Citation Nr: 21077596 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 18-07 120 DATE: December 30, 2021 REMANDED Entitlement to service connection for a right ankle condition is remanded. Entitlement to service connection for an acquired psychiatric condition is remanded. Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for a bilateral hand condition is remanded. REASONS FOR REMAND The Veteran served on active duty from December 2008 to May 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) during a hearing in August 2021. 1. Entitlement to service connection for a right ankle condition is remanded. In this case, the Veteran asserts that she continues to feel symptoms in her right ankle from the sprain injury incurred in service. In addition, she testified in August 2021 that she has seen podiatrists multiple times and has tried different shoes and inserts for her condition. Service treatment records (STRs) from April 2011 show the Veteran sprained and twisted her right ankle while running. A June 2015 VA examination indicates a diagnosis of a right ankle sprain and shows the Veteran reported her right ankle swells and is painful when she runs. The Veteran also reported experiencing shin splints. The examiner opined that the Veteran's right ankle condition was less likely than not incurred in or caused by the ankle sprain in service. The examiner stated there was no evidence of any ankle problems after the sprain in service. The Board finds this opinion inadequate, as the examiner did not address the Veteran's statements regarding current symptoms of right ankle pain and swelling, nor consider facts and evidence pertaining specifically to the Veteran. In addition, the examiner did not provide any supporting medical analysis or evidence to explain how or why the conclusion was reached. See Barr v. Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds that a new examination and opinion should be provided on remand to address the deficiencies noted above. 2. Entitlement to service connection for an acquired psychiatric condition is remanded. The Veteran asserts that her depression had its onset in service and/or is related to her experiences in service. In particular, the Veteran testified before the Board in August 2021 that she was sexually assaulted by a coworker during service. VA treatment records reflect the Veteran has been on medication for depression and sleep-related issues. STRs from May 2009 show the Veteran was seen for a behavioral analysis and "recommended for PRP" which may stand for psychiatric rehabilitation program. The record does not reflect that the Veteran has ever been afforded a VA examination regarding the etiology of her claimed psychiatric condition. The Board finds the low standard in McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) has been met. The STRs suggest the Veteran experienced psychiatric or behavioral-related issues in service, she is currently diagnosed and takes medication for depression, and she provided testimony that her psychiatric condition is due to service. As such, the matter is remanded for a VA examination and opinion. 3. Entitlement to service connection for a low back condition is remanded. In this case, the Veteran testified in August 2021 that she injured her back during service when she fell with all her gear on. In addition, she testified that she has been issued back braces and medication for low back pain. A VA counseling narrative report from October 2018 also notes the Veteran has difficulty with lifting due to her low back condition. STRs show the Veteran reported back pain while pregnant in service, as well as minor musculoskeletal pain. A June 2015 VA examination does not show a diagnosis other than "back pain" and notes the Veteran's reports of experiencing back problems during training in service. The examiner opined that the Veteran's back pain was less likely than not incurred in or caused by the back pain reported in service as her reports in service were a normal response to the bodily changes during pregnancy. The Board finds this opinion inadequate, as the examiner did not address the Veteran's statements regarding experiencing back pain since service and due to the rigors of training, nor consider facts and evidence pertaining specifically to the Veteran. In addition, the examiner did not provide any supporting medical analysis or evidence to explain how or why the conclusion was reached. See Barr v. Nicholson, 21 Vet. App. 303 (2007). In addition, as it is unclear whether the Veteran has a diagnosed low back condition, and the Veteran has reported symptoms of pain in her low back, the examiner must also offer an opinion as to whether there is any objective impairment of functioning as a result of any undiagnosed lumbar spine disability, and if so, whether that is related to service. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As such, the Board finds that a new examination and opinion should be provided on remand to address the deficiencies noted above. 4. Entitlement to service connection for a bilateral hand condition is remanded. The Veteran asserts that her bilateral carpal tunnel, claimed as a bilateral hand condition, had its onset in service and affects her typing and taking notes in school as her hands feel numb, tingly, and pressured. STRs from December 2010 show the Veteran reporting experiencing pain in her left wrist for a year, as well as receiving shock treatments without relief. The STRs further suggest the Veteran has De Quervain's syndrome or "tendinopathy and tenosynovitis of the first dorsal compartment." The record does not reflect that the Veteran has ever been afforded a VA examination regarding the etiology of her bilateral hand condition. The Board finds the low standard in McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) has been met. Given the STRs suggesting that the Veteran experienced hand-related symptoms in service, she may have a current diagnosis of a bilateral hand disorder such as carpal tunnel, and the Veteran's testimony indicates the two may be related. As such, the matter is remanded for a VA examination and opinion. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate clinician (or clinicians, if necessary) to determine whether any current right ankle, low back, or bilateral hand disabilities are related to the Veteran's active service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. For each right ankle, low back, or bilateral hand disabilities shown upon examination, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disorder began in or is otherwise related to the Veteran's active service. The examiner should address the Veteran's lay statements regarding symptoms and any other pertinent evidence of record, including the documented right ankle injury in service. If the Veteran does not have diagnosable pathology for low back pain, the VA examiner must provide an opinion on whether the low back pain causes a functional impairment of earning capacity. If so, the examiner is asked to provide an opinion as to whether the low back pain that causes functional impairment of earning capacity is at least as likely as not attributable to an in-service injury, event, or disease All findings must be reported in detail and all opinions must be accompanied by a clear rationale. 2. Schedule the Veteran for an examination with a psychiatrist or psychologist to determine whether any current psychiatric disorder, to include depression, is related to the Veteran's military service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders currently found. For each psychiatric disorder identified, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disorder began in or is otherwise related to the Veteran's active service. The examiner should address the Veteran's lay statements and any other pertinent evidence of record. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ariasaif, Mary 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.