Citation Nr: 21068700 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 14-36 324 DATE: November 12, 2021 ORDER Entitlement to service connection for a recurrent headache disability is granted. REMANDED Entitlement to service connection for a skin disability, to include a lower back subcutaneous cyst, is remanded. Entitlement to a compensable rating for right foot strain is remanded. Entitlement to a compensable rating for left foot dorsal and mid talar bony exostosis is remanded. Entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) prior to May 9, 2019, is remanded. FINDING OF FACT A recurrent headache disability originated during active service. CONCLUSION OF LAW The criteria for service connection for a recurrent headache disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from March 1998 to March 2002. In May 2019, the Veteran submitted a Veteran's Application for Increased Compensation Based on Unemployability, VA Form 21-8940. The Agency of Original Jurisdiction granted a 100 percent rating for posttraumatic stress disorder (PTSD) and major depressive disorder, effective as of May 9, 2019. When entitlement to a TDIU is raised during the adjudicatory process of evaluating the underlying disability or disabilities, it is part of the claim for benefits for the underlying disability or disabilities. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Therefore, the issue of entitlement to a TDIU prior to May 9, 2019, is on appeal and will be addressed below. Service Connection for Tension Headaches Service connection may be granted for chronic disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The service treatment records note that the Veteran was seen for headaches on multiple occasions. A June 1998 treatment record states that the Veteran complained of a headache of 48 hours' duration. The Veteran was diagnosed with a headache of unknown etiology. Clinical documentation dated in August 1999 conveys that the Veteran complained of a headache following a spinal tap. Assessments of "headaches, rule out spinal headache" and "adult headache migraine" were advanced." An April 2012 written statement from T. Anderson, M.D. conveys that the Veteran was diagnosed with migraine headaches. The doctor concluded that the headaches were initially manifested during active service. The report of an August 2012 Department of Veterans Affairs (VA) headache examination states that the Veteran presented a history of recurrent headaches since an in service spinal tap. The Veteran was diagnosed with tension headaches. The examiner stated that the headaches were initially diagnosed in 2000. The Veteran was treated for variously diagnosed recurrent headaches during active service and following service separation. A VA examiner and a private physician has concluded that the currently diagnosed recurrent headache disability was initially manifested during active service. The record is therefore in at least equipoise as to whether the diagnosed recurrent headache disability was initially manifested during active service. Accordingly, service connection for a recurrent headache disability is granted. REASONS FOR REMAND 1. Entitlement to service connection for a skin disability, to include a lower back subcutaneous cyst, is remanded. The report of an August 2012 VA skin examination states that the Veteran reported that he had "a subcutaneous non tender nodule to right of spinal column in the lumbar region" after a 2000 in service spinal tap. The Veteran was diagnosed with a subcutaneous cyst. The examiner noted that the cyst was diagnosed in 2000. A November 2020 skin evaluation conducted for VA concludes that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." The examiner commented that "a lumbar puncture involves anesthesia injected into the area and a needle is inserted between two lumbar vertebrae;" "lumbar puncture procedure can cause severe headaches from spinal fluid leaking into the epidural space;" "in an epidural blood patch, the patients' blood is taken from another site and injected into the affected area to create a seal;" and "the C-file did not support CSF leak after the blood patch and the Veteran has had an MRI of the lumbar spine which did not show evidence of the cyst supporting the cyst is superficial and not related to the lumbar puncture." The examining physician assistant did not note or otherwise address the Veteran's statements as to having exhibited a subcutaneous cyst during active service and the August 2012 VA examination report stating that the subcutaneous cyst was initially diagnosed in 2000. In light of such deficiencies, the Board finds that the VA evaluation is of limited probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, further VA skin examination is needed. 2. Entitlement to a compensable rating for right foot strain and a compensable rating for left foot dorsal and mid talar bony exostosis is remanded. The report of a June 2021 foot examination conducted for VA states that: "the diagnosis changed from the previous service connected diagnosis;" "new diagnosis: bilateral plantar fasciitis;" "the new diagnosis is a correction of the previous erroneous service connected diagnosis;" "bilateral plantar fasciitis was diagnosed and treated by 02/2000;" and "this is a more specific diagnosis than right foot strain." Given the examining nurse practitioner's comments as to the "erroneous service connected diagnosis," the Board finds that the examination report is of essentially no probative value and further VA foot examination is needed. Clinical documentation dated after May 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 3. Entitlement to a TDIU prior to May 9, 2019, is remanded. Entitlement to TDIU requires an accurate assessment of the impairment associated with all of the service connected disabilities. As the claim for TDIU prior to May 9, 2019, is inextricably intertwined with the other claims being remanded, the issue of entitlement to TDIU must also be remanded. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the low back subcutaneous cyst and the service connected right foot and left foot disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after May 2021. 3. Schedule the Veteran for a VA skin examination conducted by a medical doctor to assist in determining the current nature of any identified low back subcutaneous cyst and its relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Identify all skin cysts found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified cyst had its onset during active service or is related to any incident of service, including the August 1999 spinal tap and spinal patch. 4. Schedule the Veteran for a VA foot examination conducted by a physician to assist in determining the current nature and severity of the service-connected right foot strain and left foot dorsal and mid talar bony exostosis. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should specifically discuss the impact of the service connected right foot and left foot disabilities on the Veteran's vocational pursuits. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.