Citation Nr: 18144684 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 16-37 311 DATE: October 25, 2018 REMANDED Entitlement to service connection for bilateral lower extremity disability, to include shin splints, is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to an initial compensable rating for a left ankle sprain with tarsal tunnel syndrome is remanded. Entitlement to an initial compensable rating for pseudofolliculitis barbae is remanded. REASONS FOR REMAND The Veteran had active military service from May 1984 to April 1987, and August 2008 to February 2010. He also served in the Army Reserves. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2016, the Veteran testified before the undersigned Veterans Law Judge; a transcript is associated with the claims file. In its May 2013 rating decision, the RO denied service connection for bilateral shin splits because the Veteran did not have shin splints during service and the record did not reflect shin splints diagnosis. However, the Board notes that the Veteran has been assessed with anterior tibial tendinitis. Furthermore, the Veteran did not file a claim to receive benefits only for a particular diagnosis, but for the affliction (symptoms) associated with any lower extremity disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). Pursuant to the holding in Clemons, the Board will consider the Veteran’s original claim as encompassing a claim for bilateral lower extremity disability, to include shin splints. 1. Entitlement to service connection for bilateral lower extremity disability, to include shin splints, is remanded. The Veteran contends that he has bilateral shin splits due to or related to service. As an initial matter, the Board notes that in February 2013 VA issued a formal finding of unavailability of the Veteran’s active duty service treatment records (STRs). In cases where the Veteran’s STRs are unavailable through no fault of the Veteran, there is a heightened obligation to explain findings and to carefully consider the benefit-of-the-doubt rule. O’Hare v. Derwinski, 1 Vet. App. 365 (1991). There is also a heightened obligation to assist the claimant in the development of his case. Id. In November 2016, the Veteran testified that he experienced pain through his feet whenever he walked that felt like pins. He stated that the pain started in service during marches and from being in the field. He reported that using compression socks helped, and that while he had not been diagnosed yet, he had an upcoming appointment with a specialist. His military occupational specialty was Field Artillery, where he carried rounds weighing close to 100 pounds. He described his shin splints pain as gradual onset due to repetitive banging of his feet on hard ground. A January 2017 Disability Benefits Questionnaire (DBQ) reflects left-sided pain in the anterior tibial tendon due to severe pes planus deformity. The physician did not diagnose shin splits. Given the Veteran’s statements of pain during service; the finding of unavailability of his STRs; the diagnosis of pain in the anterior tibial tendon; and the lack of medical opinion addressing whether the Veteran has any bilateral lower extremity disability, to include shin splits, that is due to or related to service, his right ankle, or his service-connected left ankle disability; the Board finds that a remand is required for a VA examination and opinion. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Barr v. Nicholson, 21 Vet. App. 30 (2007) (holding that once VA undertakes the effort to provide an examination or obtain medical opinion, it must ensure that one is provided or obtained that is adequate for the determination being made). 2. Entitlement to service connection for a right ankle condition is remanded. The Veteran contends that he has a right ankle disability secondary to his service-connected left ankle. In November 2016, the Veteran testified that he experienced swelling and limited range of motion in his right ankle. He stated that he tended to favor his left ankle and therefore overused his right ankle, which altered his gait. Given the Veteran’s allegations of right ankle pain and symptoms, his contention that it is secondary to his service-connected left ankle, and the fact that there is no opinion addressing whether the Veteran has a right ankle disability due to or aggravated to his service-connected left ankle, the Board finds that a remand is necessary for a VA examination to address the nature and etiology of the Veteran’s right ankle disability. See McLendon, 20 Vet. App. at 79; Barr, 21 Vet. App. at 30. 3. Entitlement to an initial compensable rating for a left ankle sprain with tarsal tunnel syndrome is remanded. The Veteran’s left ankle disability is currently rated as noncompensable. The Board notes that the Veteran was provided a VA examination for his left ankle in March 2013 and a private DBQ in January 2017. During both examinations, the Veteran’s range of motion was normal. In January 2017, the Veteran reported increased pain on the anterior aspect of the left ankle along the anterior tibial tendon. He stated that his ankle pain was progressively worse and that his functional impairment worsened such that he was no longer able to run. The Board finds the VA examination and private DBQ to be inadequate because they did not include range of motion findings for passive range of motion, nor specified whether the results were weight-bearing or nonweight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). Further, the VA examiner “failed to ascertain adequate information—i.e., frequency, duration, characteristics, severity, or functional loss—regarding his flares by alternative means” and then “estimate the Veteran’s functional loss due to flares based on all the evidence of record—including the Veteran’s lay information.” Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). As noted by the Court in Sharp, such findings are contemplated by the VA Clinician’s Guide. As such, a new VA examination is necessary to properly assess the severity of the Veteran’s left ankle disability as pertaining to the Veteran’s functional limitations and additional limitation of motion due to flare-ups. 4. Entitlement to an initial compensable rating for pseudofolliculitis barbae is remanded. The Veteran’s pseudofolliculitis barbae is currently rated as noncompensable. The Board notes that the Veteran was provided a VA examination for his skin disability in February 2014. The Veteran reported that he had razor bumps and rashes after shaving if he did not use a medical cream. The Veteran stated that he had been treated with a topical razor rash relief cream, hydroglide shave gel, for 6 weeks or more but not constant. The examiner found that as long as he had an effective treatment, like a razor rash relief cream, he could shave with no problems. In November 2016, the Veteran testified that he was getting monthly facials to try to avoid lesions, and had prescription medication that he used twice a day. He also stated that he had taken some pills for his condition. As such, the Board finds that a new VA examination is necessary to properly assess the severity of the Veteran’s skin disability. 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”). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination as to the etiology of his bilateral lower extremity disability, to include shin splits. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should address the following: (a.) Whether any bilateral lower extremity disability is as least as likely as not (50 percent probability or more) related to his military service or any right ankle disability. (b.) Whether any bilateral lower extremity disability is (a) caused or (b) aggravated by his service-connected left ankle disability. The Veteran’s STRs are unavailable and the VA examiner should not base his/her reasoning solely on a lack of in-service treatments, complaints, and diagnosis. A complete rationale should accompany any opinion provided. The examiner is advised that the Veteran is competent to report symptoms, treatments, and injuries, and that his reports must be taken into account in formulating the requested opinion. 2. Schedule the Veteran for a VA examination as to the etiology of his right ankle disability. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should address whether any right ankle disability is (a) due to, or (b) aggravated by his service-connected left ankle disability. A complete rationale should accompany any opinion provided. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinion. 3. Schedule the Veteran for a VA examination to determine the current severity of his left ankle disability. The Veteran’s VA claims file and a copy of this Remand should be made available to, and should be reviewed by the examiner. All indicated tests and studies should be performed and findings reported in detail. The examiner should conduct the examination in accordance with the current disability benefits questionnaire, to include range of motion testing (expressed in degrees) in active motion, passive motion, weight-bearing, and nonweight-bearing consistent with 38 C.F.R. § 4.59 as interpreted in Correia, as well as the degree at which pain begins. In addition, the examiner must address any additional functional impairment or limitation of motion due to flare-ups, even if the Veteran is not currently experiencing a flare-up. The examiner must ascertain adequate information—i.e., frequency, duration, characteristics, severity, or functional loss—regarding his flares by alternative means, such as the medical treatment records and the Veteran’s lay statements. Such findings are consistent with the VA Clinician’s Guide. 4. Schedule the Veteran for a VA examination to determine the current severity of his skin disability. The Veteran’s VA claims file and a copy of this Remand should be made available to, and should be reviewed by the examiner. All indicated tests and studies should be performed and findings reported in detail. If the Veteran uses topical treatment for his skin disability, the physician should provide an opinion as to: (a.) Whether any topical treatment operates by affecting the body as a whole in treating a veteran’s skin condition. (b.) Whether the given treatment is like or similar to a corticosteroid or other immunosuppressive drug. Only the second question needs to be considered if the treatment is systemic. The Board notes that “for a treatment to be systemic, it must affect the entire body in its treatment of the condition.” Thus, the examiner is asked to address how the Veteran’s use of topical creams affects the body as a whole. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Leifert, Associate Counsel