Citation Nr: 18159384 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 15-32 752 DATE: December 19, 2018 ORDER Entitlement to service connection for a foot disorder, claimed as corns (hyperkeratosis, clavus) is denied. REMANDED Entitlement to service connection for chest pain is remanded. Entitlement to service connection for Lyme disease is remanded. Entitlement to service connection for hair loss is remanded. Entitlement to service connection for Bell’s palsy is remanded. FINDING OF FACT The Veteran is not shown to have a current foot disorder. CONCLUSION OF LAW Service connection for a foot disorder not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 2001 to December 2001, March 2003 to May 2004, and April 2006 to February 2008. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2013 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In May 2014, Veteran submitted a notice of disagreement (NOD) in May 2014. In June 2015, VA issued a statement of the case (SOC). The Veteran did not file a Form 9. In July 2015, The Veteran provided a statement indicating she disagreed with the SOC. The appeal was then certified to the Board in October 2015. The Veteran was notified her appeal was certified to the Board in November 2015. Although the Veteran did not provide a Form 9 to perfect her appeal, based on the documents of record and in an effort to afford the Veteran all due process, the Board finds that the appeals have been perfected and will proceed to adjudicate the claims. See Percy v. Shinseki, 23 Vet. App. 37, 42 (2009). In characterizing the issue of a foot condition on appeal, the Board recognizes that when a claimant makes a claim, she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the medical evidence of record indicates that in the past, the Veteran reported a history of a hammer toe, the issue of entitlement to service connection for corns has been expanded as noted on the title page of this decision consistent with Clemons. Entitlement to service connection for a foot disorder The Veteran contends that her foot disorder characterized as corns are related to service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a foot disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s service treatment records do not indicate any complaint, treatment or diagnosis of a foot disability in-service. The Veteran did not provide any lay statement, other than her claim for service connection for corns, that she had a foot disability. The only indication that the Veteran has a current foot disability is a VA treatment note in July 2011 that note the Veteran had a surgical history of a hammer toe repair and a December 2011 note that the Veteran had a surgical history of foot surgery in 2009. However, the Veteran’s post-service treatment records do not note any current disability or symptoms related to her foot surgery or hammer toe repair. As there is no evidence of a current foot disability diagnosed or any indicated symptom that would cause functional impairment of earning capacity the appeal must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). REASONS FOR REMAND 1. Entitlement service connection for chest pain is remanded. The Veteran contends that her chest pain is related to service. The Veteran’s service treatment records note that the Veteran complained of chest pain in-service in April 2006. In September 2009, post-service treatment records note that the Veteran was diagnosed with costochondritis. The Board cannot make a fully-informed decision on the issue of service connection for chest because no VA examiner has opined whether the Veteran’s chest pain is related to service. Therefore, upon remand a VA examination must be provided to determine whether the Veteran’s chest pain is etiologically related to service. Further, the Board notes that the Veteran underwent a Gulf War General Medical Examination in June 2014. However, the examiner did not provide an opinion concerning the Veteran’s chest pain. Therefore, upon examination the examiner should opine as to whether the Veteran’s chest pain is an undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness based on service during the Gulf War. See 38 C.F.R. § 3.317. 2. Entitlement to service connection for Lyme disease and Bell’s palsy is remanded. The Veteran contends that her Lyme disease and Bell’s palsy are related to service. The Veteran underwent a VA examination in June 2014. The examiner opined that the Veteran’s Bell’s palsy was at least as likely as not incurred in or caused by the claimed in-service injury or event. The examiner also opined that the Veteran did not have any current residuals from the Bell’s palsy. The Board finds that another VA examination is required. The June 2014 examination report noted that the Veteran complained of symptoms of right face tightness and twitching. However, the examiner opined that the Veteran did not have any current residuals. Therefore, the examiner must address the Veteran’s lay statements of symptoms related to Bell’s palsy. An opinion must also be obtained concerning whether the Veteran had any residuals of Bell’s palsy during the appellate period, since September 2010. Finally, while the June 2014 examiner discussed the Veteran’s Lyme disease concerning the Veteran’s Bell’s palsy opinion, he did not provide an opinion as to the etiology or residuals of any Lyme disease. Therefore, upon examination, the examiner should provide an opinion as to whether the Veteran has any current residuals of Lyme disease and whether they etiologically related to service. 3. Entitlement to service connection for hair loss is remanded. The Veteran contends that her hair loss is related to service. The Veteran is currently service-connected for acne. A July 2008 VA dermatology treatment record notes that the Veteran’s hair loss may have been a side effect of the Veteran’s prescribed acne medication. Therefore, an examination is required to determine whether the Veteran’s hair loss is caused or aggravated by the Veteran’s service-connected acne. Further, the Board notes that the Veteran underwent a Gulf War General Medical Examination in June 2014. However, the examiner did not provide an opinion concerning the Veteran’s hair loss. Therefore, upon examination the examiner should opine as to whether the Veteran’s hair loss is an undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness pursuant to 38 C.F.R. § 3.317. The matters are REMANDED for the following action: 1. Obtain any relevant updated VA treatment records. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any chest pain. The examiner must opine as to the following: (a.) The examiner must opine whether the Veteran’s chest pain is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s diagnosis of costochondritis. (b.) If the examiner determines that the Veteran’s complaints of chest pain cannot be attributed to a known diagnosis, is it at least as likely as not that any of the symptoms constitute an undiagnosed illness that is associated with the Veteran’s Gulf War service. (c.) A full and complete rationale must be provided for all expressed opinions. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any Bell’s palsy and/or Lyme disease. The examiner must opine as to the following: (a.) Whether the Veteran had any residuals of Bell’s palsy from September 2011 to the present. The examiner should address the Veteran’s reports of tightness and twitching in her right cheek. (b.) Whether the Veteran has any current residuals of Lyme disease. (c.) If the Veteran has residuals of Lyme disease then, whether Veteran’s residuals of Lyme are at least as likely as not the disease are related to an in-service injury, event, or disease. (d.) A full and complete rationale must be provided for all expressed opinions. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hair loss. The examiner must opine as to the following: (a.) Whether the Veteran’s hair loss least is as likely as not related to an in-service injury, event, or disease. (b.) If the examiner determines that the Veteran’s hair loss cannot be attributed to a known diagnosis, is it at least as likely as not that the symptom constitutes an undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness that is associated with the Veteran’s Gulf War service. (c.) Whether the Veteran’s hair loss is at least as likely as not proximately due to her service-connected acne, or alternatively, aggravated beyond its natural progression by her service-connected acne. The examiner must address the July 2008 VA dermatology treatment note that indicated her acne medicine may have caused her hair loss.   (d.) A full and complete rationale must be provided for all expressed opinions. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Robert Batten, Associate Counsel