Citation Nr: 18148631 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 10-34 211 DATE: November 7, 2018 ORDER Entitlement to service connection for hypertension is granted. REMANDED Entitlement to a rating greater than 10 percent disabling for residuals of shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh is remanded. Entitlement to a total disability based on individual unemployability (TDIU), to include on an extra-schedular basis, is remanded. FINDING OF FACT The Veteran’s hypertension is aggravated by his service-connected posttraumatic stress disorder (PTSD).   CONCLUSION OF LAW The criteria for service connection for hypertension have been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that his hypertension is caused or aggravated by his service-connected PTSD. In general, service connection will be granted for a current disability that resulted from an injury or disease incurred in or aggravated by active military service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2017). Establishing service connection generally requires (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted on a secondary basis for disability which is proximately due to, or the result of, a service-connected disease or injury. See 38 C.F.R. § 3.310 (a) (2017). Secondary service connection generally requires (1) a current disability; (2) a service-connected disability; and (3) a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509 (1998). Any increase in severity of a nonservice-connected disease or injury that is proximately due to, or the result of, a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. See 38 C.F.R. § 3.310 (b) (2017). The record contains several diagnoses of hypertension, thus satisfying the first Wallin element. See, e.g., June 2014 VA examination. The Veteran is also service connected for PTSD, satisfying the second Wallin element. With respect to the third Wallin element, the record includes an opinion from Dr. C.T. that indicates that the Veteran’s hypertension is made worse by his PTSD symptoms. The Board finds this opinion highly probative and, as such, service connection for hypertension is granted on a secondary basis based on aggravation of hypertension by the Veteran’s service-connected PTSD. REASONS FOR REMAND 1. Entitlement to a rating greater than 10 percent disabling for residuals of shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh is remanded. The Board regrets the additional delay, but for reasons explained below, finds that further evidentiary development is necessary and remands the case to ensure compliance with the Board’s prior remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran contends that he should be granted a rating greater than 10 percent for his service-connected shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh. The Veteran has complained of testicular pain, to include neuralgia and has been diagnosed with genitofemoral nerve neuralgia. Pursuant to its January 2016 remand, the Board instructed the agency of original jurisdiction (AOJ) to schedule the Veteran for a VA examination to assess the severity and symptomatology of his service-connected shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh, to include neurological testing, and range of motion testing for the hips. The Veteran was afforded a VA examination in August 2017. The examiner performed an assessment of the Veteran’s scars, muscle injuries, hips and thighs. The examiner did not perform an assessment regarding the Veteran’s genitofemoral nerve neuralgia. As such, a new examination is warranted to address the Veteran’s neurological symptoms related to his shell fragment wounds, to include genitofemoral nerve neuralgia. Stegall v. West, 11 Vet. App. 268, 271 (1998). Further, the August 2017 VA examiner provided conflicting opinions regarding the etiology of the Veteran’s degenerative arthritis of the bilateral hips, as well as the current severity of the Veteran’s painful scars. On the hips and thigh disability benefits questionnaire (DBQ), the examiner opined that the Veteran’s arthritis can only be attributed to his antalgic gait as a result of the shrapnel wound which caused additional stress and inflammation in his hips. See August 2017 VA examination. The examiner also opined that the Veteran’s left hip arthritis is not caused by shell fragments but is more likely related to age. The examiner also opined that the Veteran’s arthritis was not aggravated beyond natural progression but that there is insufficient information to provide clear answer without speculation. He stated that the veteran developed multiple joint arthritis which can be attributed to the normal aging process and not the direct result of Veteran’s injuries. However, the examiner noted the Veteran claims that he had an awkward gait secondary to his original injuries, which the examiner opined could cause significant inflammatory changes. Regarding the Veteran’s scars, the examiner noted that the Veteran has two painful scars and minimal left thigh pain, which has become worse over the years. However, later in the report, the examiner stated that the Veteran’s scars were not painful to palpitation and do not adhere to the underlying tissue, so should not be a cause of pain. Given the conflicting opinions of the July 2017 VA examiner, the Board finds that this appeal must be remanded to obtain an adequate medical opinion to determine the etiology of the Veteran’s hip arthritis and to determine the severity of the Veteran’s painful scars. 2. Entitlement to TDIU, to include on an extra-schedular basis is remanded. The issues of an increased rating for residuals of shell fragment wounds and TDIU are inextricably intertwined and therefore must be addressed together. Harris v. Derwinski, 1 Vet. App. 180 (1991). For this reason, the issue of TDIU must also be remanded. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the full range of symptomatology associated with the Veteran’s service-connected shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh, to include genitofemoral nerve neuralgia, painful scars, and bilateral hip degenerative arthritis. The claims file, including a copy of this remand, must be made available to the examiner. The examiner should provide the following opinions: Whether it is at least as likely as not (50 percent greater probability) that the Veteran has a neurological condition, to include genitofemoral nerve neuralgia, that is caused OR aggravated by his service-connected shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh. Whether it is at least as likely as not (50 percent greater probability) that the Veteran’s bilateral hip degenerative arthritis is caused OR aggravated by the Veteran’s service-connected shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh. The examiner should opine as to whether the Veteran has had an antalgic gait at any time during the appeal period and whether it is at least as likely as not (50 percent greater probability) that the Veteran’s antalgic gait is caused OR aggravated by the Veteran’s service-connected shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh. If the Veteran’s gait is related to his service-connected shell fragment wounds of the skin of the penis, left scrotum, and left upper inner thigh with small retained foreign body in the thigh, is it at least as likely as not (50 percent greater probability) that the Veteran’s gait caused OR aggravated the Veteran’s bilateral hip degenerative arthritis. The examiner should note the Veteran is NOT service connected for any right scrotal/testicular condition and those symptoms should not be included in the discussion. (Continued on the next page)   2. After the above development has been completed, readjudicate the claim. If the benefit sought remains denied, provide the Veteran a supplemental statement of the case, and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Brandt