Citation Nr: 1818656 Decision Date: 03/29/18 Archive Date: 04/05/18 DOCKET NO. 14-19 327 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for bilateral pes planus. 2. Entitlement to service connection for pseudofolliculitis barbae. 3. Entitlement to service connection for an acquired psychiatric disability. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. B. Yantz, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from October 1972 to February 1974. [He also had an additional period of active duty service from February 1978 to May 1979, but a June 1999 administrative decision determined that his character of discharge for that period (which was "Under Other Than Honorable Conditions") is considered a bar to all VA benefits applicable to that period.] These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2018, a videoconference hearing was held before the undersigned Veterans Law Judge, and a transcript of the hearing is associated with the record. From the date of the hearing, the record was held open for 30 days in order to allow for the submission of additional evidence for consideration; however, no additional evidence was submitted within that time. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if action on his part is required. REMAND On review of the record, the Board has found that additional development is necessary for the claims on appeal. Service Connection for Bilateral Pes Planus The Veteran contends that his current bilateral pes planus, which pre-existed his service, was aggravated beyond its natural progression during his service. It was noted on the Veteran's June 1972 enlistment examination report that he had bilateral pes planus. Thereafter, an October 1972 service treatment record noted that he had painful arches and that he was fitted for shoe inserts. [On an April 1979 Report of Medical History, it was indicated that he had a history of foot trouble; however, the Board notes that this report was created during the period of service when his character of discharge constitutes a bar to VA benefits.] Post-service, a May 2001 VA treatment record noted his bilateral flat feet, with the plan to give him custom inserts bilaterally. A March 2005 VA podiatry consultation noted his pes planus foot type bilaterally, and examination revealed that the joints of his feet were not painful upon range of motion or palpation. At a July 2011 VA foot examination, the Veteran was diagnosed with bilateral pes planus. The VA examiner opined that such disability (which pre-existed the Veteran's service, as noted on his service entrance examination) was not aggravated by his service beyond normal progression during his period of service from 1972 to 1974, with the rationale being that he had had no arch pain complaints for decades and no other foot complaints in the VA treatment reports of record (other than bilateral foot cramps which were "likely related to circulatory disturbance as they subside by moving around"). At his January 2018 hearing, the Veteran testified that he currently does have pain in his feet and that his new VA physician had recommended physical therapy. The VA treatment reports of record (which date to July 2017) do not document any physical therapy for his feet (or the aforementioned recommendation for such). On remand, all outstanding treatment records must be obtained. Service Connection for Pseudofolliculitis Barbae The Veteran contends that he currently has pseudofolliculitis barbae which began during his service. The Veteran's service treatment records do not note any complaints, findings, diagnosis, or treatment of pseudofolliculitis barbae. Post-service, a June 2012 VA treatment record noted that the Veteran wanted to get pseudofolliculitis barbae ("razor bumps" or "shave bumps") included in his service-connected problems list; however, no symptoms or treatment of this disability were noted by the examining physician at that time. At his January 2018 hearing, the Veteran testified that he had never shaved prior to entering the military and that he first developed pseudofolliculitis barbae (described as bumps on his face with pustules) when he shaved his face in service. He alleged that he was given a shaving profile in service which allowed him to only shave twice a week and to grow a beard out to a quarter-inch in length. He also testified that VA sent him to a specialist for pseudofolliculitis barbae at a facility "from a town outside of Dallas" and that he currently wears a beard and does not shave. On remand, all available treatment records from this specialist should be obtained. [The Board notes that VA treatment records in November 2002 documented the Veteran's treatment for folliculitis in the eyes, and that a December 2009 VA treatment record noted treatment for recurrent furuncles in the scrotum (thereafter listed as "furunculosis" on his medical problem list). Given the specific nature of pseudofolliculitis barbae and the way the Veteran has described his current claim as pertaining to shaving bumps on his face, the Board finds that these other medical conditions (pertaining to his eyes and scrotum) are not a part of the current appeal for service connection for pseudofolliculitis barbae.] Service Connection for an Acquired Psychiatric Disability The Veteran contends that he currently has an acquired psychiatric disability (claimed as anxiety) which began during his service. A July 1973 service treatment record noted the Veteran's complaint of difficulty sleeping and waking up four to five times a night; it was noted that he had "No apparent anxiety" and that he "gets out of NCC in 16 days." [On an April 1979 Report of Medical History, it was indicated that he had a history of frequent trouble sleeping; however, the Board notes that this report was created during the period of service when his character of discharge constitutes a bar to VA benefits.] Post-service, VA treatment records have documented the following psychiatric findings for the Veteran. In January 2005, a posttraumatic stress disorder (PTSD) screening was positive. In March 2005, he reported that he "fights in his sleep and has dreams that someone is chasing him" and was diagnosed with nightmare disorder not otherwise specified (NOS). In April 2005, he reported a history of sleep disorder and a long history of primary and middle insomnia since he started working on night shift at the VA seven years prior, and he was assessed with circadian rhythm sleep disorder (shift work type). In March 2008, it was noted that he had a past medical history of anxiety. In April 2009, his active medical problem list included anxiety. In April 2014, he reported having nightmares that were not helped with insomnia treatment. In August 2015, he again reported that he "fights in his sleep and has dreams that someone is chasing him" and also described vivid nightmares (including of falling), and he was again diagnosed with nightmare disorder NOS. In July 2016, it was noted that he had no combat exposure and was a "Victim of non-combat military trauma" (though such trauma was not described), and he again reported having nightmares; it was also noted at this time that his past mental health history included receiving services from "Central Texas" in 2011. [The Board notes that the VA treatment reports currently of record are from the Dallas VA Medical Center, which is part of the VA North Texas Health Care System. On remand, all outstanding VA treatment records must be obtained, to include from the Central Texas Veterans Health Care System.] At his January 2018 hearing, the Veteran testified that he did not start having problems with anxiety until after he got out of the military (in approximately 1976) and that he was first diagnosed with anxiety at the Dallas VA Medical Center in approximately 2002. On remand, after all outstanding treatment records have been obtained, a VA psychiatric examination should be scheduled in order to determine the nature and etiology of all acquired psychiatric disabilities that the Veteran has been diagnosed with during the period of the current claim. Accordingly, the case is REMANDED for the following actions: 1. With any needed assistance from the Veteran, including securing from him a VA Form 21-4142 (Authorization and Consent to Release Information to VA) for each identified provider, obtain all records of the Veteran's treatment for his claimed disabilities during the period of claim, to specifically include all records of physical therapy for his feet as well as all records of treatment for pseudofolliculitis barbae from a specialist he saw outside of Dallas (as identified during his testimony at the January 2018 hearing). If any identified records cannot be obtained and it is determined that further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records on his own behalf. 2. Obtain all VA treatment records from the Central Texas Veterans Health Care System as well as updated VA treatment records (from July 2017 to the present) from the VA North Texas Health Care System. 3. After completing the development requested in items 1 and 2, schedule the Veteran for a VA psychiatric examination with a clinician with appropriate expertise in order to ascertain the nature and etiology of all acquired psychiatric disabilities that the Veteran has been diagnosed with during the period of the current claim. The claims file should be made available to the examiner for review. Any indicated tests should be accomplished and all pertinent symptomatology and findings must be reported in detail. After reviewing the claims file, the examiner should provide an opinion on the following questions: (a) Identify all valid diagnoses of acquired psychiatric disabilities present at any time since the pendency of the claim (including nightmare disorder NOS, as documented in the medical evidence outlined above). (b) For each acquired psychiatric disability that is diagnosed, including the diagnosis outlined above: Is it at least as likely as not (50 percent probability or greater) that such disability was incurred in, related to, or caused by any incident of the Veteran's military service (including his complaint of difficulty sleeping as documented in a July 1973 service treatment record)? The examiner should provide a complete rationale for any opinion provided. If the examiner cannot provide any requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Thereafter, review the record, ensure that all development is completed (and arrange for any further development suggested by additional evidence received, to include obtaining an updated medical opinion regarding the Veteran's bilateral pes planus if needed in light of any pertinent evidence received for that disability), and readjudicate the claims on appeal for entitlement to service connection for bilateral pes planus, entitlement to service connection for pseudofolliculitis barbae, and entitlement to service connection for an acquired psychiatric disability. If any benefit sought on appeal remains denied, in whole or in part, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. § 5109B (2012). _________________________________________________ M. SORISIO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).