Citation Nr: 18160993 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 17-28 258 DATE: December 28, 2018 ORDER Entitlement to a 10 percent initial rating for left heel spur is granted. Entitlement to a 10 percent initial rating for early Dupuytren's contracture is granted. Entitlement to a 50 percent initial rating for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for a skin condition diagnosed as seborrheic dermatitis is granted. Entitlement to an initial rating in excess of 20 percent for status post radius and ulna fracture is denied. REMANDED Entitlement to service connection for amblyopia is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for an intestinal condition, to include as irritable bowel syndrome, to include as a medically unexplained chronic multisymptom illness as a result of service in Southwest Asia, is remanded. Entitlement to service connection for left wrist ganglion cyst is remanded. Entitlement to service connection for right wrist carpal tunnel syndrome is remanded. Entitlement to service connection for nocturnal bruxism is remanded. Entitlement to a higher initial rating for left hand tremor is remanded. Entitlement to a higher initial rating for right hand tremor is remanded. Entitlement to a higher initial rating for lumbosacral strain is remanded. Entitlement to a higher initial rating for a right forearm scar is remanded. Entitlement to a higher initial rating for migraine headaches is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s left heel spur is manifested by functional limitation, including pain with standing and walking. 2. Early Dupuytren’s contracture is manifested by functional impairment of the right fourth finger which approximates a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm. 3. Throughout the appeal period, the Veteran’s PTSD symptoms more closely approximated occupational and social impairment with reduced reliability and productivity. 4. Dermatitis had its onset in service. 5. The Veteran’s status post radius and ulna fracture is manifested by painful motion and with flexion to 145 degrees and full extension. He does not have limitation of pronation with motion lost beyond the middle of arc. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent rating, but no higher, for a left heel spur have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5271. 2. The criteria for an initial 10 percent rating, but no higher, for early Dupuytren's contracture have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5229. 3. The criteria for an initial 50 percent rating, but no higher, for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.21, 4.130, Diagnostic Code (DC) 9411 (2016). 4. Service connection for dermatitis is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 5. The criteria for an initial rating in excess of 20 percent for status post radius and ulna fracture have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5213. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 2002 to June 2014. The request for a TDIU has been added to this appeal pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board acknowledges that the Veteran submitted a Rapid Appeals Modernization Program (RAMP) opt-in election form that was received by VA on May 31, 2018. However, the appeal for the Veteran’s claims had already been activated at the Board and is therefore no longer eligible for the RAMP program at this time. Accordingly, the Board will undertake appellate review of the case. Increased Rating Disability evaluations (ratings) are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate or "staged" evaluations may be assigned for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Court has held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The United States Court of Appeals for Veterans' Claims also has held, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [,or] endurance." Id., quoting 38 C.F.R. § 4.40. In both claims for an increased rating on an original claim and an increased rating for an established disability, only the specific criteria of the Diagnostic Code are to be considered. Massey v. Brown, 7 Vet. App. 204, 208 (1994). In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). 1. Entitlement to an Increased Initial Rating for Left Heel Spur A July 2014 VA rating decision granted service connection for left heel spur and assigned a 0 percent rating from June 2014. The Veteran asserts that a compensable rating is warranted due to left heel pain and numbness with prolonged standing. Limitation of motion of the ankles is rated according to Diagnostic Code 5271. A 10 percent rating is assignable for moderate limitation of motion. A 20 percent (maximum schedular) rating is assignable for marked limitation of motion. The rating criteria provide that normal dorsiflexion of the ankle is to 20 degrees. Normal plantar flexion is to 45 degrees. See 38 C.F.R. § 4.71, Plate II. The Veteran had a VA examination in July 2013. The Veteran reported flare-ups of his ankle with prolonged standing. He reported bilateral ankle pain with exercise. Examination showed left ankle plantar flexion to 45 degrees or greater and left ankle dorsiflexion to 20 degrees, with no objective evidence of painful motion. There was no additional limitation of motion with repetitive use testing. The examiner indicated that the Veteran did not have functional limitation of the left ankle and did not have pain on palpation of the ankle. The Veteran had 5/5 muscle strength of the left ankle with plantar flexion and dorsiflexion. The Veteran had shin splints. He did not have stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy (astragalectomy). He reported that his symptoms included pain after running. The Board finds that a 10 percent rating, but no higher, is warranted for left heel spur, based on painful motion. The Board finds that a rating in excess of 10 percent is not warranted. The evidence does now show findings which warrant a rating in excess of 10 percent under the criteria pertaining to ankle injuries. The Veteran has normal plantar flexion and dorsiflexion of his left ankle. He does not have any other manifestations of the left heel spur which warrant a rating in excess of 10 percent. The Board has considered the benefit-of-the-doubt rule in making this decision. 38 U.S.C. § 5107 (b). 2. Entitlement to an Initial Compensable Rating for Early Dupuytren's Contracture, Right Fourth Finger A July 2014 rating decision granted service connection for right fourth finger Dupuytren’s contracture (dominant). The RO has assigned a non-compensable rating for Dupuytren’s contracture, according to Diagnostic Code 5230. Diagnostic Code 5230 pertains to limitation of motion of the ring or little finger. A non-compensable (0 percent) rating is provided for any limitation of motion. Diagnostic Code 5229 pertains to limitation of motion of the index or long finger. A 0 percent rating is warranted with a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extension possible; extension is limited by no more than 30 degrees. A 10 percent rating is warranted with a gap of one inch (2.5 cm) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. A July 2013 VA examination reflects that the examiner diagnosed Dupuytren’s contracture, right fourth finger. The Veteran reported that he broke the pinky in his hand and had a pin surgically placed in his pinky. His current symptoms included pain in his hand. Physical examination showed that the Veteran did not have a gap between his thumb pad and fingers. The examination showed pain beginning at a gap of less than 1 inch (2.5 cm). There was no gap between any fingertips and the proximal transverse crease of the palm and no evidence of painful motion in attempting to touch the palm with the fingertips. There was no limitation of extension or evidence of painful motion of the index or long finger. The Veteran did not have additional limitation of motion of any fingers with repetition. There was no gap between the thumb and the fingers post-test. There was no limitation of motion of the fingers post-test. There was no ankylosis of the fingers. The examiner noted that the Veteran had decreased grip strength, including pain, weakness, fatigability, incoordination, and additional limitation of motion after flare-ups or repeated use. The July 2013 examination did not show a gap between the right ring finger and the thumb pad. The examination did show functional impairment of the grip and with flare-ups. The functional loss of the right fourth finger more nearly approximates the criteria for a 10 percent rating under Diagnostic Code 5229. A higher rating in excess of 10 percent is not warranted, in the absence of favorable ankylosis of two digits. There is no evidence of any ankylosed fingers associated with the Veteran’s right fourth finger disability. Accordingly, the Board finds that a 10 percent rating, but no higher, is warranted for right fourth finger Dupuytren’s contracture (dominant). The Board has considered the benefit-of-the-doubt rule in making this decision. 38 U.S.C. § 5107 (b). 3. Entitlement to a Higher Initial Rating for PTSD A July 2014 rating decision granted service connection for PTSD and assigned a 30 percent rating, effective from June 2014. The Veteran seeks a higher initial evaluation for PTSD. PTSD is evaluated (rated) under the general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). The Veteran had a VA examination in July 2012. The examiner diagnosed chronic posttraumatic stress disorder and major depressive disorder, recurrent, in remission. The examiner opined that all of the Veteran’s psychiatric symptoms are the result of his PTSD. The examiner noted occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran described a good relationship with his mother and fair relationships with his half siblings. The Veteran reported that his first marriage ended in divorce. He reported that he was separated from his second wife. The Veteran reported that he had many close friends at present and a girlfriend. He was employed as a receptionist with a HVAC company. On mental status examination, the Veteran was alert and fully-oriented. His appearance and hygiene were appropriate, and he maintained good eye contact during the examination. His affect and mood were abnormal. He showed a disturbance of motivation and mood. He demonstrated evidence of anxiety throughout the interview, frequently shifting in his chair, bouncing his knees, and tapping his feet. He endorsed problems with impulse control as evidenced by frequent episodes of verbal aggression toward others. He indicated that these problems affected his motivation and his mood. He denied panic attacks. His thought processes were normal. There was no evidence of delusions, hallucinations, or obsessions. His judgment appeared intact. There was no evidence of suicidal or homicidal ideation. The Veteran had a VA examination in July 2013. The examiner diagnosed PTSD related to deployments in Iraq and Afghanistan. The Veteran reported suicidal ideation for two weeks. He reported that he attempted suicide with an alcohol overdose. The Veteran reported current suicidal ideation. The examiner noted that the Veteran’s current symptoms included anxiety, suspiciousness, and chronic sleep impairment. The examiner opined that the Veteran was competent to manage his financial affairs. A September 2013 mental health evaluation reflects that the Veteran denied suicidal ideation. He was alert and well oriented. His mood was euthymic and affect congruent. His long-term memory was intact. He denied hallucinations and delusions. His judgment and impulse control appeared to be intact. He denied obsessions and compulsions. The report noted adequate socialization with both active duty members and civilians. The examiner opined that the Veteran was competent. A VA outpatient mental health evaluation dated in August 2015 reflects that the Veteran complained that was forgetful. He stated that he felt like he had Alzheimer’s. The Veteran reported that he was fearful and anxious around others. He exhibited a pleasant mood. He denied suicidal or homicidal ideation. He denied any hallucinations or delusions. His judgment and insight were fair. The Veteran had a VA examination in December 2016. He reported that he was separated from his wife. He reported that he had his own gaming business, which had taken off. He reported that, prior to launching the gaming business, he was working full-time, going to school, and working on his product. He was attending school for a bachelor’s degree in management and information systems and had a gaming business which was going well. He reported that he spent all of his time working, which kept his mind off his marriage problems. He reported that he focused on his son. The examiner noted that the Veteran’s symptoms included anxiety, suspiciousness, and chronic sleep impairment. His hygiene and grooming were good. He was cooperative throughout the examination. There was no evidence of psychosis. On review of all the evidence, the Board finds that the Veteran's PTSD more nearly approximates occupational and social impairment with reduced reliability and productivity. VA examinations and treatment records show that the Veteran has complained of impulse control, anxiety, suspiciousness, and memory problems. He reported disturbances of motivation and mood in August 2012, but he had euthymic mood on examination in September 2013 and August 2015. He reported suicidal ideation in August 2013 but denied suicidal ideation at other times during the appeal. The Board finds that the evidence of record does not support a rating of 70 percent. The Board acknowledges that the Veteran had mentioned suicidal ideation in August 2013. However, he has denied suicidal ideation at all other times during the appeal. The evidence also shows that the Veteran has not experienced obsessional rituals which interfere with routine activities, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, impaired impulse control, or near-continuous panic affecting the ability to function independently, appropriately and effectively. While the Veteran reported problems with his relationship with his ex-wife, he has not demonstrated a complete inability to establish and maintain effective relationships. Therefore, the Board does not find that the overall frequency, severity, and duration of the Veteran's PTSD approximates the severity required for a 70 percent rating. The Board also finds that the evidence of record does not support a rating of 100 percent. Although the Veteran has at times reported social isolation, he has generally indicated that he socializes with his family and has friends at work. With respect to occupational functioning, he reported that he maintains a gaming business which has been successful. The evidence also does not show delusions hallucinations, or disorientation to time or place. While he has some memory loss, he does not have memory loss for names of close relatives, his own occupation, or his own name. Therefore, the Board finds that the criteria for a 100 percent rating for PTSD are not met. The Board has considered the benefit-of-the-doubt rule in making this decision. 38 U.S.C. § 5107 (b). 4. Entitlement to Service Connection for a Skin Condition The Veteran asserts that a current skin condition began in service. He asserts that his current skin condition is related to seborrheic dermatitis which was diagnosed in service. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Treatment records during the Veteran’s period of active service reflect multiple skin complaints. In December 2011, he was diagnosed with seborrhea. A February 2012 treatment note reflects that he complained of skin lesions and was diagnosed with dermatofibroma. A March 2013 treatment record reflects that he was seen for seborrheic dermatitis of the left parietal scalp, right parietal scalp, left medial eyebrow, and right central eyebrow. He was diagnosed with seborrheic dermatitis. A July 2013 VA examination reflects that the Veteran reported dry skin on his face and scalp. He reported that his condition started in 2002. The examination indicated that the Veteran did not have an active rash on his face. The examination noted that the Veteran had a facial rash, which was treated with topical corticosteroids more than 6 weeks per year. A March 2015 VA treatment note showed no active skin lesions. Treatment records from Camp Lejeune, dated in September 2013, reflect diagnoses of dermatitis, which was being treated by a dermatologist. The Veteran's service treatment records reflect diagnoses of dermatitis. On VA examination, he reported dermatitis outbreaks which he treats with topical medications. While the Veteran did not have a rash at the time of the 2013 examination, he is competent to report his dermatitis symptoms. The Board finds that the evidence in favor of the claim is at least in equipoise. Therefore, resolving reasonable doubt in the Veteran’s favor, service connection is warranted for dermatitis. 5. Entitlement to a Higher Initial Evaluation for Status Post Radius and Ulna Fracture A July 2014 rating decision granted service connection for status post right mid radius and ulna fractures with open reduction and internal fixation. A 20 percent rating was assigned from June 2014. The RO has assigned a 20 percent rating for status post right mid radius and ulna fracture with open reduction internal fixation (ORIF), pursuant to Diagnostic Code 5213. The rating is based on limitation of pronation of the elbow, with motion lost beyond the last quarter of arc, when the hand does not approach full pronation. The Board notes that the Veteran is separately rated for complex regional pain syndrome of his right arm (musculospiral nerve), which was previously characterized as a right-hand tremor. The Veteran is right-handed. The criteria pertaining to the major extremity applicable. Diagnostic Code 5213, impairment of supination and pronation, provides that loss supination or pronation (bone fusion) with the hand fixed in supination or hyperpronation warrants a 40 percent evaluation. The hand fixed in full pronation warrants a 30 percent evaluation and the hand fixed near the middle of the arc or moderate pronation warrants a 20 percent rating. Limitation of pronation with motion lost beyond the middle of arc warrants a 30 percent evaluation and motion lost beyond the last quarter of arc, with the hand not approaching full pronation, warrants a 20 percent evaluation. The Veteran had a VA examination in July 2013. The Veteran reported a right forearm condition with pain since 2012. He reported that he was unable to perform normal activities because of pain, numbness, and sensitivity. Examination showed flexion of the right elbow to 145 degrees or greater without pain. The Veteran had extension to 0 degrees. Repetitive use testing did not show additional limitation of motion of the elbow. The examiner indicated that the functional impairment of the right elbow included less movement than normal and pain on movement. He had pain on palpation of the right arm. He had 5/5 muscle strength with flexion and extension of the elbow. He did not have ankylosis of the elbow. There was no flail joint, joint fracture, or impairment of supination or pronation. A private orthopedic treatment record dated in September 2014 shows that the Veteran continued to have activity-related pain in the ulnar shaft/ fracture region and in the dorso-radial proximal forearm near the top of his surgical scar. He reported pain with activity. He felt limited in gripping and lifting. The Veteran indicated that he would like to proceed with removal of hardware from his arm. Private treatment records reflect that the Veteran was seen for follow up after the removal of a plate and screws from his healed mid shaft radius and ulna fractures in October 2014. He reported improvement in the pain in his forearm. He had regained good digital, wrist, and forearm motion. He had good elbow motion. The Board finds that the evidence of record does not warrant a rating in excess of 20 percent for status post radius and ulna fracture. The evidence does not show that the Veteran’s right radius and ulna fracture has been manifested by limitation of pronation with motion lost beyond the middle of arc. The evidence also does not indicate the hand is fixed in supination or hyperpronation, as is required for a rating of 40 percent. As noted above, on VA examination in July 2013, he did not have impairment of supination of the right arm. The Board acknowledges the evidence of the Veteran's pain and functional limitations of the right forearm. However, the evidence does not show pain and functional limitation of the severity to warrant the assignment of a higher rating under 38 C.F.R. § 4.71a, Diagnostic Code 5213. The Board has considered all other diagnostic codes pertaining to the elbow and forearm, but none apply. The record does not reflect ankylosis of the elbow or limitation of flexion or extension of the elbow sufficient to warrant a rating under DCs 5205-5208. Diagnostic Code 5209 does not apply as the record does not indicate a flail joint or fracture. Diagnostic Codes 5210-5212 do not apply as the record does not show nonunion of the radius and ulna or other impairment of the ulna or radius. The Veteran has impairment of the fingers of his right hand, which is separately rated. See Note, Diagnostic Code 5213. Accordingly, as there is a preponderance of the evidence against the claim for a higher rating for right radius and ulna fracture, the claim must be denied. The Board has considered the benefit-of-the-doubt rule in making this decision. 38 U.S.C. § 5107 (b). REASONS FOR REMAND 1. Entitlement to service connection for amblyopia is remanded The Veteran asserts that amblyopia of the right eye initially manifested in service. The June 2002 enlistment examination did not note any eye disabilities. An August 2012 entry in the service treatment records noted possible mild meridional amblyopia of the right eye. The Veteran was afforded a VA examination in July 2012. The examination reflects a diagnosis of amblyopia, right eye. The Veteran reported that the condition began in 2002. VA regulation provides that refractive errors of the eyes are congenital or developmental defects and are not a disease or injury within the meaning of applicable legislation. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303 (c), 4.9. The July 2012 VA examination did not address whether the amblyopia of the right eye that was diagnosed during service constitutes a congenital or developmental defect or a superimposed injury or the eye. As the examination is inadequate, a new examination and opinion is necessary. 2. Entitlement to service connection for sinusitis is remanded. The Veteran asserts that has sinusitis, which is related to upper respiratory symptoms he had in service. The Veteran was afforded a VA examination in July 2013. The examiner opined that the Veteran does not have chronic sinusitis but also noted that the Veteran had four episodes of sinusitis per year. The information in the examination is contradictory and is therefore inadequate. As the examination is inadequate, a new examination and opinion is necessary. 3. Entitlement to service connection for an intestinal condition is remanded. The Veteran asserts that he has an intestinal condition which began in service. He further asserts that service connection is warranted on a presumptive basis for a chronic multi-symptom illness based upon his service in Southwest Asia. Service treatments reflect that the Veteran was diagnosed with gastroenteritis in November 2003. In July 2006, he was diagnosed with constipation. In February 2011, when the Veteran was deployed to Afghanistan, he reported cramping and diarrhea and was diagnosed with viral gastroenteritis. He continued to report abdominal pain and gas in March 2011. Private treatment records dated in February 2012 reflect a diagnosis of chronic gastroenteritis. An August 2012 entry in the service treatment record noted a diagnosis of colitis. The Veteran has not been afforded a VA examination for his intestinal disability. The case is being remanded for a VA examination and medical opinion. 4. Entitlement to service connection for left wrist ganglion cyst is remanded. 5. Entitlement to service connection for right wrist carpal tunnel syndrome is remanded. 6. Entitlement to service connection for nocturnal bruxism is remanded. The July 2014 rating decision denied service connection for left wrist ganglion cyst, right wrist carpal tunnel syndrome, and nocturnal bruxism. The Veteran submitted a timely notice of disagreement with the July 2014 rating decision, but a statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 7. Entitlement to a higher initial rating for left hand tremor is remanded. 8. Entitlement to a higher initial rating for right hand tremor is remanded. The RO has assigned non-compensable ratings for left and right hand tremor, pursuant to Diagnostic Code 8616 (neuritis of the ulnar nerve). A January 2012 entry in the service treatment record noted minimal carpal tunnel symptoms. A July 2013 VA examination reflects that the Veteran complained that his hands shake. The examiner noted fine resting tremors of the bilateral hands. The examination did not identify the affected nerves or the degree or paralysis of the nerves. The Board notes that the Veteran was afforded a VA examination in April 2016, which identified peripheral nerve conditions affecting the right arm. A May 2016 rating decision granted service connection for complex regional pain syndrome of the right arm involving the musculospiral nerve. The rating decision did not address any nerve impairments of the hands. A new VA examination is necessary to ascertain the severity of the Veteran’s left and right hand tremors. 9. Entitlement to a higher initial rating for lumbosacral strain is remanded. 10. Entitlement to a higher initial rating for a right forearm scar is remanded. The July 2014 rating decision granted service connection for thoracolumbar strain and assigned a 10 percent rating, effective from June 2014. The rating decision also granted service connection and assigned a noncompensable rating for a right forearm scar. The Veteran submitted a timely notice of disagreement with the July 2014 rating decision. While a January 2017 rating decision increased the rating for a lumbar disability to 20 percent and increased the rating for right forearm scar to 10 percent, this is not a full grant of benefits. A statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 11. Entitlement to a higher initial rating for migraine headaches is remanded. The Veteran’s last VA examination for migraine headaches was in July 2013. VA treatment records since that time reflect that he complained of worsening migraine symptoms that caused him to leave work. In light of the treatment records indicating a possible increase in the severity of his migraine headaches, the Veteran should be afforded a new examination to assess severity of migraine headaches. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Snuffer, 10 Vet. App. at 403. 12. Entitlement to a total disability rating based upon individual unemployability is remanded. In correspondence received in October 2016, the Veteran’s representative asserted that the Veteran’s has been unable to secure or follow substantially gainful employment due to his service-connected disabilities. The Veteran’s representative requested that VA obtain a medical opinion addressing the combined effects of the Veteran’s service-connected conditions on his ability to secure or follow substantially gainful employment. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any amblyopia of the right eye. a) The examiner must opine whether it is at least as likely as not that a disability of the right eye had its onset in service or is otherwise related to the Veteran’s period of service. The examiner should address the July 2012 and August 2012 treatment records which reflect a diagnosis of amblyopia of the right eye. b) The examiner must opine whether it is at least as likely as not (a 50 percent or higher degree of probability) that a refractive error of the right eye was subjected to a superimposed disease or injury during service which created additional disability. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sinusitis. The examiner must opine whether the Veteran currently has sinusitis. If sinusitis is diagnosed, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the upper respiratory infections treated in service. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any gastrointestinal disability. a) The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. b) The examiner must consider the service treatment records which reflect diagnoses of gastroenteritis, constipation and colitis. c) The examiner is further asked to specifically address if the Veteran has any objective signs of an intestinal disorder not accounted for by any diagnosed condition. If so, list each sign/symptom and address the level of impairment and whether it is at least as likely as not that any sign/symptom is related to an undiagnosed illness or related to a medically unexplained chronic multisymptom illness. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right and left hand tremors. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. a) Identify the affected nerve(s) and indicate whether there is incomplete or complete paralysis; b) b) If there is incomplete paralysis, the VA examiner should state whether it is mild, moderate or severe. 5. Send the Veteran and his representative a statement of the case that addresses the issues of entitlement to service connection for left ganglion cyst, entitlement to service connection for right wrist carpal tunnel syndrome, entitlement to service connection for nocturnal bruxism, higher initial rating for lumbar strain, and entitlement to a higher initial rating for right forearm scar. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his migraine headaches. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 7. Ask the Veteran to complete a TDIU claim form. Then, schedule the Veteran for an examination by an appropriate clinician regarding the functional impact of his service-connected disabilities. The examiner should elicit from the Veteran his complete educational, vocational, and employment history and should note his complaints regarding the impact of his disabilities on employment. The examiner should identify all limitations or functional impairment caused solely by his service-connected disabilities, including: kidney stones; migraine headaches; PTSD; status post right mid radius and ulna fractures with open reduction internal fixation (ORIF); thoracolumbar strain; myofascial pain syndrome of the upper trapezius; cervical myofascial pain syndrome; complex regional pain syndrome of the right arm; tinnitus; superficial linear scars of the left upper extremity, right upper extremity, and anterior trunk; left heel spur; status post right metacarpal fracture; right fourth finger Dupuytren’s contracture; bilateral great toe ingrown toenails; allergic rhinitis; hypertension; prostate gland hypertrophy; left hand fine tremor; and right hand fine tremor. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Catherine Cykowski