Citation Nr: 18156563 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-43 726 DATE: December 11, 2018 REMANDED Entitlement to service connection for a spine disability, to include degenerative disc disease, is remanded. Entitlement to service connection for a left leg disability, to include loss of muscle control as secondary to the claimed spine disability, is remanded. Entitlement to service connection for residuals of a left ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from September 1975 to September 1979. The Veteran originally filed two claims of service connection for left leg disabilities in May 2013, one for loss of muscle control secondary to his back disability, and one for residuals of a left leg fracture. The claim of service connection for residuals of a broken left leg have been denied thus far in part because the Regional Office found that service treatment records show no evidence of a broken left leg during active service. Instead, his service treatment records reflect that the Veteran reported twisting his ankle in sand on a basketball court on April 30, 1976. X-rays were negative for fracture. However, as there was still discomfort when twisting side to side, the ankle was casted for one week on May 3, 1976 as documented in the Veteran’s service treatment records. The Veteran’s Notice of Disagreement (NOD) in this appeal references casting of the left leg. Although the history of casting as reported by the Veteran differs slightly, the Veteran’s statement in his NOD may refer to the May 1976 casting of the left ankle as documented in the service treatment records. The Court of Appeals for Veterans Claims has held that when a Veteran makes a claim for a specific disability or condition, he is seeking service connection for the symptoms presented by that condition, not merely the specific diagnosis or label used. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Additionally, although the Veteran does not have the specialized medical training, knowledge or skills to distinguish between a broken bone, or a fracture and a sprain, he is competent and credible in describing his own experience of wearing a cast on his leg during service. As such, the Board interprets the Veteran’s claim of service connection broadly as not merely residuals of left leg “fracture” or broken left leg, but also including any residual of the in-service event in April 1976 that precipitated his requiring a left lower extremity cast. For this reason, the issue of service connection herein is changed from entitlement to service connection for residuals of a broken left leg, to entitlement to service connection for residuals of a left ankle disability. The matter of a left leg disability, as opposed to the ankle, is already contemplated by the existing service connection claim. In this regard, the Veteran is given the broadest possible interpretation of his claim and consideration is given to both the left ankle and the left leg, as components of the left lower extremity claimed. 1. Entitlement to service connection for a back disability, to include degenerative disc disease, is remanded. The Veteran asserts two near-simultaneous back injuries occurring one day apart. VA Form 9 , September 2016. First, he reports he was thrown against a counter and a refrigerator during a violent assault in May 1976. This history is credible as the individual named by the Veteran as the perpetrator of the attack was later convicted by court-martial for a similar assault and was dishonorably discharged for his crimes. The Board finds the in-service event of being thrown against a counter and a refrigerator to be credible. Second, on the following day, the Veteran reports an earthquake struck his airbase at Aviano, Italy, and he was injured when rapidly trying to remove tanks from planes that needed to make an emergency departure from the base. He describes feeling a tearing sensation and pain in his back, and lying on the ground for 15 minutes without being able to get up, but that he could not seek medical attention because the medical facility was overrun with injured locals. The Board takes judicial notice that the Friuli earthquake occurred in this area of Italy on May 6, 1976. However, the Veteran’s service treatment records appear to indicate he was stationed in the Netherlands at the time, rather than in Italy. A detailed history should be taken from the Veteran if needed to establish the second of these two in-service events. The Veteran’s recent medical records document lumbar anterolisthesis with disc space narrowing and “failed back syndrome.” See, e.g., Social Security Administration records; VA treatment records, June 2017. On this basis, there is evidence of a current back disability. Where there is competent evidence of a current disability or persistent or recurrent symptoms of a disability, evidence establishing that an event, injury, or disease occurred in service, and an indication that the disability or persistent symptoms of a disability may be associated with service or another service-connected disability, but there is insufficient competent medical evidence to decide the claim, the Veteran must be afforded a VA examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for a left leg disability, to include loss of muscle control as secondary to the claimed back disability, is remanded. 3. Entitlement to service connection for residuals of a left ankle disability is remanded. On both of the left lower extremity issues above, including the left leg and ankle, there is evidence of an in-service event, as reported in the service treatment records based upon the casting occurring in May 1976. The Veteran also asserts that his left leg disability is secondary to his back disability. The claim is therefore intertwined with that remanded above, and adjudication must be deferred until entitlement to service connection for a spine disability is resolved or the claims may be adjudicated together. As above, there is evidence of persistent symptoms of left lower extremity disability during the appeals period, and evidence of an event involving the left lower extremity during service, with some indication of a claimed association between the two, but without sufficient competent medical evidence to decide the claim. In such instance, a medical examination should be afforded the Veteran. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the nature and etiology of any diagnosed spine disability. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s credible report of the assault in May 1976, or the alleged airfield injury when removing tanks from aircraft on the following day. If arthritis is diagnosed, opine whether it at least as likely as not (1) began during active service, (2) manifested within 1 year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 2. Schedule the Veteran for an examination to determine the nature and etiology of any diagnosed left leg or ankle disability. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the sprain injury requiring casting in May 1976. The examiner must also opine whether any currently diagnosed left lower extremity disability is at least as likely as not (1) proximately due to the Veteran’s spine disability, or (2) aggravated beyond its natural progression by the Veteran’s spine disability. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. McDonald