Citation Nr: 21007040 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 17-27 216 DATE: February 8, 2021 REMANDED The claim for service connection for calcaneal spur, left foot and ankle (claimed as residuals of left foot strain) is remanded. The claim for service connection for disabilities of the feet, to include plantar fasciitis and bilateral pes planus with fallen arches, is remanded. The claim for service connection for diabetes mellitus, Type II is remanded. The claim for service connection for residuals of a head injury, traumatic brain injury (TBI) is remanded. The claim for service connection for a psychiatric disorder is remanded. The claim for an initial rating in excess of 10 percent for hypertension. The claim for an initial rating in excess of 10 percent prior to August 27, 2019; 20 percent prior to March 1, 2020; and 10 percent since for lumbar strain with arthritis and intervertebral disc syndrome (IVDS).   REASONS FOR REMAND This matter is before the Board of Appellants’ Appeals (Board) on appeal of September 2013 rating decision of the (RO) of the Department of Appellants Affairs (VA). In April 2020, the Veteran was afforded a hearing before the undersigned Veterans Law Judge. A hearing transcript is incorporated into the record. In the September 2013 rating action, the RO denied service connection for psychiatric disorders to include PTSD and bipolar disorder to include transitional disorder with anxiety. Post service VA treatment records include psychiatric diagnoses of depression. In considering these claims, the Veteran seeks service connection for a mental disability however variously diagnosed as due to military service. Accordingly, the issue has been recharacterized on the title page as such. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). 1. Service connection for calcaneal spur, left foot and ankle (claimed as residuals of left foot strain) The Veteran maintains that her currently diagnosed calcaneal spur is a residual of inservice left ankle sprain. VA examination was conducted in July 2013 to determine the etiology of the Veteran’s left foot calcaneal spur. The examiner determined that the left foot calcaneal spur was unrelated to inservice sprain. However, this opinion offers no medical guidance as to the basis of the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further explanation is needed. 2. Service connection for disabilities of the feet The Veteran also contends that service connection should be granted for plantar fasciitis and bilateral pes planus. The Veteran reports inservice foot pain. A September 2004 VA treatment record includes a notation regarding falling arches. The Veteran should undergo a VA compensation examination for a medical nexus opinion regarding the etiology of her bilateral foot disabilities – to include whether there is the required clear and unmistakable evidence indicating her pes planus pre existed her military service (i.e., is congenital or developmental), and, if there is, also clear and unmistakable evidence indicating it was not aggravated during or by her service beyond its natural progression, versus initially manifested during her service (i.e., is acquired). 3. Service connection for diabetes mellitus, Type II The Veteran also contends that service connection should be granted for diabetes mellitus Type II. VA treatment records show that within a year and a half of service discharge, a diagnosis of borderline diabetes was reported. See VA treatment record dated in September 2011. VA opinion is needed as to whether there may have been earlier onset of diabetes mellitus. 4. Service connection for TBI The Veteran also contends that service connection should be granted for TBI. VA treatment records dated August 13, 2008, show that she was involved in motor vehicle accidents in May and June 2008. She reported symptoms of headaches since then, for which service connection has been granted. She has not examined for any TBI residuals. VA examination and opinion are needed. 5. Service connection for a psychiatric disorder The Veteran also contends that service connection should be granted for a psychiatric disorder to include PTSD. During the appeal period the Veteran reported that her stressors included domestic violence. See stressor statement received in August 2019. At her hearing she also reported that she suffered a still born birth in 2000, which is confirmed by service treatment records. Since service discharge, variously diagnosed psychiatric disorders have been reported. The Veteran also reported that she received private inpatient psychiatric treatment in 2018 due to military stress. (See VA treatment record dated June 6, 2008) The Board finds that outstanding questions as to current diagnosis and etiology in connection with the claim on appeal remains, and VA examination and opinion are needed. 6. Higher rating for hypertension 7. Higher rating for lumbar strain with arthritis and IVDS At the hearing, the Veteran reported that her service connected hypertension and lumbar disability had increased in severity since the last examinations. Based on the evidence of increased severity, the Board remands for updated VA examinations. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. The Veteran reports that she received private inpatient psychiatric treatment in Chicago in 2008. (See VA treatment record dated June 6, 2008) The RO should assist the Veteran in obtaining theses records. 3. After completing directives1-2, forward the e-file to a qualified medical professional to provide as opinion as to whether it is at least as likely as not (50 percent or greater probability) that the calcaneal spur resulted from the inservice left ankle strain. A complete rationale for the opinion should be provided. 4. After completing directives 1-2, schedule the Veteran for appropriate VA examinations to determine the etiology of the remaining claimed disabilities. Feet The examiner must identify all feet disorders found to be present. Regarding pes planus, did the Veteran clearly and unmistakably have pre existing pes planus when beginning her military service in September 1999 and/or June 2008? If she did, is there also clear and unmistakable evidence this pre existing condition was not aggravated during or by her military service, that is, beyond its natural progression? If, instead, it is determined she has acquired pes planus, then what is the likelihood this acquired disorder initially manifested during her military service or is otherwise attributable to her military service? Because the Veteran is competent to report the onset of foot pain in service, the examiner must specifically address the Veteran’s complaints of foot pain while in service. Diabetes Mellitus The examiner should provide an opinion as to whether it is at least as likely as not diabetes mellitus had its clinical onset during active service, specifically whether it had onset during service or within a year of service discharge. TBI The examiner should provide an opinion as to whether the Veteran has TBI, and, if so, is it is at least as likely as not it had clinical onset during active service or is related to any in-service disease, event, or injury, to include the Veteran’s motor vehicle accidents. Psychiatric Disability After reviewing the record, the examiner should identify all current psychiatric disorders. The examiner should then provide an opinion as to whether it is at least as likely as not that each diagnosed acquired psychiatric disorder manifested in or is otherwise related to the Veteran’s period of service. If PTSD is diagnosed, the stressor(s) that caused the PTSD should be identified. To the best of his/her ability, the examiner must reconcile all previous psychiatric diagnoses documented in the records and offer an opinion as to the onset date of the Veteran’s psychiatric condition(s), if any. A complete rationale must accompany all opinions rendered. 5. After completing directives1-2, schedule the Veteran for appropriate VA examination to determine the severity of her hypertension and lumbar spine disabilities. Nathaniel Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.D. Jackson, 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.