Citation Nr: 20004422 Decision Date: 01/21/20 Archive Date: 01/17/20 DOCKET NO. 17-04 416 DATE: January 21, 2020 REMANDED Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for heart disease is remanded. Entitlement to service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 2006 to September 2009. At a November 2019 videoconference hearing, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. 1. PTSD The Veteran underwent a VA PTSD examination in December 2016. In a January 2018 letter, his treating VA social worker stated that the reduction in reliability and productivity in the Veteran’s functional capacity caused by his PTSD would appear to be sufficient to warrant further efforts toward establishing an increased rating. At the hearing, the Veteran stated that his psychiatric symptomology had worsened since that last evaluation. He and his wife described increased anxiety, social isolation, hyperawareness, anger issues, panic attacks, and trouble sleeping. The Veteran had recently moved and had not established mental health treatment in his new location. He stated that he was in the process of restarting psychiatric treatment with VA providers. The Board finds that, given the evidence of worsening since the last evaluation, a new VA examination is needed to assess the current extent and severity of the Veteran’s PTSD. Further, updated VA records should be obtained to reflect any current psychiatric treatment. 2. Heart Disease During active service, the Veteran reported irregular heartbeats accompanied with dizziness and random heart palpitations with shortness of breath several times in June 2006 and June 2007. He underwent two electrocardiograms (ECG) in June 2006 and June 2007 which had abnormal results. He had a normal sinus rhythm, however a right bundle branch block (RBBB) was detected. At his July 2009 separation examination, it was noted that he had a history of palpitations, dizziness, and vertigo. Post-service, he visited an emergency room with complaints of chest pain and anxiety in August 2012. An ECG was conducted and it revealed a normal sinus rhythm and RBBB. Another ECG was performed in February 2013 with similar results. In an August 2013 VA treatment record, the Veteran was told that RBBB was very common and occurring in 98 percent of the population. The clinician noted that the Veteran’s RBBB was asymptomatic, so there was nothing further to be done. A chest x-ray done in April 2014 revealed no evidence of acute or chronic disease. The Veteran underwent another ECG in August 2014 which demonstrated a normal sinus rhythm and RBBB. Due to his complaints of palpitations and irregular heartbeat, a Holter Monitor was conducted in September 2014. However, the results were normal with a regular sinus rhythm and no significant dysrhythmia. He was prescribed Propanolol for irregular heartbeat. The Veteran underwent another ECG in June 2015 which demonstrated normal sinus rhythm and RBBB. An echocardiogram and exercise stress test were performed in July 2015 which yielded normal results. The Veteran underwent a VA examination in December 2015. The examiner found that he did not have a heart condition/disease. The examiner noted the in-service complaints of palpitations and the discovery of RBBB. His heart rate and rhythm were normal, and another ECG demonstrated RBBB. The examiner determined it was less likely than not that the claimed condition was caused by active service. In support, she stated that the palpitations and RBBB were probably a normal variant, not associated with any structural heart disease. There was no evidence of heart disease. At the hearing, the Veteran described experiencing a “skipping” of his heartbeat while serving in Iraq. He noted that after discharge, he sought treatment when he experienced a racing heart, but clinicians attributed the symptoms to anxiety. The Board finds that a new VA opinion is needed. The Veteran did not have any complaints of palpitations or an irregular heartbeat prior to service. An abnormal ECG found RBBB during service. The Veteran continues to have symptomology of heart palpitations and RBBB has been demonstrated upon testing numerous times. Although there was no evidence of heart disease, the Veteran does have symptomology which began during active service and continues to the present. Because clinicians found RBBB to be a normal variant or asymptomatic, a medical opinion is needed to determine whether his palpitations and described heartbeat irregularity and dizziness is attributable to the RBBB found in service. Further, the examiner should discuss whether his symptoms are attributable in part or whole to his service-connected PTSD, as has been suggested. 3. Right Knee At the hearing, the Veteran described an instance that occurred in approximately late 2006 when he went on a run and felt his right knee pop out or dislocate. He was able to pop the knee back in and he did not want to be limited in his duties, so he ignored it and did not seek treatment. His knees were further strained and stressed while deployed to Iraq. After returning from deployment, he stated that his right knee would pop out of place frequently. Currently, he described the knee popping out all of the time. He also had cracking, pain, and swelling. In the Veteran’s service treatment records (STRs), it was noted in December 2008 that he had patellofemoral syndrome (PFS) in his left knee and had a history of dislocations in both knees. In July 2009, it was recorded that his knee was worse and that he now had bilateral knee pain. In a July 2009 separation physical examination, he checked that he had knee trouble and noted that he had dislocated his left knee in the past and that due to constant running, he had a lot of knee trouble. He stated that he had occasional pain in his right knee. PFS of the left knee was noted as a current problem. Another treatment record from July 2009 reported bilateral knee pain. Post-service, in a February 2013 treatment record it was noted that the Veteran denied any knee pain. In March 2018, he complained of chronic right knee pain to VA clinicians. He stated that he had a past injury where he dislocated the knee while in service and it popped out. Upon examination, the right knee was mildly tender, exhibited mild crepitus, and had good range of motion. The Veteran reported frequent swelling, as well. The Board notes that many of the symptoms described by the Veteran were recorded in his STRs as occurring in the left knee, rather than the right knee. However, he did report to treating clinicians at the time that he had a history of dislocations in both knees and he had bilateral knee pain. The VA Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and the appellant’s service. The types of evidence that indicate that a current disability may be associated with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McClendon, 20 Vet. App. 79. The Board finds that the low threshold has been met in this case as the Veteran is competent to report a frequent popping out sensation and pain in his knee. He described such symptoms to clinicians contemporaneously, and at the hearing, he reported frequent popping out of his right knee continuously since service. VA treatment records indicate complaints of current symptomology. As such, a VA examination and opinion should be obtained to determine the nature and etiology of any current right knee condition. The matters are REMANDED for the following action: 1. Obtain relevant and outstanding VA treatment records, specifically to include records since June 2018 from VA facilities in Rainbow City and Gadsden, Alabama, and Bozeman, Montana. 2. Schedule the Veteran for a VA psychiatric evaluation to assess the current extent and severity of his PTSD. The Veteran’s record should be reviewed by the examiner. All appropriate tests and studies should be conducted, and the results reported in detail. The report should include all subjective complaints and objective symptoms. In addition to objective test results, the examiner should fully describe the functional limitations caused by the Veteran’s PTSD, including the effect of his disability on his occupational and daily functioning. A full rationale for all opinions expressed should be provided. 3. Schedule the Veteran for an appropriate VA examination to address the nature and etiology of any currently-diagnosed heart condition, to include RBBB and his reports of palpitations and irregular heartbeat. The claims file should be made available for review. After a review of the claims file, the examiner is requested to answer the following: (a.) Whether it is at least as likely as not (probability of 50 percent or better) that any current condition had its onset during service or is otherwise the result of a disease or injury during service, to include the in-service complaints of palpitations, dizziness, and irregular heartbeat and the ECG findings of RBBB; and (b.) Whether the Veteran’s described symptoms are the result of RBBB or any other heart condition. (c.) The examiner is specifically asked to discuss the Veteran’s lay statements regarding his symptoms of heart palpitations, irregular heartbeat, and dizziness; the August 2013 clinician’s determination that the Veteran’s RBBB was asymptomatic; the December 2015 examiner’s findings and conclusions that his RBBB was a normal variant; and to determine whether the Veteran’s described symptoms are attributable in whole or in part to his service-connected PTSD. (d.) A rationale should be provided for all opinions reached. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 4. Schedule the Veteran for an appropriate VA examination to address the nature and etiology of any currently-diagnosed right knee condition. The claims file should be made available for review. After a review of the claims file, the examiner is requested to answer the following: (a.) Whether there are any current right knee diagnoses; and (b.) Whether it is at least as likely as not (probability of 50 percent or better) that any current condition had its onset during service or is otherwise the result of a disease or injury during service, to include the in-service complaints of frequent dislocations and pain in the right knee. (c.) The clinician is specifically asked to address the Veteran’s lay statements regarding the onset and continuity of right knee symptoms. (Continued on the next page)   (d.) A rationale should be provided for all opinions reached. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 5. Readjudicate the issues on appeal. If any benefit sought remains denied, issue a Supplemental Statement of the Case and return to the Board, if otherwise in order. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, Associate 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.