Citation Nr: 21072402 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 16-60 823 DATE: December 3, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected schizophrenia, is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for residuals of a head injury, to include a traumatic brain injury (TBI), claimed as fainting spells and headaches, is remanded. Entitlement to an initial rating higher than 10 percent for ganglion cyst of the right wrist is remanded. REASONS FOR REMAND The Veteran had active service from December 1979 to September 1981. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a November 2013 and December 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board but canceled his hearing in August 2021. Of note, the Veteran was previously denied service connection for blackout spells and a head injury in a September 1988 rating decision, however, at the time of the rating decision service treatment records were not associated with the claims file. Despite the prior rating decision denying service, reconsideration of the claims is required as relevant service treatment records were subsequently received that existed and had not been associated with the claims file when VA first decided the claims. 38 C.F.R. § 3.156 (c); Blubaugh v. McDonald, 773 F.3d 1310, 1313 (Fed. Cir. 2014); Emerson v. McDonald, 28 Vet. App. 200, 208 (2016). 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a bilateral shoulder disability. The Veteran seeks entitlement to service connection for a low back disability and a bilateral shoulder disability. In a September 2021 statement, the Veteran described injuring his low back and shoulders during service when he fell during an obstacle course and asserts that he has experienced pain since service. The Veteran also argues that in addition to the fall, the strenuous physical training he endured during service caused low back and bilateral shoulder disabilities. To date, the Veteran has not yet been afforded VA examinations for his low back and bilateral shoulders. On remand, the Veteran should be afforded VA examinations and VA medical opinions should be obtained. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected schizophrenia. The Veteran seeks entitlement to service connection for hypertension. In a September 2021 statement, the Veteran asserts his hypertension is aggravated by his schizophrenia. The Board notes the Veteran was granted service connection for schizophrenia in a January 2021 rating decision. To date, the Veteran has not been afforded a VA examination for his hypertension. On remand, the Veteran should be afforded a VA examination for his hypertension and a VA medical opinion should be obtained. 4. Entitlement to service connection for a heart disability. 5. Entitlement to service connection for residuals of a head injury, to include a TBI, claimed as headaches and fainting spells. The Veteran seeks entitlement to service connection for a heart disability as well as residuals of a head injury. See April 2013 statement. He asserts he has a heart disability that causes fainting spells. He also asserts he has headaches and fainting spells as a result of a head injury during service. Service treatment records document the Veteran responded "yes" to having shortness of breath, swelling of the ankles, and/or palpitation of the heart during an August 1980 medical history for dental care. Service treatment records also document the Veteran fell in December 1980 and received a small laceration to the right eyebrow and right hand due to glass. Approximately three weeks later, in December 1980, the Veteran reported dizziness and nausea. The Veteran asserts that after his fall, he began experiencing fainting spells and headaches. A March 2013 VA treatment note indicates the Veteran reported he believed he fainted and that he had similar episodes in the past. A June 2016 VA treatment notes indicates the Veteran reported feeling lightheadedness, especially when standing, since he started in the military many years ago. To date, the Veteran has not yet been afforded a VA examination for his claimed heart disability. On remand, the Veteran should be afforded a VA examination and a VA medical opinion should be obtained. The Board notes that the Veteran was afforded a VA examination for a TBI in November 2013, at which time he reported experiencing headaches after service. The VA examiner then opined that the Veteran did not have any residuals of a head injury, as headaches were reported as having an onset several years after service; however, the Board notes that the Veteran reported memory loss during the VA examination, and it was noted that the Veteran did not even recall the head injury during service, although it was documented in service records. The Veteran recently reported in a September 2021 statement that his headaches began during service, indicating that he often went into the freezer while serving as a cook to relieve his headache symptoms. Additionally, the November 2013 VA examination failed to conduct any neurological testing and did not offer any opinion or discussion regarding the Veteran's reported fainting spells or an explanation as to his reported memory loss. The Board finds a remand is necessary to afford the Veteran a new VA examination for his claimed head injury residuals and a VA opinion must be obtained. 6. Entitlement to an initial rating higher than 10 percent for ganglion cyst of the right wrist. The Veteran seeks entitlement to a rating higher than 10 percent for ganglion cyst of the right wrist. Of note, he is currently receiving the maximum rating available under Diagnostic Code 5215 for limitation of motion of the wrist. Ratings higher than 10 percent are available, however, for ankylosis of the wrist. Importantly, the Veteran asserted in a September 2021 statement that he cannot bend his wrist down. Unfortunately, he has not been afforded a VA examination of the wrist since July 2013, more than 8 years ago. On remand, the Veteran should be afforded a VA examination to determine whether he has ankylosis of the wrist and to determine the current severity of his disability. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Afford the Veteran a VA examination for his claimed low back disability. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please answer the following: a) For any low back disorder diagnosed, or functional impairment of the low back, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder/functional impairment had its onset during the Veteran's service or is causally or etiologically due to service, to include the asserted fall during an obstacle course in service and/or strenuous physical training during service. b) In so opining, the examiner should consider and discuss the Veteran's theory that his current disorder is due to his asserted fall during service, his lay statements of continuous back pain since service, as well as his theory that strenuous physical training during service may have caused his current low back disorder. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 3. Afford the Veteran a VA examination for his claimed bilateral shoulder disability. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please answer the following: a) For any shoulder disorder diagnosed, or functional impairment of the shoulders, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder/functional impairment had its onset during the Veteran's service or is causally or etiologically due to service, to include the asserted fall during an obstacle course in service and/or strenuous physical training during service. b) In so opining, the examiner should consider and discuss the Veteran's theory that his current disorder is due to his asserted fall during service, his lay statements of continuous shoulder pain since service, as well as his theory that strenuous physical training during service may have caused his current bilateral shoulder disorder. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 4. Afford the Veteran a VA examination for hypertension. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please opine as to whether it is at least as likely as not (a 50 percent or greater probability): a) that his hypertension had an onset during service or within one year after discharge, or is causally or etiologically due to service; OR b) that his hypertension is proximately due to or aggravated (beyond a natural progression) by his service-connected schizophrenia. In so opining, the examiner should consider and discuss the Veteran's theory that his hypertension is aggravated by the symptoms of his schizophrenia, particularly when he is experiencing more severe psychiatric symptoms. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 5. Afford the Veteran a VA examination for his claimed heart disability. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please answer the following: a) All current heart disorders should be diagnosed and noted for the record. b) For each diagnosed disorder, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that it had an onset during service or is causally or etiologically due to service. c) In so opining, the examiner should consider and discuss: i) the Veteran's theory that his fainting spells are due to a heart disorder; ii) August 1980 medical history for dental care wherein the Veteran responded "yes" to having shortness of breath, swelling of the ankles, palpitation of the heart; iii) report of dizziness and nausea during service in December 1980; iv) March 2013 VA treatment note reporting he believed he fainted and that he had similar episodes in the past; v) June 2016 VA treatment notes indicating the Veteran reported feeling lightheadedness, especially when standing, since he started in the military many years ago. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 6. Afford the Veteran a VA examination for his claimed residuals of a head injury, to include a TBI. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail, to include any indicated neurological testing. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please answer the following: Please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran has any current residuals of a head injury, to include, but not limited to, headaches, fainting spells or memory problems. In so opining, the examiner should consider and discuss: i) the Veteran's theory that his fainting spells are due to his documented head injury during service in December 1980; ii) report of dizziness and nausea during service several weeks after his head injury in December 1980; iii) March 2013 VA treatment note reporting he believed he fainted and that he had similar episodes in the past; iv) June 2016 VA treatment notes indicating the Veteran reported feeling lightheadedness, especially when standing, since he started in the military many years ago; v) the Veteran's reports of experiencing headaches during service in a September 2021 statement. A complete rationale should be given for all opinions and conclusions expressed. 7. Afford the Veteran a VA examination to determine the current severity of his ganglion cyst of the right wrist. The Veteran's claims folder must be reviewed by the examiner. The examiner should identify and completely describe all current symptomatology, to include whether the Veteran has favorable or unfavorable ankylosis of the right wrist. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Andersen, 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.