Citation Nr: 19164038 Decision Date: 08/20/19 Archive Date: 08/19/19 DOCKET NO. 04-09 333 DATE: August 20, 2019 REMANDED An initial increased rating for hallux valgus, right foot, currently rated 10 percent disabling, is remanded. Service connection for hypertension is remanded. An effective date earlier than July 30, 2011, for the grant of a 20 percent rating for radiculopathy, left upper extremity, is remanded. An effective date earlier than March 23, 2011, for the grant of a 70 percent rating for posttraumatic stress disorder (PTSD), is remanded. Service connection for polyneuropathy, lower extremities, is remanded. REASONS FOR REMAND The Veteran had active service from April 1982 to November 1986. He later served as a reservist. In a June 2012 rating decision, a 70 percent rating was assigned to PTSD, effective March 23, 2011. The earlier effective date issue was remanded in February 2018 for further development. In a January 2015 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for intervertebral disc syndrome, cervical spine, effective March 10, 2004; assigned a separate 20 percent rating for radiculopathy, left upper extremity, effective July 30, 2011; granted service connection for hallux valgus, right foot, assigning a 10 percent rating, effective September 26, 2002; and, denied service connection for hypertension. A notice of disagreement was filed in March 2016 with regard to all issues and a statement of the case was issued in November 2018. Pursuant to the January 2019 substantive appeal, the Veteran is only appealing the effective date assigned to radiculopathy, left upper extremity; the rating assigned to hallux valgus, right foot; and, the denial of service connection for hypertension. It is noted that in September 2013, the issue of entitlement to VA vocational rehabilitation services was remanded for issuance of a notification letter and for inclusion in the claims file of materials pertaining to vocational rehabilitation. Another September 2013 Remand pertained to reimbursement of expenses for private medical treatment in which the Board requested that the RO include in the claims file all relevant information pertaining to the reimbursement claim. To date, these issues are still in remand status. Hallux valgus, right foot The Veteran’s most recent VA examination was conducted in December 2014. As such examination was over four years ago he should be afforded a VA examination to assess the severity of his hallux valgus, right foot. Hypertension The Veteran asserts that his hypertension is due to service and/or due to or aggravated by his PTSD. A December 2014 VA examination reflects the opinion that the Veteran’s hypertension is not secondary to PTSD. The examiner stated that some studies suggest a link between PTSD and an increased risk of developing hypertension, as does the article provided by the Veteran. Literature suggests hyperadrenergic state induced by stress and anxiety may result in increased plasma and urinary norepinephrine, epinephrine and their metabolites which in turn exert a stimulatory effect on the cardiovascular system. Some studies indicated a higher basal heart rate and blood pressure in patients with PTSD over those without PTSD. However, not all people with PTSD have hypertension. The Veteran has several risk factors for developing hypertension including prolonged tobacco use, age and race. Additionally, treatment records are silent for outward signs of autonomic overstimulation (sweating, tremor, increased heart rates) that would be expected to be present if the hypertension were attributable to autonomic overstimulation caused by PTSD. On examination, the Veteran had elevated blood pressure, with normal heart rate of 86 with no tremor or sweating. In October 2015, Dr. C.N.B. opined that the Veteran’s hypertension is caused by PTSD stress and his in-service experiences. Dr. C.N.B. stated that the Veteran likely had a stressful military tour and service connection is in effect for PTSD; and, that stress from PTSD is known to cause hormonal changes that cause hypertension and that his hypertension is caused by his PTSD. Dr. C.N.B. cited to articles in support of his opinion. 03/16/2016 Medical Treatment Record-Non-Government Facility. In January 2016, Dr. C.N.B. acknowledged that the VA examiner discussed smoking as a risk factor as a cause of the Veteran’s blood pressure and smoking and PTSD are both risk factors as per the literature. Dr. C.N.B. stated that it is impossible to assign a percent increased risk due to smoking vs. PTSD. Additionally, smoking does not prevent PTSD from effecting blood pressure. Dr. C.N.B. opined that it is impossible to tell which caused his high blood pressure as either his smoking or PTSD can do it. 03/16/2016 Medical Treatment-Non-Government Facility. In light of the conflicting opinions above, additional opinion should be sought regarding etiology of the Veteran’s hypertension that addresses direct, secondary, and aggravation etiology. Earlier effective date – radiculopathy, left upper extremity The Veteran asserts that the 20 percent radiculopathy rating should be made effective March 10, 2004, which corresponds to the date service connection was established for his cervical spine disability. An opinion should be sought regarding the earliest date radiculopathy of the left upper extremity associated with his cervical spine disability was shown. Earlier effective date - PTSD In February 2018, this effective date issue was remanded by the Board for further development. Moreover, the Board had also determined that this issue is inextricably intertwined with the Veteran’s claim regarding VA vocational rehabilitation benefits. It was determined that information pertaining to vocational rehabilitation may impact the question regarding whether the 70 percent rating should apply prior to March 23, 2011. It was determined that this issue could not be decided until the Board’s remand directives regarding vocational rehabilitation have been complied with. See Smith v. Gober, 236 F.3d. 1370 (Fed. Cir. 2001). In September 2013, the Board remanded the issue of entitlement to vocational rehabilitation training benefits under Chapter 31 (Docket # 05-17596A). On Remand, the Veteran’s vocational rehabilitation folder, to include any counselor’s assessments, were to be associated with the claims folder, and then the claim was to be readjudicated. On March 2, 2017, VA requested the Veteran’s vocational rehabilitation folder; to date, there has been no response and the folder is not of record. To proceed with the PTSD effective date issue, there must be compliance with the remand directives regarding the vocational rehabilitation issue, to include readjudicating the issue. Polyneuropathy, lower extremities In the May 2015 rating decision, service connection was denied for polyneuropathy of the lower extremities. In May 2016, the Veteran submitted a notice of disagreement. Remand is necessary for issuance of a statement of the case per Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following actions: 1. Associate with the virtual folder updated VA treatment records for the period from February 1, 2019. 2. Schedule the Veteran for a VA examination with a clinician with appropriate expertise to assess hallux valgus, right foot. The virtual folder is to be made available to and reviewed by the examiner in connection with the examination. Any medically indicated special tests should be accomplished, and all special test and clinical findings should be clearly reported. The examination report should comply with the latest Disability Benefits Questionnaire (DBQ) for rating foot disabilities. The examiner should comment on whether the Veteran’s hallux valgus is equivalent to amputation of the great toe or if he has undergone an operation which resulted in resection of the metatarsal head. The examiner should comment on whether the Veteran has a foot disability that is moderate, moderately severe, or severe. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to hallux valgus alone and discuss the effect of the Veteran’s hallux valgus on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. 3. Request that a VA examiner review the claims folder to provide an etiological opinion regarding his hypertension. The examiner should respond to the following: a) whether hypertension is at least as likely as not related to an in-service injury, event, or disease; b) whether hypertension is at least as likely as not (1) proximately due to PTSD, or (2) has been aggravated beyond its natural progression by his PTSD. If aggravation is found, the examiner should identify baseline level of disability prior to such aggravation. The examiner must provide a comprehensive rationale for all opinions proffered, and consideration should be given to the VA and private opinions of record and the treatise materials of record. An examination should be scheduled if deemed necessary by the examiner. 4. Schedule the Veteran for a VA examination to assess the initial date of onset of his radiculopathy, left upper extremity, for any period prior to July 30, 2011, and the severity of any radiculopathy for any period prior to July 30, 2011. It is imperative that the claims file be made available to the examiner in connection with the examination. Any medically indicated special tests should be accomplished, and all special test and clinical findings should be clearly reported. The examiner should identify any neurological findings in the left upper extremity related to the service-connected cervical spine disability for any period prior to July 30, 2011, and fully describe the extent and severity of those symptoms for any period prior to July 30, 2011. The examiner should identify the specific nerve(s) involved, to include whether there is incomplete or complete paralysis, and offer an opinion as to the degree of impairment of the nerve (that is, whether it is mild, moderate, moderately severe, or severe in nature). The examiner should also identify any muscular atrophy. The examiner is to provide a statement concerning how for any period prior to July 30, 2011, the radiculopathy, left upper extremity, affects his functioning and activities, to include in an occupational setting. The examiner is asked to describe the types of limitations he would experience as a result of his radiculopathy. The examiner must provide a comprehensive rationale for the opinions. (Continued on the next page)   5. Comply with the September 2013 Remand directives with regard to entitlement to vocational rehabilitation training benefits pursuant to Chapter 31, and readjudicate the vocational rehabilitation claim. Thereafter, readjudicate the claim of entitlement to an effective date earlier than March 23, 2011, for the grant of a 70 percent rating for PTSD. 6. Issue a statement of the case to the Veteran with regard to the issue of service connection for polyneuropathy, lower extremities. This issue should only be certified to the Board if a timely substantive appeal is received. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.