Citation Nr: 20028024 Decision Date: 04/21/20 Archive Date: 04/21/20 DOCKET NO. 17-42 986 DATE: April 21, 2020 REMANDED Entitlement to service connection for flat feet is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection a left knee disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection a right arm disability (to include the right elbow and wrist) is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder and major depressive disorder is remanded. REASONS FOR REMAND The Appellant served on active duty for training (ACDUTRA) from November 1982 to May 1983 and served in the United States Army Reserve from November 1982 to October 1995. This matter comes before the Board of Veterans’ Appeals from a rating decision by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Appellant testified before the undersigned at a February 2020 Board hearing. A transcript of the hearing is of record. A claim for service connection for a mental disability may encompass claims for service connection of any mental disability that may reasonably be encompassed by several factors, including the claimant’s description of the claim, the symptoms the claimant describes and the information the claimant submits or that the Secretary obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Board has taken an expansive view of the Appellant’s claim for service connection for mental disorder pursuant to Clemons and recharacterized it as entitlement to service connection for an acquired psychiatric disability. 1. Confirmation of service, records, and service connection for an acquired physiatric disorder. The Appellant contends that all of her claimed disabilities stem from her time in officer candidate school (OCS) at Camp Lincoln around June 1991 and ended in March 1992. Notably, the Appellant contends her acquired psychiatric disorder was related to harassment she received during OCS. The Board notes that the record on appeal contains an AOJ Administrative Decision in which the AOJ found that the Appellant did not have active duty, active duty for training (ACDUTRA), or inactive duty for training (INACDUTRA) from June 1991 through September 1992. The AOJ noted that a VADIR search indicated that indicated the Appellant served from November 1982 to October 1995 as a member of the Army Reserve. The AOJ found the Appellant was “USAR-Ready” status from August 1990 to September 1992, however there was no indication of the Appellant was on ACDUTRA or INACDUTRA during this period. Although the AOJ submitted a formal decision regarding the matter of the Appellant’s service, the Board finds that there is additional development that must be accomplished before appellate review. The Appellant’s personnel records note that the Appellant was given an award for her service in annual training from August 1990 to May 1991. The award was for “successfully [leading] the unit through annual training with excellent comments on 1-R.” Records indicate that the Appellant was promoted in April 1991. The Board finds it unclear how the Appellant was promoted in April 1991 and presented an award for leading training from August 1990 to September 1992 with no active duty, ACDUTRA, or INACDUTRA during this period. The Board also notes that the Appellant stated she attended OCS in June 1991, which the Board finds credible, noting that she was promoted in April 1991 to a non-commissioned officer. There is no indication that there was an attempt to obtain records from Camp Lincoln, where the Appellant stated she went to OCS. Therefore, the Board finds that a remand is required to verify the Appellant’s service from June 1991 to March 1992. VA must also attempt to obtain any personnel and treatment records from that time. 2. Service connection for disabilities of the left knee, right arm (to include the right elbow and wrist), and right shoulder The Appellant contends that she was injured at OCS. Specifically, she testified at the February 2020 Board hearing that she injured her left knee, right wrist, and right shoulder when she was involved in a fall during training. The Board finds that if it is verified through official channels that the Appellant does have a qualifying period of service for the period of May 1991 to March 1992, the Appellant must be provided the opportunity to undergo examinations to determine whether these disabilities are related to service. The Board testified in February 2020, that shortly after she left OCS, she went to Westlake Hospital in Melrose Park, Illinois for treatment of a service-related injury to her knee, wrist, and elbow that occurred at OCS. Therefore, upon remand VA must attempt to obtain any of these records. 3. Service connection for flat feet, lumbar spine, cervical spine, and bilateral ankle disabilities The Appellant contends that her bilateral pes planus was aggravated during OCS from June 1991 to March 1992 from marching. The Board notes that Appellant underwent a VA foot examination in August 2014. The examiner found the Appellant’s pes planus was noted upon entry in service and it was not aggravated by her service. The Board finds that another medical opinion is required if the Appellant’s service is confirmed to determine whether the Appellant’s bilateral pes planus was aggravated during any confirmed period of service from June 1991 to March 1992. The Appellant also contends that her back and ankle disabilities were caused or aggravated by her pes planus disability. The Board finds that if the Appellant’s service during OCS is confirmed the Appellant must be provided the opportunity to undergo an ankle examination and spine examination to determine if they are etiologically related to her service or any pes planus. The matters are REMANDED for the following action: 1. Undertake appropriate development to verify through official channels all periods of active duty service, ACDUTRA and INACDUTRA. Specifically, determine whether the Appellant was in OCS from June 1991 to March 1992 at Camp Lincoln in Illinois. All efforts to obtain the evidence must be documented in the claims file. If, after all procedurally appropriate actions to locate and secure the records have been exhausted, and it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile, make a formal finding to that effect and address the following: (a.) The Appellant was promoted in April 1991. (b.) The Appellant received an award for leading training from August 1990 to May 1991. 2. Obtain the Appellant’s complete service treatment records and personnel records, to include documents pertaining to her service in the Army Reserve from 1990 to 1992, specifically, at Camp Lincoln. Document all requests for information as well as all responses in the claims file. 3. Ask the Appellant to complete a VA Form 21-4142 for Westlake Hospital in Melrose Park, Illinois. Make two requests for the authorized records from Westlake Hospital, unless it is clear after the first request that a second request would be futile. 4. If the evidence indicates that the Appellant has a qualifying period of service between 1991 and 1992 then, obtain a VA medical opinion from an appropriate examiner to determine whether the Appellant’s pes planus was aggravated by her service. Specifically, whether the Appellant’s marching in OCS aggravated her pes planus beyond the natural progression of the disorder. 5. If the evidence indicates that the Appellant has a qualifying period of service between 1991 and 1992 then, schedule the Appellant for an examination by an appropriate clinician to determine the nature and etiology of her disabilities of the lumbar spine, cervical spine, and bilateral ankles. The examiner must provide the following opinions: (a.) Identify all current disabilities of the lumbar spine, cervical spine, and bilateral ankles, to include pain alone if productive of functional impairment. (b.) The examiner must opine whether any disabilities of the lumbar spine, cervical spine, and bilateral ankles are at least as likely as not related to an in-service injury, event, or disease, including a fall during OCS. i. Address the Appellant’s private treatment provider which states that the Appellant’s disabilities of the lumbar spine, cervical spine, and bilateral ankles are related to her military injury in 1991. (c.) whether any disabilities of the lumbar spine, cervical spine, and bilateral ankles are at least as likely as not (1) proximately due to the Appellant’s pes planus, or (2) aggravated beyond its natural progression her pes planus. (d.) For each opinion provide a complete medical rationale. 6. If the evidence indicates that the Appellant has a qualifying period of service between 1991 and 1992 then, schedule the Appellant for an examination by an appropriate clinician to determine the nature and etiology of her disabilities of the left knee, right arm (to include the right elbow and wrist), and right shoulder. The examiner must provide the following opinions: (a.) Identify all current disabilities of the left knee, right arm (to include the right elbow and wrist), and right shoulder to include pain alone if productive of functional impairment. (b.) The examiner must opine whether any disabilities of the left knee, right arm (to include the right elbow and wrist), and right shoulder are at least as likely as not related to an in-service injury, event, or disease, including a fall during OCS. i. Address the Appellant’s private treatment provider that stated that the Appellant’s leg disabilities had been present since at least 1991. (c.) For each opinion provide a complete medical rationale. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert Batten 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.