Citation Nr: 18157316 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 16-33 217 DATE: December 12, 2018 ORDER Entitlement to service connection for lumbar spine degenerative disc disease and facet arthritis is granted. Entitlement to service connection for right wrist carpal tunnel syndrome is granted. Entitlement to service connection for pseudofolliculitis barbae (PFB) is granted. Entitlement to service connection for left hip bursitis is granted. REMANDED Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a right ankle disability, to include as secondary to the service-connected left ankle fracture of distal fibula, is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his lumbar spine degenerative disc disease and facet arthritis is at least as likely as not related to the documented back injury incurred during a period of active duty for training in 2009. 2. Resolving reasonable doubt in the Veteran’s favor, his right wrist carpal tunnel syndrome is at least as likely as not related to the documented right wrist carpal tunnel syndrome incurred during a period of active duty for training in 2009. 3. Resolving reasonable doubt in the Veteran’s favor, his PFB began during active service. 4. Resolving reasonable doubt in the Veteran’s favor, his left hip bursitis began during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar spine degenerative disc disease and facet arthritis are met. 38 U.S.C. § 101; 38 C.F.R. § 3.6. 2. The criteria for service connection for right wrist carpal tunnel syndrome are met. 38 U.S.C. § 101; 38 C.F.R. § 3.6. 3. The criteria for service connection for PFB are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for left hip bursitis are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1985 to September 1993. He also served in the Texas Army National Guard. This matter is on appeal from an August 2012 rating decision. Service Connection Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A veteran may also be granted service connection for a disability from a disease or injury incurred in or aggravated in the line of duty during active duty for training, or from an injury incurred or aggravated in the line of duty during inactive duty training. See 38 U.S.C. §§ 101(24), 106, 1131; 38 C.F.R. §§ 3.6; Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Entitlement to service connection for lumbar spine degenerative disc disease and facet arthritis and right wrist carpal tunnel syndrome The Veteran contends that he has a lumbar spine and right wrist disability that began as a result of an injury incurred during his period of active duty for training in 2009 which has continued to worsen thereafter. The Board concludes that the Veteran has current diagnoses of lumbar spine degenerative disc disease and face arthritis and right wrist carpal tunnel syndrome that are related to the documented injury during his period of active duty for training in 2009. 38 U.S.C. § 101; 38 C.F.R. § 3.6. The April 2017 VA examination report shows the Veteran has current diagnoses of lumbar spine degenerative disc disease and facet arthropathy and right wrist carpal tunnel syndrome. Moreover, a Statement of Medical Examination and Duty Status dated September 2009 noted that the Veteran was stacking and moving boxes all day, when pain began to develop. As a result, he was placed on a physical profile for his back and right hand carpal tunnel. A subsequent Line of Duty Investigation report dated November 2009 indicated that the Veteran’s carpal tunnel syndrome and other and unspecified disc disorder of the lumbar region had been determined to be incurred in the line of duty. On examination in August 2011, the Veteran was diagnosed with degenerative disc disease of the lumbar spine at L4-5. He was also diagnosed with right carpal tunnel syndrome which was persistent and had progressed since 2009. On VA examination in December 2011, the Veteran was diagnosed with lumbar sprain with spasms and right ulnar neuropathy with carpal tunnel syndrome. As the result of a March 2012 Physical Evaluation Board, the Veteran was found physically unfit to continue military service due, in part, to his intervertebral disc syndrome. The Board acknowledges that the May 2016 and April 2017 VA examiners gave a negative nexus opinion for the Veteran’s lumbar spine degenerative disc disease. However, these examiners failed to address the 2009 line of duty injury resulting in a diagnosis of lumbar spine degenerative disc disease. The Board acknowledges that the April 2017 VA examiner gave a negative nexus opinion for the Veteran’s right wrist carpal tunnel syndrome. However, this examiner failed to address the 2009 line of duty injury resulting in a diagnosis of right wrist carpal tunnel syndrome. In light of the above evidence showing an injury incurred during the line of duty resulting in lumbar spine degenerative disc disease and facet arthritis and right wrist carpal tunnel syndrome, service connection is warranted. Entitlement to service connection for PFB The Veteran contends that his PFB began during his active duty service and continued thereafter. The Board concludes that the Veteran has a current diagnosis of PFB that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A December 2011 VA examination and subsequent VA treatment records show the Veteran has a current diagnosis of PFB, and a service treatment record dated in August 1990 shows an assessment of possible pseudofolliculitis. Moreover, the Veteran reported PFB on a July 2003 annual medical certificate and was placed on a shaving profile during his National Guard service as a result of his continued problems with PFB. The Veteran has competently and credibly testified that his PFB began during active duty service and continued thereafter. He indicated that he kept a beard to reduce the inflammation process. The Board acknowledges that the May 2016 VA examiner found that the Veteran’s PFB was less likely than not caused by the documented treatment for possible pseudofolliculitis during active duty service in August 1990. The examiner instead found that the Veteran’s current PFB was at least as likely as not caused by spontaneous recurrence. The examiner pointed to the lack of any immediate post-active duty medical record evidence to indicate treatment for PFB. However, as noted above, the Veteran reported PFB on a July 2003 annual medical certificate and was placed on an active shaving profile during his National Guard service. Therefore, resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s PFB began during active duty service and continued thereafter. Service connection for PFB is warranted. Entitlement to service connection for left hip bursitis The Veteran contends that his left hip disability began in 1993 during his active duty service and worsened around September 2011. The Board concludes that the Veteran has a current diagnosis of left hip bursitis that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A December 2011 VA examination shows the Veteran has a current diagnosis of left hip bursitis, and the December 2011 VA examiner opined that it was at least as likely as not that the Veteran’s left hip condition was caused and/or aggravated while on active duty service. The rationale was that the Veteran reported pain that started in 1993 while still on active duty. Moreover, a National Guard service treatment record dated in November 1994, shortly after the Veteran’s discharge from active duty service, noted a clinical history of increasing pain and stiffness of the left hip. The Veteran has competently and credibly testified that his left hip pain began during active duty service and worsened in September 2011. Therefore, resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s left hip bursitis began during active duty service and continued thereafter. Service connection for left hip bursitis is warranted. REASONS FOR REMAND The Board cannot make a fully-informed decision on the issues of entitlement to service connection for a right and/or left foot disability because no VA examiner has opined whether the Veteran has a current right and/or left disability related to his active duty service, to include his reports of overuse from working as a lab technician in a hospital, which involved being on his feet all day. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a right ankle disability because no VA examiner has opined whether the Veteran’s right ankle sprain is aggravated by his service-connected left ankle fracture of distal fibula. While on remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from September 2018 to the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any currently diagnosed right and/or left foot disability. The examiner must opine whether any currently diagnosed right/and or left foot disability is at least as likely as not related to an in-service injury, event, or disease, to include the Veteran’s reports of overuse from working as a lab technician in a hospital, which involved being on his feet all day The examiner should consider the prior diagnoses of bilateral plantar fasciitis (December 2011) and calcaneal spurs (February 2017). 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s right ankle sprain is at least as likely as not aggravated beyond its natural progression by the service-connected left ankle fracture of distal fibula. The examiner should consider the Veteran’s contentions that his service-connected left ankle disability resulted in gait changes and overuse of the right ankle. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs