Citation Nr: 21007905 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 18-30 321 DATE: February 11, 2021 REMANDED The claim of entitlement to service connection for left knee pain syndrome is remanded. The claim of entitlement to service connection for a psychiatric disability, including posttraumatic stress disorder (PTSD), is remanded. The claim of entitlement to service connection for a cervical spine disability, including spondylosis, degenerative disc disease and intervertebral disc syndrome, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1992 to August 1994. His claims come before the Board of Veterans' Appeals (Board) on appeal of a July 2017 rating decision. Entitlement to service connection for left knee pain syndrome The Veteran perfected an appeal on this claim in June 2018. In February 2020, the Agency of Original Jurisdiction (AOJ) issued a supplemental statement of the case, and, of record, attached thereto, is a written statement withdrawing this claim from appellate review. It does not identify the Veteran or his claim number, and it is not signed or dated. It thus does not meet the criteria for withdrawing an appeal before the Board. See 38 C.F.R. § 20.205. The Veteran’s representative recently issued another written statement discussing only the two claims that follow and not mentioning the left knee claim, suggesting the Veteran intended for the claim to be withdrawn from this appeal. To clarify this matter, another, more comprehensive withdrawal statement is needed. Entitlement to service connection for a psychiatric disability, including PTSD The Veteran has been diagnosed with a psychiatric disability, variously characterized, including as PTSD. He seeks service connection for such disability on a direct basis, as related to in-service stressors. The first stressor reportedly occurred between January 14, 1992 and January 17, 1992, while in the holding area at Fort Benning. One soldier’s mistakes allegedly resulted in the other soldiers being reprimanded. That night, some of the reprimanded soldiers sought revenge by beating the soldier at fault in his chest and ribs with a pillowcase filled with solid bars of soap; the Veteran unsuccessfully tried to intervene but was warned he would be next. He never forgot and remained bothered by the incident. The second stressor reportedly occurred between June 1994 and July 1994 (initially reported a different time frame: between April 1992 and July 1994), while training in the Kahuku Mountains in Hawaii. A fellow soldier, Jason A. Barnett, was injured, necessitating extraction by a helicopter using a lift basket. After the soldier was secured in the basket, the helicopter climbed into the air too quickly, causing one of the four corners of the rope to break. The basket reportedly began spinning into a G-force rotation at a great rate of speed, an incident the soldier later indicated caused severe brain trauma with blood coming out of his ears, nose and mouth. The third stressor involved being twice seriously injured during service. The first injury reportedly occurred right after the helicopter incident, during the same training exercise. The Veteran and others were climbing up a steep, completely vertical incline when they fell on to sharp-edged lava rocks below, to the bottom of a gulch. The Veteran injured his left knee. The second injury reportedly occurred in 1994 when the Veteran was rappelling and injured his neck and right shoulder. The Veteran claims that, although he was profiled for these injuries, because his chain of command failed to take them seriously, his profiles were ignored, and he was forced to participate in field exercises, carrying rucksacks weighing 80 to 100 pounds. The Veteran has submitted written statements from his spouse and RK, a soldier with whom the Veteran served in Hawaii, which corroborate events the Veteran reported during his 1994 training in the Kahuku Mountains in Hawaii. According to these statements, the Veteran’s spouse recalls the left knee injury, and RK recalls that injury and the helicopter incident. In October 2016, the Veteran submitted a Review PTSD Disability Benefits Questionnaire (DBQ), which included PTSD and generalized anxiety disorder diagnoses and a reference to the following “sentinel event(s) (other than stressors)”: two serious injuries the Veteran observed and an injury he sustained while in the military. This report is inadequate to decide this claim as it is signed by two social workers and does not specifically relate either of the Veteran’s psychiatric disabilities to the sentinel events. Another examination is therefore necessary. In addition, in a June 2017 Memorandum, the AOJ formally found that the record lacked sufficient information to try and corroborate the Veteran’s alleged stressors. The Board disagrees. The Veteran has described the helicopter incident in detail and provided the unit to which he was assigned at the time, the possible months and year the incident occurred, the location of the incident and the full name of the soldier involved. Given RK’s lay statement, which supports the Veteran’s assertions, a more diligent effort should be made to research and obtain detailed information on the incident. Entitlement to service connection for a cervical spine disability, including spondylosis, degenerative disc disease and intervertebral disc syndrome The Veteran seeks service connection for a cervical spine disability on a direct basis, as related to an in-service injury involving, in part, his neck. During the course of this appeal, he underwent VA examinations of his neck and submitted an addendum opinion from one of the VA examiners, but the reports of the examinations and the opinion are inadequate to decide this claim. One examination report focuses solely on the severity rather than etiology of the neck disability; the other includes an opinion on the etiology of the cervical spine disability, but it is based on an incomplete accounting of the record (discusses neck x-ray on discharge not in-service neck injury). The opinion concludes that an in-service cervical strain contributed to the Veteran’s current cervical spine conditions, which suggests there are other causes that too contribute. The question here involves the likelihood of any current cervical spine disability having been incurred in or aggravated by the Veteran’s service. An addendum opinion is thus needed. These matters are REMANDED for the following action: 1. Clarify whether the Veteran wishes to withdraw from appeal the claim of entitlement to service connection for left knee pain syndrome. If so, ask him to submit a signed written statement to this effect, which includes all necessary information, to include a signed statement. 2. Exhaust all avenues of development in an effort to verify that, between June 1994 and July 1994, while training with the 5/14 Golden Dragons in the Kahuku Mountains in Hawaii, Jason A. Barnett was injured and lifted off the mountain by helicopter in a basket, after which he sustained further injury when one rope broke and the basket began speedily rotating. 3. Associate with the record as much information on the alleged stressor as is available. 4. Once the above information is part of the record, afford the Veteran a VA mental health examination. The examiner should review the Veteran's file, including: (a) the Veteran’s stressor statements (summarized briefly above); (b) post-service treatment records dated since 2002, which show variously diagnosed psychiatric disabilities, including PTSD; (c) an October 2016 DBQ report; (d) the Veteran’s spouse’s statement recalling the Veteran’s in-service knee injury; (e) RK’s statement recalling the in-service knee injury and helicopter incident; and (f) any additional information obtained on the helicopter incident. The examiner should record in detail the Veteran’s history of mental health symptoms. The examiner should also record in detail the Veteran’s in-service stressors. The examiner should list any psychiatric disability shown on examination or which was diagnosed during the claims process. The examiner should indicate whether the verified stressors (sustaining an in-service knee injury and witnessing another soldier’s injury (helicopter incident, as described by the Veteran and in any additional information obtained in response to above request)) are sufficient to support any of these diagnoses, including the PTSD. The examiner should provide rationale for each opinion. 5. Obtain an addendum opinion from the VA examiner who submitted a nexus statement in support of the Veteran’s neck claim in September 2017. The examiner should review the Veteran's file, including: (a) service treatment records showing an in-service injury affecting, in part, the neck; (b) post-service treatment records confirming a current cervical spine disability, variously diagnosed; (c) December 2016 and November 2017 VA neck examination reports; (d) the September 2017 nexus statement; and (e) the Veteran’s assertion that, after the 1994 injury, he had persistent neck problems, including pain and headaches. The examiner should note the Veteran's history of neck symptoms. The examiner should list all cervical spine disabilities diagnosed since 2015. Accepting as competent all reports of lay-observable neck symptoms, the examiner should opine whether any diagnosed cervical spine disability initially manifested during service or within a year of discharge therefrom or is at least as likely as not (50 percent or greater probability) related to such service, including the in-service injury that affected the Veteran’s neck. The examiner should provide rationale for each opinion. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. N. 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.