Citation Nr: 21011686 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 17-29 195 DATE: March 2, 2021 REMANDED Entitlement to service connection for bilateral plantar fasciitis is remanded. Entitlement to an initial disability rating in excess of 30 percent for service-connected post-traumatic stress disorder (PTSD) is remanded. Introduction The Veteran served honorably on active duty in the United States Army during the Gulf War Era, from July 1998 to October 2002. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2013 and March 2015 Rating Decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida and Nashville, Tennessee respectively. When these matters came before the Board previously in March 2019, they were denied. However, in August 2020, the United States Court of Appeals for Veterans Claims (Court) issued an Order vacating and remanding these matters for action consistent with the terms of an agreed upon Joint Motion for Partial Remand (JMPR). 38 U.S.C. § 7252(a). REASONS FOR REMAND Entitlement to service connection for bilateral plantar fasciitis is remanded. Pursuant to the August 2020 JMPR, “the Board erred when it failed to obtain an adequate [VA] examination” regarding the Veteran’s claim of entitlement to service connection for bilateral plantar fasciitis. Specifically, the JMPR determined that the March 2015 VA examination “only provided an opinion as to whether [the Veteran’s] pes planus was related to service and not his diagnosed plantar fasciitis.” As a result, the JMPR provides that, “[o]n remand, the Board must obtain a new opinion that addresses whether [the Veteran’s] diagnosed plantar fasciitis is related to service.” Based upon the foregoing, the Board finds that remand is required to afford the Veteran a new VA examination and to procure a medical opinion adequate for purposes of determining service connection for bilateral plantar fasciitis that comports with the Court’s Order and considers all pertinent evidence of record. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Entitlement to an initial evaluation in excess of 30 percent for service-connected PTSD is remanded. The August 2020 JMPR states that, “the Board erred when it failed to provide adequate reasons or bases for its decision” denying the Veteran’s claim of entitlement to an initial rating in excess of 30 percent for PTSD. Specifically, the JMPR takes issue with the Board’s finding that, “’the lack of objective medical evidence regarding panic attacks at least twice per week … [was] most probative.” According to the JMPR, “[i]t is unclear from the Board’s reasons or bases what ‘objective medical evidence’ of panic attacks is, or why the Board favored the lack of a medical notation indicating panic attacks over [the Veteran’s] subjective reports.” The JMPR states that, on remand, “the Board must address [the Veteran’s] reports of panic attacks and provide adequate reasons or bases in determining whether an evaluation in excess of 30% for PTSD is warranted.” In his September 2013 Notice of Disagreement (NOD), the Veteran stated that he is “unable to secure and hold steady work/employment,” suffers panic attacks “at least twice per week,” and has a “subdued” affect. Further, the Veteran indicated having difficulty understanding complex instructions and “establishing and maintaining good work and social relationships,” as well as, being forgetful and having “fluctuating moods.” In his VA Form 9 received in June 2017, the Veteran indicated having intrusive memories, avoidance behavior, changes in physical and emotional reactions (“i.e., self-destructive behavior, overwhelming guilt and shame”), negative changes in thinking and mood, and difficulty maintaining close relationships. The Board observes that the Veteran last underwent a VA examination regarding his service-connected PTSD in May 2013. Due to the more than seven years since the last VA examination, the Board finds that there is a potential for worsening of the Veteran’s PTSD, including reported panic attacks, difficulty understanding complex commands, difficulty establishing and maintaining effective relationships, impaired memory, and disturbances of motivation and mood, and that the current record is therefore insufficient to fully comply with the deficiencies noted in the JMPR. Thus, the Board finds that remand is necessary to afford the Veteran a new VA examination to assess the current nature and severity of his disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997). Accordingly, these matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with a physician possessing the necessary expertise to fully assess and provide an opinion regarding the nature, severity, and likely etiology of the Veteran’s claimed bilateral plantar fasciitis for the entire period on appeal. The examiner must obtain a full history from the Veteran. It should be noted the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology. All pertinent symptomology, including any continuity of symptomology since military service, must be reported in detail. Any indicated studies should be performed. Based upon a review of all pertinent evidence in the Veteran’s claims file, including medical records, lay statements, and the examination results, the examiner must provide a full description of the disability and opine as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s foot condition(s), including bilateral plantar fasciitis, manifested during active duty service; or, is due to, related to, or otherwise etiologically associated with an in-service injury, event, or disease. A complete and thorough rationale for any opinion(s) expressed must be provided 2. Schedule the Veteran for a VA examination with a physician possessing the necessary expertise to fully assess and provide an opinion regarding the nature and severity of the Veteran’s service-connected PTSD for the entire period on appeal. The examiner must obtain a full history from the Veteran. It should be noted the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology. All pertinent symptomology must be reported in detail. Any indicated studies should be performed. Based upon a review of all pertinent evidence in the Veteran’s claims file, including medical records, lay statements, and the examination results, the examiner must provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s service-connected PTSD for the entire period on appeal, including any distinct periods of exacerbation. In offering the above opinion(s), the examiner must consider and discuss as necessary all pertinent lay and medical evidence of record including, but not limited to, the following: (a.) the Veteran’s statements received January 18, 2012, and January 24, 2012, regarding, inter alia, sudden outbursts of anger and difficulty concentrating; (b.) statement received January 24, 2012, by the Veteran’s in-service chaplain, Mr. M.R.L., regarding complaints of memory loss, lack of concentration, and loss of interests; (c.) the May 2013 VA examiner’s report noting a restricted range of affect; and (d.) the Veteran’s NOD dated September 2013 wherein he reports “panic attacks … at least twice per week,” as well as, “subdued” affect, difficulty understanding complex instructions, difficulty establishing and maintaining “good work and social relationships,” impaired memory, and fluctuating moods. A complete and thorough rationale for any opinion(s) expressed must be provided. (Continued on the next page)   (Continued on next page) T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.