Citation Nr: 18158872 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-58 683 DATE: December 18, 2018 REMANDED The issue of entitlement to service connection for muscle pain is remanded. The issue of entitlement to service connection for shin splints, left leg, is remanded. The issue of entitlement to service connection for shin splints, right leg, is remanded. The issue of entitlement to service connection for right shoulder condition is remanded. The issue of entitlement to service connection for left wrist condition is remanded. The issue of entitlement to service connection for right wrist condition is remanded. The issue of entitlement to service connection for a finger condition is remanded. The issue of entitlement to service connection for low back condition is remanded. The issue of entitlement to service connection for neck condition is remanded. The issue of entitlement to service connection for left knee condition is remanded. The issue of entitlement to service connection for right knee condition is remanded. The issue of entitlement to service connection for left leg condition is remanded. The issue of entitlement to service connection for left ankle condition is remanded. The issue of entitlement to service connection for a cardiac condition, with reported symptoms of chest pain, is remanded. The issue of entitlement to service connection for athlete’s foot, left foot, is remanded. The issue of entitlement to service connection for athlete’s foot, right foot, is remanded. The issue of entitlement to service connection for headaches is remanded. The issue of entitlement to service connection for joint pain is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2010 to February 2014. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Military personnel records listed the Veteran’s miliary occupational specialty as infantryman. The Veteran was awarded the combat infantryman badge and parachutist badge. The Veteran submitted correspondence describing the signs and symptoms associated with each condition and averring the basis of entitlement to service connection for each condition. See October 2015 notice of disagreement and November 2016 substantive appeal. Generally, the Veteran contends that he developed several musculoskeletal conditions as a consequence of the unique physical strain associated with duties as an infantry airman, including a low back condition, neck condition, shin splints, a bilateral knee condition, unspecified muscle pain, and unspecified joint pain. In the October 2015 notice of disagreement, the Veteran stated that he developed headaches as a result of mortars exploding in his proximity. Additionally, the Veteran noted that he was “supposed to be scanned for a TBI assessment as well.” Regarding his bilateral wrist and finger conditions, the Veteran described chronic finger pain and chronic symptoms, to include popping and locking, in his wrist joints. The Veteran attributed his finger and wrist conditions to service. In the November 2016 substantive appeal, the Veteran stated that his left leg is “mostly due to shin splints.” Regarding his chest pain, the Veteran alleged that this condition relates to posttraumatic stress disorder. As to his right shoulder claim, the Veteran referred to in service treatment for a right should condition and reported chronic right shoulder pain. While further delay is regrettable, the Veteran should be afforded new VA examinations associated with each of his service connection claims on remand. 1. Service Connection for Right Shoulder The Veteran was afforded a VA right shoulder examination in October 2015. Range of motion tests revealed limitation of flexion, abduction, and rotation. The examination report did not document a diagnosis for the right shoulder condition. Further, in opining the likely etiology of the shoulder condition, the examiner concluded that the condition was less likely than not incurred or caused by the claimed-service, event, or illness. The examiner did not support his conclusion with a rationale or explanation. As such, the examination is inadequate and the Veteran should be afforded a new medical examination. Stefl v. Nicholson, 21 Vet. App. 120 (2007).   2. Service Connection for Low Back The Veteran was afforded a VA spinal examination in October 2015. The examination report did not document a diagnosis for the low back condition. The examiner stated that “there is no pathology to render a diagnosis.” Further, in opining as to the likely etiology of the low back condition, the examiner concluded that the condition was less likely than not incurred or caused by the claimed-service, event, or illness. The examiner did not support his conclusion with a rationale or explanation. See id. Here, although a formal diagnosis of a low back condition was not made, the Veteran asserts that he experiences functional impairment associated with low back condition. If that impairment is associated with an in-service event, service connection may be warranted. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (holding that pain resulting in functional impairment constitutes a disability as contemplated in 38 U.S.C. § 1110, even in the absence of a presently-diagnosed condition). Because the October 2015 examination did not address this question, it is inadequate, and remand for an additional examination and opinion is required. 3. Service Connection for Left Ankle The Veteran was afforded a VA ankle examination in October 2015. The examination report did not document a diagnosis for the left ankle condition. The Veteran reported that his ankle flares up, resulting in “swelling, hurting, and harder to move.” Further, offering an etiological opinion, the examiner concluded that the condition was less likely than not incurred or caused by the claimed-service, event, or illness. The examiner did not support his conclusion with a rationale or explanation. See Stefl, 21 Vet. App. 120. Here, although a formal diagnosis of a left ankle condition was not made, the Veteran asserts that he experiences functional impairment associated with the left ankle. If that impairment is associated with an in-service event, service connection may be warranted. See Saunders, 886 F.3d at 1361. Because the October 2015 examination did not address this question, it is inadequate, and remand for an additional examination and opinion is required. 4. Service Connection for Neck Condition The Veteran was afforded a VA spinal examination in October 2015. Range of motion tests revealed limitation of extension, right lateral rotation, and left lateral rotation. The examination report neither documented a diagnosis of the neck condition nor included an etiological opinion. Here, although a formal diagnosis of a neck condition was not made, the Veteran asserts that he experiences functional impairment associated with his neck. If that impairment is associated with an in-service event, service connection may be warranted. Id. Because the October 2015 examination did not address this question, it is inadequate, and remand for an additional examination and opinion is required. 5. Service Connection for Headaches, Cardiac Condition, Right Shin Condition, and Left Shin Condition In October 2015, the Veteran was afforded a VA headaches examination, VA heart condition examination, and VA knee and lower leg examination. In each VA examination report, the VA examiner verified a medical diagnosis: migraines for the headache claim, incomplete right bundle branch block for the heart condition claim, and bilateral shin splints for the shin condition claim. However, the VA examiner did not offer an etiological opinion for the claimed conditions. As such, a remand is warranted to obtain VA medical opinions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 6. Service Connection for Bilateral Athlete’s Foot VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); 38 C.F.R. § 3.159(a)(2). The first element of McLendon is met. Specifically, the October 2015 notice of disagreement competently stated that the veteran developed athlete’s foot in service as a result of his occupational duties. See Layno, 6 Vet. App. at 470. The second and third elements of McLendon are met as well. The Veteran asserted in the November 2016 substantive appeal that his athlete’s foot has been a chronic condition. In light of the foregoing, the Board finds that the low threshold of the McLendon standard has been met in this instance and that the Veteran should be afforded VA examination to determine whether a causal relationship exists between service and any of his current conditions. McLendon, 20 Vet. App. at 81. Additionally, updated VA treatment records should also be requested. In the November 2016 substantive appeal, the Veteran reported that several VA medical professionals have treated his foot condition, but his symptoms have not lessened. However, review of VA treatment records does not reveal documented treatment for a foot condition. 38 U.S.C. § 5103A(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). As such, the RO should attempt to obtain any relevant treatment records on remand. 7. Service Connection for Left Knee Condition, Right Knee Condition, Right Wrist Condition, Left Wrist Condition, and Finger Condition The Veteran was afforded a VA examination in October 2015 for each of the claimed conditions: bilateral knees, bilateral wrists, and a finger condition. The examination reports did not document diagnoses of the conditions nor include an etiological opinion. Here, although formal diagnoses were not made, the Veteran asserts that he experiences functional impairment associated with his bilateral knees, bilateral wrists, and finger condition. See e.g. October 2015 NOD. If the impairments are associated with an in-service event, service connection may be warranted. Saunders, 886 F.3d at 1361. Because the October 2015 examinations did not address this question, they are inadequate, and remand for additional examinations and opinion are required.   8. Service Connection for Muscle Pain, Joint Pain, and Left Leg Condition As the Veteran’s pending claims may affect the outcome of the claims of entitlement service connection for muscle pain, joint pain, and left leg condition, a final decision to those issues would, at this point, be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). Thus, these claims are also being remanded. The matters are REMANDED for the following action: 1. Update the claims file with any relevant VA treatment records for the period from May 2015 to the Present. 2. After item (1) has been completed, to the extent possible, schedule the Veteran for a spinal examination with an appropriate clinician to determine the nature and etiology of his low back and neck condition. (a.) Please identify by medical diagnosis the Veteran’s neck and low back conditions, if any. If a diagnosis cannot be made, please describe the nature and degree of functional impairment associated with the reported neck and low back pain. The examiner should describe the nature and extent of the Veteran’s neck and low back conditions and symptoms. To the extent possible, the examiner should distinguish symptoms due to other service-connected disabilities. If this is not possible, the examiner should identify all symptoms that overlap. (b.) For each diagnosis and/or functional impairment, the examiner should state whether it is at least as likely as not that the neck or low back conditions were incurred in or caused by an in-service event or injury. The exam should specifically comment on the Veteran’s contention that his neck and low disability is due to or a result of his military occupational specialty: infantry airman. (c.) If the Veteran is diagnosed with arthritis, please indicate whether it is at least as likely as not (50 percent probability or more) that the arthritis disability was present within one year after separation of service. (d.) If the Veteran is diagnosed with arthritis, please indicate the level of severity of the disability at the time of its onset. (e.) Additionally, the clinician should provide a complete rationale for the requested opinions. If the clinician cannot provide an opinion without resorting to speculation, he or she should expressly indicate that and provide a supporting rationale as to why that is so. 3. After item (1) has been completed, to the extent possible, schedule the Veteran for a joints examination with an appropriate clinician to determine the nature and etiology of his right shoulder condition, left ankle condition, joint pain, right knee condition, left knee condition, left leg condition, muscle pain, right wrist condition, left wrist condition, and finger condition. (a.) Please identify by medical diagnosis the Veteran’s right shoulder condition, ankle condition, joint pain, right knee condition, left leg condition, muscle pain, right wrist condition, left wrist condition, and finger conditions, if any. If a diagnosis cannot be made, please describe the nature and degree of functional impairment associated with the reported right shoulder condition ankle pain, joint pain, bilateral knee pain, left leg pain, muscle pain, bilateral wrist pain, and finger pain. (b.) The examiner should describe the nature and extent of the Veteran’s conditions and symptoms. To the extent possible, the examiner should distinguish symptoms due to other service-connected disabilities, and other claimed conditions. The examiner should differentiate and clarify, to the extent possible, the Veteran’s reports of muscle pain, left leg pain, and joint pain. If this is not possible, the examiner should identify all symptoms that overlap. (c.) For each diagnosis and/or functional impairment, the examiner should state whether it is at least as likely as not that the conditions were incurred in or caused by an in-service event or injury. (d.) The exam should specifically comment on the Veteran’s contention that his disabilities are due to or a result of his military occupational specialty: infantry airman. (e.) If the Veteran is diagnosed with arthritis, please indicate whether it is at least as likely as not (50 percent probability or more) that the arthritis disability was present within one year after separation of service. (f.) If the Veteran is diagnosed with arthritis, please indicate the level of severity of the disability at the time of its onset. (g.) Additionally, the clinician should provide a complete rationale for the requested opinions. If the clinician cannot provide an opinion without resorting to speculation, he or she should expressly indicate that and provide a supporting rationale as to why that is so. 4. After item (1) has been completed, to the extent possible, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of his athlete’s foot condition. (a.) Please identify by medical diagnosis the Veteran’s athlete’s foot conditions, if any. If a diagnosis cannot be made, please describe the nature and degree of functional impairment associated with the reported athlete’s foot. (b.) For each diagnosis and/or functional impairment, the examiner should state whether it is at least as likely as not that the athlete’s foot conditions were incurred in or caused by an in-service event or injury. (c.) Additionally, the clinician should provide a complete rationale for the requested opinions. If the clinician cannot provide an opinion without resorting to speculation, he or she should expressly indicate that and provide a supporting rationale as to why that is so. 5. After item (1) has been completed, to the extent possible, send the Veteran’s claims file to an appropriate VA clinician to issue a medical opinion as to the nature and etiology of the Veteran’s headaches. The entire claims file, including a copy of this Remand, must be made available to and must be reviewed by the clinician. If the clinician determines that an examination should be conducted, one should be scheduled. Thereafter, the clinician should address the following: (a.) Please identify any current headache disabilities by medical diagnosis. (b.) For each disability identified in part (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was caused by, arose in, or is otherwise related to service. The examiner should specifically the Veteran’s contention that his headaches are a result of a mortar explosion in service. (c.) In offering the requested opinion, the clinician must consider medical and lay evidence dated both prior to and since the filing of the claim (May 2015). (d.) Additionally, the clinician should provide a complete rationale for the requested opinions. If the clinician cannot provide an opinion without resorting to speculation, he or she should expressly indicate that and provide a supporting rationale as to why that is so. 6. After item (1) has been completed, to the extent possible, send the Veteran’s claims file to an appropriate VA clinician to issue a medical opinion as to the nature and etiology of the Veteran’s cardiac condition. The entire claims file, including a copy of this Remand, must be made available to and must be reviewed by the clinician. If the clinician determines that an examination should be conducted, one should be scheduled. Thereafter, the clinician should address the following: (a.) Please identify any current cardiac condition by medical diagnosis. (b.) For each disability identified in part (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was caused by, arose in, or is otherwise related to service. (c.) In offering the requested opinion, the clinician must consider medical and lay evidence dated both prior to and since the filing of the claim (May 2015). (d.) Additionally, the clinician should provide a complete rationale for the requested opinions. If the clinician cannot provide an opinion without resorting to speculation, he or she should expressly indicate that and provide a supporting rationale as to why that is so. 7. Send the Veteran’s claims file to an appropriate VA clinician to issue a medical opinion as to the nature and etiology of the Veteran’s bilateral shin disability. The entire claims file, including a copy of this Remand, must be made available to and must be reviewed by the clinician. If the clinician determines that an examination should be conducted, one should be scheduled. Thereafter, the clinician should address the following: (a.) Please identify any current bilateral shin disabilities by medical diagnosis. (b.) For each disability identified in part (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was caused by, arose in, or is otherwise related to service. (c.) In offering the requested opinion, the clinician must consider medical and lay evidence dated both prior to and since the filing of the claim (May 2015). (d.) Additionally, the clinician should provide a complete rationale for the requested opinions. If the clinician cannot provide an opinion without resorting to speculation, he or she should expressly indicate that and provide a supporting rationale as to why that is so. 8. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence in this case, or a lack of knowledge among the medical community at large, and not the insufficient knowledge of the individual examiner). 9. If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner’s lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. (Continued on next page) S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD I. Altendorfer, Associate Counsel