securing the necessary releases, attempt to obtain all copies of pertinent treatment records identified by the Veteran that are not currently of record. 2. Regarding the claim for PTSD, request information from the Veteran regarding in-service stressors. After the that has been completed and the Veteran has been provided with a reasonable amount of time to provide any information regarding in-service stressors, examine the evidence submitted by the Veteran regarding the claimed in-service stressors and, if deemed necessary, make an appropriate attempt to corroborate the alleged stressors. Develop any other relevant factual information provided by the Veteran. 3. Schedule the Veteran for a VA examination to determine the severity of a service-connected headache disability. The examiner must review the claims file and should note that review in the report. The examiner should opine as to whether the Veteran's headache disability is manifested by symptomatology more nearly approximating characteristic prostrating attacks averaging one in two months over the last several months; characteristic prostrating attacks occurring on an average of once a month over the last several months; or very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The examiner should also opine as to whether it is at least as likely as not (50 percent or greater probability) that the service-connected disabilities makes the Veteran unable to secure or follow a substantially gainful occupation. If the Veteran's service-connected disabilities do not make him unemployable, the examiner should suggest the type of employment the Veteran would be capable of performing, considering his current skills and educational background. The examiner should also state what accommodations would be necessary due to the service-connected headache disability. A complete rationale should be given for all opinions and conclusions expressed. 4. Schedule the Veteran for a VA examination by a medical doctor specializing in orthopedics to determine the current severity of cervical spine, low back, right hallux valgus, left shoulder, right shoulder, and right lateral humeral epicondylitis disabilities. The examiner must review the record and should note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner must report the range of motion of the cervical spine, low back, left shoulder, right shoulder, and right forearm, expressed in degrees, to include, if possible, readings for weighted, non-weighted, passive, and active motion, and comparisons to uninjured paired joints. The examiner must make specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, or incoordination associated with those joints. If pain on motion is observed, the examiner should indicate the point at which pain begins. The examiner should also indicate whether, and to what extent, the Veteran experiences functional loss of those joints due to pain, or any other symptoms during flare-ups or with repeated use. To the extent possible, the examiner should express any additional functional loss in terms of additional degrees of limited motion. The examiner should indicate whether there is malunion or dislocation of the shoulder. The examiner should also note whether there is ankylosis of any joint. Regarding the right hallux valgus disability, the examiner should opine as to whether the metatarsal head has been surgically resected or if the condition is functionally equivalent to the amputation of the great toe. The examiner should also opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities make him unable to secure or follow a substantially gainful occupation. If the Veteran's service-connected disabilities do not make him unemployable, the examiner should suggest the type of employment the Veteran would be capable of performing, considering his current skills and educational background. The examiner should also state what accommodations would be necessary due to the service-connected orthopedic disabilities. A complete rationale should be given for all opinions and conclusions expressed. 5. Schedule the Veteran for a VA examination to determine the etiology of claimed fatigue with joint pain and muscle pain. The examiner should review the evidence, to include the Veteran's in-service reports of fatigue and post-service treatment for possible sleep disorders, and perform all necessary tests. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's claimed fatigue with joint pain and muscle pain are symptoms of an undiagnosed illness or a medically unexplained chronic multi-symptom illness, or are otherwise related to the Veteran's service. A complete rationale should be given for all opinions and conclusions expressed. 6. Then, schedule the Veteran for a VA mental disorders examination with a psychiatrist or psychologist examiner who has not previously examined him. The examiner must review the record and should note that review in the report. The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any psychiatric disorder diagnosed during the pendency of the claim is related to service or any incident of service. The examiner should also provide an opinion as to whether any psychiatric disorder was caused or permanently aggravated beyond its natural progression by a service-connected disability or disabilities. The examiner should provide a full multi-axial diagnosis pursuant to DSM-IV and should specifically state whether or not each criterion for a diagnosis of PTSD is met. If a diagnosis of PTSD is warranted, the examiner should state whether any PTSD is the result of a corroborated in-service stressor incident, or the fear of hostile military or terrorist activity during service. The examiner should reconcile the opinion with the October 2011 VA examination report and the June 2012 private medical examination report. A complete rationale should be given for all opinions and conclusions expressed. 7. Then, readjudicate the claims on appeal. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ Harvey P. Roberts 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).