Citation Nr: 20048024 Decision Date: 07/17/20 Archive Date: 07/17/20 DOCKET NO. 16-12 493A DATE: July 17, 2020 REMANDED Entitlement to an increased evaluation for service-connected scars, residuals burns right upper chest, right axilla and medial surface right upper arm are remanded. Entitlement to service connection for a neck disability, to include degenerative arthritis of the cervical spine is remanded. Entitlement to service connection for a bilateral foot disability, to include plantar fascitis and plantar callouses is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability, to include degenerative arthritis is remanded. REASONS FOR REMAND The Veteran had active service in the United States Marine Corps from August 1982 to June 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) located in Louisville, Kentucky. In February 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the electronic claims file. 1. The Claims on Appeal are Remanded. The Veteran contends that the service-connected scar, right upper chest is more severe than the currently assigned 10 percent rating. Additionally, the Veteran contends that service connection is warranted for a neck disability, bilateral foot disability, and bilateral ankle disability. After review of the evidence, both lay and medical, the Board finds a remand is necessary to allow for a fully informed decision. Increased Rating for Scars The Veteran last underwent a VA examination for the service-connected scars in October 2019. The VA examiner indicated that the service-connected scars were not painful. However, during his February 2020 Board hearing, the Veteran indicated that he was prescribed opiates, acupuncture, and exercise for the service-connected scar. While the passage of time alone does not warrant a new examination, given the Veteran's continued treatment and discrepancies in the record, a current examination is necessary. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Service Connection for a Neck Disability Next, the Veteran contends that service connection is warranted for a neck disability. Specifically, the Veteran contends there were multiple potential in-service injuries that resulted in a neck disability, including a time that he fell from a ladder when removing a ceiling. Next, he contends that a current neck disability is secondary to his service-connected right shoulder disability. VA treatment records show that the Veteran is currently treated for degeneration in the cervical intervertebral disc. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). To date, the Veteran has not been provided with a VA examination to determine the etiology of the neck disability, therefore, a remand is necessary. Service Connection for a Bilateral Ankle Disability Next, the Veteran contends that service connection is warranted for a bilateral ankle disabilities. Service treatment records show the Veteran injured his right ankle in service while conduction physical training and was diagnosed with ankle sprain. In October 2012, the Veteran underwent a VA examination to determine the etiology of his current ankle disability. The VA determined the Veteran had normal bilateral ankles. In September 2016, the Veteran submitted a DBQ completed by a private physician. The physician diagnosed bilateral lateral collateral ligament sprain and opined that the Veteran’s ankle disabilities were at least as likely as not caused by service. However, the rationale provided was that ankle sprain can cause chronic ankle instability and failed to discuss any specifics of the Veteran’s medical history. The Board notes that a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995); see also LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (a bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a health care professional). A December 2016 MRI showed osteoarthritis in the right ankle. During the February 2020 Board hearing, the Veteran reported that he experienced ankle pain during service. Specifically, he indicated marching in boots caused ankle pain. Given the deficiencies in the record and the additional testimony from the Veteran, a remand is necessary to ensure an adequate examination is provided. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Service Connection for a Bilateral Foot Disability Finally, the Veteran contends that service connection is warranted for a bilateral foot disabilities. Service treatment records show the Veteran was treated for plantar warts in service. In October 2012, the Veteran underwent a VA examination to determine the etiology of any current bilateral foot disability. The VA examiner diagnosed the Veteran with plantar fasciitis and opined it was less likely than caused by service. The rationale provided was that there was significant time between service and the presentation of the current disability. In August 2015, the Veteran underwent an additional VA examination for the bilateral feet. On examination, the examiner found no plantar keratosis and opined that it was less likely than not that any foot disability was caused by the Veteran treatment in service. The rationale provided was that the plantar keratosis was resolved. In September 2016, the Veteran submitted a DBQ completed by a private physician. The physician diagnosed bilateral metatarsalgia but failed to offer an opinion on the etiology of the disability. During the February 2020 Board hearing, the Veteran reported that he experienced foot pain during service. Given the deficiencies in the record and the additional testimony from the Veteran, a remand is necessary to ensure an adequate examination is provided. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The matters are REMANDED for the following action: 1. Contact the Veteran and ask him to provide sufficient information and necessary authorization in order to obtain copies of any outstanding records of treatment by VA or non-VA health care providers for any of the claimed disabilities. The letter should invite the Veteran to submit any pertinent medical evidence in support of his claims. If the Veteran provides the necessary information and authorizations, obtain any outstanding clinical records and incorporate them into the electronic claims file. 2. Associate any outstanding VA treatment records with the electronic claims file. 3. After completion of the above specified development, schedule the Veteran for a scars examination. The examiner must describe in detail the current status of the service-connected scars, including all signs and symptoms necessary for rating the disability under the rating criteria. In particular, the examiner must include the sizes and locations of all scars and should also indicate whether they are unstable or painful; deep or superficial; and linear or nonlinear. The examiner must also indicate the total area of the scars, and whether the scars cause any functional loss. 4. Forward the claims file to an appropriate examiner to determine the nature and etiology of any cervical spine disabilities. The examiner should provide an opinion on the following: a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current cervical spine disability is directly related to service? b) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current cervical spine disability is secondary to the Veteran's service-connected disabilities or permanently aggravated beyond its natural progression due to the service-connected disabilities? The examiner must comment on the Veteran’s lay reports of in-service neck pain. For all opinions provided the examiner must provide a rationale (i.e., why or why not). A new examination is not necessary unless the examiner writing the report deems an examination is needed in order to render the necessary opinion. 5. Forward the claims file to an appropriate examiner to determine the nature and etiology of any bilateral foot disabilities. The examiner should provide an opinion on the following: a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current bilateral foot disabilities are directly related to service? b) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current bilateral foot disabilities are secondary to the Veteran's service-connected disabilities or are permanently aggravated beyond their natural progression due to the service-connected disabilities. The examiner must comment on the Veteran’s in-service foot treatment, lay reports of in-service foot pain, and the September 2016 medical examination regarding the feet. For all opinions provided the examiner must provide a rationale (i.e., why or why not). A new examination is not necessary unless the examiner writing the report deems an examination is needed in order to render the necessary opinion. 6. Forward the claims file to an appropriate examiner to determine the nature and etiology of any bilateral ankle disabilities. The examiner should provide an opinion on the following: a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current bilateral ankle disabilities are directly related to service? b) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current bilateral ankle disabilities are secondary to the Veteran's service-connected disabilities or are permanently aggravated beyond their natural progression due to the service-connected disabilities. The examiner must comment on the Veteran’s in-service ankle treatment and the September 2016 medical opinion regarding the ankles. (Continued on the next page)   For all opinions provided the examiner must provide a rationale (i.e., why or why not). A new examination is not necessary unless the examiner writing the report deems an examination is needed in order to render the necessary opinion. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Teague, 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.