Citation Nr: 18147369 Decision Date: 11/06/18 Archive Date: 11/05/18 DOCKET NO. 16-32 012 DATE: November 6, 2018 REMANDED Entitlement to service connection for residuals of a traumatic brain injury (TBI) with cognitive difficulties and periventricular matter demyelination is remanded. Entitlement to a compensable rating for costochondritis is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from July 2006 to July 2010, including service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision by the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). 1. Entitlement to service connection for residuals of a TBI with cognitive difficulties and periventricular matter demyelination is remanded. The Veteran contends that he has residuals of a TBI as a result of active service, including due to head injuries sustained during service in Iraq. In statements in support of his claim, including an August 2013 statement, he asserted that his present residuals of a TBI developed either as a result of a board having been dropped on his head or as a result of chemical and/or environmental exposure during service in Southwest Asia. The Board notes that the Veteran’s claims file was destroyed by fire during private carrier transit and that he subsequently provided copies of service treatment records he noted were incomplete. The available service treatment records show he denied having or having ever had VA treatment records in June 2011 noted the Veteran reported a history of a skull fracture when he was five years old and that during active service he had been disoriented after having been hit with pugil sticks and when a board hit him on the head. He also reported that after returning from Iraq he was “knocked senseless” when he headed a soccer ball during physical training. A diagnosis of TBI was noted in a July 2011 sleep study, but no rationale for the opinion was provided. An August 2011 magnetic resonance imaging (MRI) study noted a history of TBI due to combat training and childhood accident resulting in a skull fracture. The examiner’s impression was small punctate focus of white matter demyelination in the left inferior centrum semiovale, but otherwise an age-appropriate examination of the brain. A May 2017 private medical opinion found it was at least as likely as not that the Veteran’s current TBI condition was a continuation or, progression of, and/or aggravated by his head injury during active service. The Board notes, however, that no comments were provided as to the Veteran’s skull fracture when he was five years old. As this matter has not been addressed by VA compensation examination, further development is required. 2. Entitlement to a compensable rating for costochondritis is remanded. The Veteran contends that his service-connected costochondritis is more disabling than reflected by the present evaluation. In an August 2013 statement he reported that left-sided thoracic nerve dysfunction and serratus anterior muscle weakness had been documented by his VA physical therapy provider. He asserted that an examiner told him that his chest pain symptoms were probably due to a nerve condition rather than a muscle condition, and that extra-schedular rating consideration was warranted. A December 2010 VA examination found no objective evidence of active costochondritis, but noted significant occupational effects apparently based upon the Veteran’s report that he avoided strenuous labor. A December 2011 VA treatment report noted the examiner explained that it was just as likely as not that chest pain and respiratory complaints are related to exposure or illness in service. An April 2017 private medical report noted the Veteran’s August 2013 statements and found that his functional loss due to costochondritis was a severe or moderately severe muscle injury. The Board finds that it is unclear if the service-connected disability at issue includes neurological symptom manifestations. Therefore, an additional VA examination is required for an adequate determination. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any residuals of a TBI. The examiner must opine whether any such residuals at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) whether any chronic neurological signs or symptoms developed as a result of Southwest Asia. The examiner must address the Veteran’s reported skull fracture at age five and whether any residuals of a TBI clearly and unmistakably (undebatable) preexisted the Veteran’s service. If the examiner finds it did clearly and unmistakably preexist service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected costochondritis. The examiner should provide a full description of the disability and report all signs and symptoms, including any manifest nerve and/or neurological symptoms, attributable to the service-connected disability. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the service-connected costochondritis disability alone and discuss the effect on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Douglas, Counsel