Citation Nr: 1803233 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 14-12 506 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased rating in excess of 10 percent for plantar fasciitis of the right foot. 2. Entitlement to service connection for pseudofolliculitis barbae. 3. Entitlement to service connection for a right knee disability. 4. Entitlement to service connection for a left foot disability. 5. Entitlement to service connection for residuals of a cold injury of the right hand. 6. Entitlement to service connection for residuals of a cold injury of the left hand. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ashley Castillo, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1975 to June 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In the February 2012 rating decision, the RO increased the rating for the plantar fasciitis of the right foot to a 10 percent disability, effective December 9, 2011, the date of Veteran's claim for an increased rating. Additionally, the RO denied service connection for left foot disability, right knee disability, pseudofolliculitis barbae, residuals of a cold injury of the right hand, and residuals of a cold injury of the left hand. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND As to the increased rating claim for plantar fasciitis of the right foot, the Veteran was afforded an examination in January 2012. The January 2012 VA examination report reflects a diagnosis of mild plantar fascitis and pes planus. Notably, the examiner did not document any of the Veteran's right foot complaints or note any other findings, to include upon physical examination. Since the January 2012 VA examination, a September 2014 VA treatment report documents the Veteran's complaints of pain in his right arch. Upon physical examination, the VA treatment provider found excessive foot pronation, abducted gait, and heel eversion. Additionally, the VA treatment provider indicated that there was mild lateral deviation of hallux with non-painful, limited ranges of motion of the toe. There was minimal inflammation at the bunion site. The VA treatment provider diagnosed onychomycosis, onychauxis, pes planus, hallux valgus/rigidus, and hammertoes. In light of the lack of examination findings in January 2012, and that the evidence of record suggest that the Veteran's plantar fasciitis of the right foot has worsen since his examination in January 2012, the Board finds that a remand is necessary to afford him a new VA examination to determine the current severity of his service-connected plantar fasciitis of the right foot. See, e.g., Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) ("Where the appellant complained of increased hearing loss two years after his last audiology examination, VA should have scheduled the appellant for another examination"). With respect to the service connection claim for pseudofolliculitis barbae, the Veteran relates his disability to his military service. His service treatment records (STRs) reveal that he was treated on multiple occasions for pseudofolliculitis barbae and that he had a shaving profile. See, e.g., STRs dated Januray1976, April 1976, May 1976 and February 1977. In January 2012, the Veteran was afforded an examination. The VA examiner noted that although the Veteran was diagnosed with pseudofolliculitis barbae during service, he currently does not have a diagnosis. To this end, although the examiner indicated that the Veteran does not have a current diagnosis, the examiner provided a positive nexus opinion between the Veteran's pseudofolliculitis barbae and his military service. Although the Veteran's VA treatment records do not show a diagnosis of pseudofolliculitis barbae, as indicated above, there may be outstanding VA treatment records. Furthermore, the Board finds that based upon the January 2012 VA examiner's positive nexus opinion, the evidence is unclear whether the Veteran has a current diagnosis of pseudofolliculitis barbae. Therefore, the Board finds that after the Veteran's VA treatment records have been associated with the claims file, the Veteran should be afforded an examination to determine if he has a current diagnosis of pseudofolliculitis barbae at any time since the date of his service connection claim. As to the right knee disability, the Veteran claims that his right knee disability is related to his military service. Specifically, he asserts that during service cannon fell on his right knee and that he has had right knee pain since service. See VA examination report dated October 2013. An August 1975 STR shows right knee sub-patellar crepitus. In a December 2011 VA orthotics prosthetic consult, the VA orthotist assessed right knee osteoarthritis. In October 2013, the Veteran was afforded an examination. The VA examiner indicated that the Veteran had a current right knee diagnosis; however, the examiner did not specify the diagnosis; furthermore, the examiner referred to the Veteran's right knee disability as "right knee pain." The VA examiner opined that his right knee disability is less likely than not related to his military service. The VA examiner reasoned that the Veteran's right knee pain is unrelated to his in-service diagnosed of patellar chondromalacia, as a current right knee x-ray is absent osteoarthritic changes. The Board finds that the evidence is conflicting as to whether the Veteran has a right knee disability and, if so, the nature of the disability. Although the December 2011 VA orthotist diagnosed right knee osteoarthritis, it is uncertain whether such diagnosis was based on x-ray report evidence. Therefore, the Board finds that upon remand, the Veteran should be afforded a right knee examination to determine the nature and etiology of his right knee. With regard to the left foot disability, the Veteran claims that it is due to his military service. Alternatively, he asserts that his left foot disability is secondary to his service-connected plantar fasciitis of the right foot. In a February 2012 opinion, the VA examiner opined that it is less likely than not that the Veteran's currently diagnosed left plantar fasciitis is related to his in-service left ankle sprain or his service-connected plantar fasciitis of the right foot. The VA examiner reasoned that the etiology of plantar fasciitis is not related to ankle sprain that occurred more than 35 years ago. The February 2012 VA examiner did not provide an opinion as to whether the Veteran's left foot disability is caused or aggravated by service-connected plantar fasciitis of the right foot. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). Therefore, upon remand, the Board finds that an opinion should be obtained to determine the etiology of the Veteran's left foot disability. In addition, the Veteran claims that he has residuals of cold injury of the right hand and left hand that are due to his military service. A November 1976 STR documents the Veteran's complaints of left hand pain, due to jamming his left hand. An x-ray report shows no abnormalities. VA treatment records include complaints of right hand pain and a diagnosis of right hand mild degenerative changes at the first metacarpocarpal articulation and sclerosis. See VA treatment records dated in May 2014. In this case, the Veteran has not been afforded an examination to determine the nature and etiology of his claimed residuals of cold injury of the right hand and left hand. Accordingly, the Board finds that upon remand, he should be afforded a VA examination as to his claimed residuals of a cold injury of the right hand and left hand. See 38 U.S.C.§ 5103A(d)(2) (West 2012); 38 C.F.R. § 3.159(c)(4)(i) (2017); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Finally, a review of the record suggests that there are VA treatment records and examinations reports that have not been associated with the Veteran's claims file. For instance, the December 2015 Supplemental Statement of the Case (SSOC) list as evidence July 2014 VA examination report and April 2015 VA examination report. However, the most recent VA examination in the Veteran's claims file is dated in October 2013. Moreover, the December 2015 SSOC indicates that the Veteran's treatment records show "ongoing treatment for arthritis of the right knee;" however, the Veteran's available VA treatment records do not show continued treatment for right knee arthritis. Therefore, the Board finds that a remand is warranted to obtain any unassociated VA examination reports and VA treatment records. Accordingly, the claims are REMANDED for the following action: 1. Obtain updated records of treatment and VA that the Veteran may have received at any VA health care facility, to include VA examination reports dated in July 2014 and April 2015 noted in the December 2015 SSOC. All such available documents should be associated with the claims file. If the Board is in error that the documents are not in the claims file, it apologizes, and requests that the RO prepare a memorandum to the file indicating the location of the documents. 2. Then, schedule the Veteran for a new VA examination as to the severity of his service-connected plantar fasciitis of the right foot. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should examine the Veteran and render findings in accordance with the currently applicable disability benefits questionnaire. All opinions must be supported by a detailed rationale. 3. Then, the claims folder should be referred to an appropriate VA physician for an opinion as to the nature of his pseudofolliculitis barbae. A copy of this remand must be made available to the physician for review in connection with the requested opinion. After a review of the claims, the physician should identify whether the Veteran has a current diagnosis of pseudofolliculitis barbae, i.e., since approximately the date of his claim for service connection in December 2011. The physician must provide a rationale for any opinion given. The physician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 4. Then, the claims folder should be referred to an appropriate VA physician for an opinion as to the nature and etiology of the Veteran's right knee disability, left foot, residuals of a cold injury of the left hand, and residuals of a cold injury of the right hand. A copy of this remand must be made available to the physician for review in connection with the requested opinion. The physician should identity any right knee disability, residuals of a cold injury of the left hand, and residuals of a cold injury of the right hand since the date of the Veteran's claim in December 2011. Then, the physician should provide an opinion as to whether any such disabilities, to include the left foot disability, are at least as likely as not (50 percent probability or greater) had their onset during military service or is otherwise related to service. As to any left foot disability, the physician should provide an as to whether it is at least as likely as not (50 percent probability or greater) that it was either (a) caused or (b) aggravated by his service-connected right foot disability. If aggravated, specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. The physician must provide a rationale for any opinion given. The physician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 5. Thereafter, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, provide the Veteran and his representative with a Supplemental Statement of the Case and afford them a reasonable opportunity to respond. Then return the case to the Board for further appellate review, if otherwise in order. 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 by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252, only a decision of the Board is appealable to the Court. 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).