Citation Nr: 18150193 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 17-06 049 DATE: November 14, 2018 REMANDED Entitlement to an initial compensable rating for tension headaches is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for diabetes mellitus type II, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for carpal tunnel syndrome of the left hand, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for carpal tunnel syndrome of the right hand, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for a low back disorder, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for varicose veins of the left leg, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for varicose veins of the right leg, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for pulmonary sarcoidosis, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for a left foot disorder, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for a right foot disorder, to include as secondary to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active duty service from July 1973 to December 1977. The Board acknowledges that in April 2018, the Veteran elected to participate in the Rapid Appeals Modernization Program (RAMP). However, as her claim was certified to the Board in February 2017, over one year prior to her RAMP election, the appeal will be processed in the current legacy system. Further, there is no prejudice to the Veteran as her appeal is being remanded for additional evidentiary development, which is discussed below. 1. Entitlement to an initial compensable rating for tension headaches is remanded. The Board notes that the Veteran’s most recent and pertinent VA headaches examination took place in April 2016. The examiner continued the diagnosis of tension headaches. Upon examination, the examiner determined that the Veteran does not suffer from characteristic prostrating attacks of headache pain. In July 2018, the Veteran and her representative indicated that the Veteran’s symptoms had worsened since her most recent and pertinent VA examination. See Green v. Derwinski, 1 Vet. App. 121 (1991) (VA has a duty to conduct a thorough and contemporaneous examination of the Veteran in an increased rating claim); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (a Veteran is entitled to a new examination after a two-year period between the last VA examination and the Veteran’s contention that the pertinent disability had increased in severity). Given the above contentions, a new VA examination is thereby warranted. 2. Entitlement to service connection for bilateral hearing loss is remanded. The Board observes that the Veteran’s DD-214 lists her military occupational specialty as a dental specialist. She contends that the loud, high-pitched noises from the dental equipment that she used eventually led to her current hearing problems. For the purpose of applying the laws administered by the VA, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000 or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores utilizing the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). The Veteran’s July 1973 entrance examination revealed the following results: Frequency 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Left 5 5 0 - 0 Right 5 5 10 - 5 The Veteran’s December 1977 separation examination revealed the following results: Frequency 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Left 15 15 10 10 10 Right 25 15 15 15 15 The Veteran’s service treatment records are otherwise silent as to any audiological problems. The Veteran received a VA audiological examination December 2013. Audiological testing revealed the following results: Frequency 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Left 10 15 15 15 20 Right 20 20 15 25 35 Additionally, Maryland CNC Speech Discrimination testing yielded scores of 100 percent, bilaterally. The VA examiner diagnosed the Veteran with right ear hearing loss (in the frequency range of 6000 Hz or higher frequencies) and normal left ear hearing. Thus, it does not appear that the Veteran suffers from hearing loss disability for VA purposes. See 38 C.F.R. § 3.385. Regardless, the examiner determined that the Veteran’s claimed hearing loss is less likely than not attributable to service. The examiner explained that post-service, the Veteran worked as a dental hygienist for 33 years, where she was essentially exposed to the same high-pitched dental noises that she experienced in-service. The examiner also reported that the Veteran’s hearing levels were normal during service. In a July 2018 Informal Hearing Presentation, the Veteran and her representative challenged the adequacy of the previous VA examination and opinion of record. Given the Veteran’s statements and the significant time period since the Veteran’s previous VA examination, the Board finds that a new VA audiological examination would be of considerable assistance in determining the claim. 3. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected disabilities is remanded. The Veteran contends that her left knee disorder is secondary to her service-connected right knee and right ankle disorders, respectively. She contends that she uses her left knee more often to compensate for weakness and loss of control in her right knee and ankle. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also 38 C.F.R. § 3.310(b) (2017). The Veteran’s service treatment records reveal that in May 1976, she was seen for complaints of left knee pain. At her separation examination, the Veteran complained of swollen or painful joints. The Board notes that the Veteran has received both VA and private orthopedic treatment for her left knee disorder, including injections to manage pain. The Veteran underwent a VA examination in April 2016, wherein she was diagnosed with bilateral meniscus tears, bilateral anterior cruciate ligament (ACL) tears, and bilateral degenerative arthritis. The examiner determined that the Veteran’s left knee disorder is less likely than not attributable to service. The examiner provided limited rationale and cited to medical studies pertaining to ACL injuries. An opinion as to secondary service connection was not provided. The Board further notes a June 2017 report from the Veteran’s private provider, Dr. S. Carr. The report suggests that the Veteran’s left knee disorder is related to her time in the military. As discussed previously, the Veteran and her representative have since challenged the adequacy of the April 2016 examination and report, and a theory of secondary service connection has also been raised. Given the above, a new VA examination would help shed considerable light on her claim. 4. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected disabilities is remanded. Similarly, the Veteran contends that her left ankle disorder is secondary to her service-connected right knee and right ankle disorders. The Board acknowledges that the Veteran received a VA ankle examination in August 2013. While the examiner diagnosed the Veteran with a right ankle strain, she was not diagnosed with a left ankle disorder. The Veteran was afforded a new VA ankle examination in April 2016. The examiner again diagnosed the Veteran with a right ankle strain, but she was not diagnosed with a left ankle disorder. The Board finds it unclear whether the Veteran suffers from a chronic left ankle disorder for VA rating purposes. Given this uncertainty, a VA examination would help resolve this issue. 5. Entitlement to service connection for diabetes mellitus type II, to include as secondary to service-connected disabilities is remanded. The Veteran has alleged that her diabetes mellitus type II is secondary to her service-connected disabilities. Specifically, it is argued that due to her injuries sustained in-service, she is unable to exercise and this has caused the development of her diabetes mellitus type II. The Board notes that the Veteran has received some private medical treatment, which includes a diagnosis of diabetes mellitus type II. It does not appear that the Veteran has ever received a VA diabetes mellitus examination. In light of the above, the Board finds that a VA examination would be particularly helpful in this instance. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 6. Entitlement to service connection for carpal tunnel syndrome of the left and/or right hand, to include as secondary to service-connected disabilities is remanded. Initially, the Board observes that the Veteran’s service records document treatment for pain in her right wrist, index finger, and middle finger with complaints of numbness that felt like pins and needles. A follow-up report showed tender extension and pain on flexion of the wrist and hand. The Board further observes that the Veteran’s post-service medical records include a diagnosis of carpal tunnel syndrome. It does not appear that the Veteran has ever been afforded a VA examination for her claimed bilateral carpal tunnel syndrome. Considering the above, a VA examination is warranted in this instance. 7. Entitlement to service connection for a low back disorder, to include as secondary to service-connected disabilities is remanded. The Veteran has stated that her duties as a dental specialist required her to constantly be on her feet, which ultimately led to the development of her low back disorder. She has also stated that her low back disorder is secondary to her service-connected disabilities. The Board notes that the Veteran has received both VA and private medical treatment for her low back disorder. A June 2017 report from Dr. S. Carr includes a diagnosis of degenerative joint disease of the low back. Dr. S. Carr also posited that the Veteran’s low back disorder is attributable to her military service. Under these circumstances, the Board finds that a VA examination would help clarify this matter. 8. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities is remanded. The Veteran has argued that her hypertension is secondary to her service-connected disabilities. Specifically, it is argued that due to her injuries sustained in-service, she in unable to exercise and this has caused the development of her hypertension. Alternatively, she contends that her hypertension onset during service and is due to the stress she experienced while in the military. The Board acknowledges that the Veteran’s private medical treatment records include a diagnosis of hypertension. It does not appear that the Veteran has ever received a VA examination for her claimed hypertension. As such, a VA examination is warranted in this instance. 9. Entitlement to service connection for varicose veins of the left and/or right leg, to include as secondary to service-connected disabilities is remanded. The Veteran contends that her varicose veins of the left and/or right leg are due to her always having to be on her feet, which caused her veins to break. She also has alleged that her varicose veins of both legs are secondary to her service-connected disabilities. Specifically, the Veteran claims that she uses braces on her knees, which compress the veins in her legs and causes them to burst. It does not appear that the Veteran has ever received a VA examination for her claimed left and/or right varicose veins. Further, the Board finds it unclear whether the Veteran suffers from varicose veins for VA rating purposes. Considering the above, a VA examination would clarify the matter. 10. Entitlement to service connection for pulmonary sarcoidosis, to include as secondary to service-connected disabilities is remanded. The Veteran contends that her pulmonary sarcoidosis is either due to her military service, and/or secondary to her service-connected disabilities. In this regard, she alleges that her pulmonary sarcoidosis was misdiagnosed in-service and the stress of her job as a dental specialist caused her condition to become more severe. She also claims that that due to her injuries sustained in-service, she is unable to exercise and this has caused the development of her pulmonary sarcoidosis. The Board acknowledges that the Veteran’s private medical records include a diagnosis of pulmonary sarcoidosis. It does not appear that the Veteran has ever received a VA examination for her claimed pulmonary sarcoidosis. As such, a VA examination is warranted in this instance. 11. Entitlement to service connection for a left and/or right foot disorder, to include as secondary to service-connected disabilities is remanded. To begin, the Board observes that the Veteran’s separation examination includes a notation for bilateral pes planus. The Veteran received a VA flatfoot examination in April 2013. The VA examiner determined that there is no objective evidence to support a diagnosis of pes planus. She also received a VA foot examination in April 2013, wherein she was diagnosed with bilateral ganglion cysts and joint space narrowing of the right foot. Essentially, the examiner determined that since there is no evidence of bilateral pes planus, it cannot be the cause of the Veteran’s ganglion cysts and right foot arthritis. No opinion as to secondary service connection was provided. Due to the limited rationale provided by the April 2013 VA examiner, the Board finds it to be inadequate for rating purposes at this time. Moreover, an opinion as to secondary service connection was not provided. Therefore, a new VA examination and opinion would help resolve these issues. Finally, as noted above, the Veteran has received both VA and private treatment for her assorted conditions. Her most recent VA treatment records are from approximately late 2017. Therefore, it would be prudent for all outstanding medical treatment records to be obtained.   These matters are REMANDED for the following actions: 1. With the assistance of the Veteran as necessary, identify and obtain any outstanding, relevant treatment records and associate them with the Veteran’s electronic claims file. If the Agency of Original Jurisdiction (AOJ) cannot locate or obtain such records, it must specifically document the attempts that were made to locate or obtain them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. All attempts to obtain records should be documented in the Veteran’s electronic claims file. 2. Then, after pertinent records are obtained, but whether or not records are obtained, schedule the Veteran for an appropriate examination to ascertain the current level and severity of her service-connected tension headaches using the most recent Disability Benefits Questionnaire (DBQ) form. The electronic claims file should be made available to the examiner for review. Any indicated diagnostic tests and studies should be performed and the results should be reported in detail. 3. Next, schedule the Veteran for a VA examination with an audiologist to determine the nature and etiology of the Veteran’s claimed hearing loss. The audiologist is to be provided access to the Veteran’s electronic claims file. The audiologist is requested to review all pertinent records associated with the claims file, the Veteran’s service treatment records, post-service medical records, and the Veteran’s own assertions. Any indicated diagnostic tests and studies should also be accomplished. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology and in-service noise exposure. If there is a medical basis to support or doubt the history provided by the Veteran, the audiologist should provide a fully reasoned explanation. The VA audiologist must opine whether it is at least as likely as not (50 percent or higher degree of probability) that any hearing loss manifested in-service or is otherwise causally or etiologically related to military service, to include potential in-service noise exposure. The significance, if any between recorded findings on entrance and separation should be discussed, even though the hearing was essentially normal at separation. It should be indicated whether the recorded change suggests the early onset of hearing loss. It should also be indicated whether any hearing loss found is the type typically seen in cases of acoustic trauma, or is more likely due to advancing age, infection, or other cause. All prior reports should be reconciled, as necessary. *In the directives below, examinations are requested regarding claims for service connection. These examinations may be conducted by a single qualified examiner if otherwise indicated, as long as complete responses are recorded. That separate paragraphs are used need not be taken to mean that separate examinations need to be conducted.* 4. Then, schedule the Veteran for VA examinations with examiners of appropriate expertise in order to determine the nature and etiology of the Veteran’s claimed left knee disorder, left ankle disorder, diabetes mellitus type II, bilateral carpal tunnel syndrome, low back disorder, hypertension, varicose veins of the left and/or right leg, pulmonary sarcoidosis, and bilateral foot disorder. The examiners are to be provided access to the Veteran’s electronic claims file. They are requested to review all pertinent records associated with the claims file, the Veteran’s service treatment records, post-service medical records, and the Veteran’s own assertions. Any indicated diagnostic tests and studies should also be accomplished. It should be noted that the Veteran is competent to attest to factual matters of which she had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiners should provide a fully reasoned explanation. (a) The VA appropriate VA examiner must opine whether it is at least as likely as not (50 percent or higher degree of probability) that the Veteran’s claimed left knee disorder, left ankle disorder, diabetes mellitus type II, bilateral carpal tunnel syndrome, low back disorder, hypertension, varicose veins of the left and/or right leg, pulmonary sarcoidosis, and bilateral foot disorder manifested in-service or is otherwise causally or etiologically related to her military service. (b) If not directly related to service, the appropriate VA examiner should offer an opinion as to whether it is at least as likely as not (50 percent or higher degree of probability) that the Veteran’s claimed left knee disorder, left ankle disorder, diabetes mellitus type II, bilateral carpal tunnel syndrome, low back disorder, hypertension, varicose veins of the left and/or right leg, pulmonary sarcoidosis, and bilateral foot disorder is caused by her service-connected disabilities. (c) That examiner should then opine whether the claimed left knee disorder, left ankle disorder, diabetes mellitus type II, bilateral carpal tunnel syndrome, low back disorder, hypertension, varicose veins of the left and/or right leg, pulmonary sarcoidosis, and bilateral foot disorder is aggravated (i.e., permanently worsened beyond the normal progression of that disease) by her service-connected disabilities. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. All prior reports (including the June 2017 report from Dr. S. Carr) should be addressed and/or reconciled, as necessary.   5. After the development requested has been completed, the AOJ should review any report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Miller, Associate Counsel