Citation Nr: 21012819 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 16-57 376 DATE: March 5, 2021 ORDER Entitlement to service connection for tinea pedis is granted. REMANDED Entitlement to service connection for pseudofolliculitis barbae (PFB) is remanded. Entitlement to service connection for pes planus is remanded. Entitlement to service connection for medial plica syndrome, claimed as shin splints is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to an initial compensable evaluation for cluster headaches is remanded. FINDING OF FACT The Veteran’s current chronic tinea pedis was incurred in and has continued since service. CONCLUSION OF LAW The criteria for service connection for tinea pedis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the Navy from April 1999 to March 2007 and in the Army and from March 2007 to August 2012. These matters are on appeal from a September 2014 rating decision. In August 2020, the Veteran testified at a Board hearing before the undersigned. A transcript of the proceeding has been associated with the record. 1. Entitlement to service connection for tinea pedis is granted. The Veteran contends that service connection for athlete’s foot (tinea pedis) is warranted. Specifically, the Veteran asserts that he experienced recurrent tinea pedis infections while he was on active duty. Service connection may be granted for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran consistently and credibly complained of tinea pedis symptoms in service and since active duty. These infections are demonstrated by the service record and in-service disease is established. Here, the records show the Veteran is currently treated for tinea pedis with onychomycosis. See August 2014 Medical Record; see also August 2020 Hearing Transcript. Essentially, the Veteran contends he has chronic tinea pedis, and the record demonstrates treatment in service and continuing to the present. The Veteran is competent to describe tinea pedis symptoms as these symptoms are experienced through his senses and require only personal knowledge rather than medical expertise. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board finds the Veteran’s statements to be credible and consistent with the treatment record showing in-service treatment with clotrimazole, continuing treatment following service with clotrimazole, and his testimony regarding post-service systemic treatment with an oral medication. As to nexus between a current disability and in-service disease, the Veteran was examined in September 2014. While the VA examiner addressed the Veteran’s dermatophytosis, they failed to provide an opinion on the etiology of the Veteran’s claimed tinea pedis disability. The Board has considered whether it may be necessary to remand this claim for an adequate VA medical opinion on this matter. However, the Board has also considered whether, with resolution of reasonable doubt in the Veteran’s favor, the Board may grant the claim at this time. The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Layno, 6 Vet. App. at 465. In this case, the Board finds that the evidence is at least in equipoise, and the lay testimony provides sufficient support for the present claim. The Board finds that lay testimony to be credible. There is no medical opinion of record that refutes that lay testimony that the Veteran began experiencing symptoms while on active duty and since service that have been identified as tinea pedis. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current tinea pedis of the bilateral feet is related to service, and the evidence currently of record in this matter is legally sufficient to grant the claim without further development. Accordingly, after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for tinea pedis of the bilateral feet is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for pseudofolliculitis barbae (PFB) is remanded. The Veteran has perfected an appeal as to service connection for pseudofolliculitis barbae, he is already service connected for dermatophytosis of the head, neck, and hands and is evaluated for this disability based on symptoms affecting his exposed skin. See November 2014 Rating Decision. The November 2014 rating decision on appeal denied service connection for PFB. The Veteran testified in August 2020 that during service he requested a shaving profile due to PFB and since discharge from service he has experienced symptoms of PFB, but that he has not had manifestations of PFB in many years; the Veteran testified that he was not experiencing PFB after growing his beard. The Veteran’s service records do not show a diagnosis of PFB. Service medical records do show treatment for tinea pedis, dermatophytosis, eczema, and contact dermatitis. Service records also show a September 2007 treatment record noted the Veteran was being seen in response to a request for a shaving profile. The record does not show a diagnosis of PFB or that a profile was granted, the assessment was no skin symptoms were present. A March 2008 service record shows an assessment of “shaving lesion”, and noted it was mild and inactive. See September 2007 Service Record; see also March 2008 Service Record. Following the issuance of a September 2016 Statement of the Case (SOC), VA received and associated with the claims file some of the Veteran’s VA treatment records in July 2020. However, the Veteran’s VA treatment records from July 2020 to the present are not associated with the claims file. In light of the Veteran’s testimony of symptoms of PFB following in service and thereafter, the Board finds remand is warranted to obtain his complete records. The Veteran’s VA medical records are constructively before the Board and remand is necessary to obtain his outstanding treatment records. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). 2. Entitlement to service connection for pes planus is remanded. The Veteran contends he has a disability characterized by bilateral arch pain on use of the feet and reported he experienced an onset of bilateral foot pain prior to discharge from active service. The Veteran was noted to have mild, asymptomatic pes planus on entrance and discharge. See February 1999 Medical Examination; see also November 2011 Medical Examination. As the Veteran’s pes planus was noted on entrance to service, his claim for service connection is based on aggravation of pre-existing disability. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). Moreover, VA is obligated to determine whether the pes planus is congenital or acquired. 38 C.F.R. § 4.57. The Veteran was afforded a VA examination in September 2014 and the examiner found there was clear and unmistakable evidence of pre-existing pes planus that was not aggravated by service. However, the examiner did not note or discuss any contentions from the Veteran in determining there was no record of symptomatic pes planus. As noted above, the Veteran testified that during his period in the Army, he experienced the onset of bilateral arch pain as a result of increased load bearing during duty. See August 2020 Hearing Transcript. The Board finds the September 2014 VA examination inadequate because the examiner did not provide adequate rationale regarding the Veteran’s lay statements of an onset of bilateral arch pain in service, or even list the Veteran’s lay statements regarding his claimed disability. The September 2014 VA opinion does not contain an adequate rationale, because the rationale only considers the absence of medical records without addressing the Veteran’s lay statements regarding his bilateral arch pain prior to his discharge from active duty. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (finding an examination was inadequate where the examiner did not comment on the Veteran’s report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). The examiner also did not address the necessary question of whether the Veteran’s pes planus is either congenital or acquired, or, if congenital, if it is a defect (essentially static in nature) or a disease (capable of worsening or improving). The Veteran was also diagnosed with hallux valgus and plantar fasciitis, but the examiner did not address these disabilities. Therefore, the Board finds an additional examination and opinion should be obtained that addresses the Veteran’s competent and credible statements regarding bilateral arch pain prior to discharge and whether this is evidence of aggravation of bilateral pes planus or incurrence of hallux valgus or plantar fasciitis. 3. Entitlement to service connection for medial plica syndrome, claimed as shin splints is remanded. The Veteran contends he has a disability characterized by pain in his bilateral shin pain that occurs when running. The Board notes service records show a diagnosis of medial plica syndrome. See January 2008 Medical Record. A VA examination is warranted to address the Veteran’s contentions and determine if his diagnosis of medial plica syndrome and complaints of bilateral shin splints are related. Given the above, the Board finds there is insufficient information to make a decision on the Veteran’s claim and that the low threshold for providing a VA examination, in order to obtain a medical opinion, has been met in this case. See 38 U.S.C. § 5103A; McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 4. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. The Veteran also testified that he has PTSD due to experiences while deployed to Iraq and in his duties guarding detainees. The Board notes medical record dated July 2020 show treatment for PTSD. See July 2020 Medical Record. The Veteran’s VA medical records are constructively before the Board and remand is necessary to obtain his outstanding treatment records. Bell, 2 Vet. App. at 613. The Veteran has been scheduled for a VA examination but has failed to report. The Veteran is provided a final opportunity to present for a VA examination. The Veteran is advised that failure to report for the VA examination, without good cause, may have adverse consequences. 38 C.F.R. § 3.655. 5. Entitlement to service connection for hearing loss is remanded. 6. Entitlement to service connection for tinnitus is remanded. The Veteran testified at the August 2020 hearing that he experienced the onset of hearing loss and tinnitus in service and the he has undergone testing at VA to determine the presence of hearing loss. The Veteran’s medical records show an assessment of tinnitus. See March 2017 Medical Record. The Veteran has been scheduled for VA examinations for hearing loss and tinnitus but has failed to report. The Veteran is provided a final opportunity to present for a VA examination. The Veteran is advised that failure to report for the VA examination, without good cause, may have adverse consequences. 38 C.F.R. § 3.655. 7. Entitlement to an initial compensable evaluation for cluster headaches is remanded. The Veteran was last afforded a VA headaches examination in September 2014. In August 2020, the Veteran testified that his symptoms, although intermittent, resulted in debilitating pain, indicating his headache disability had worsened since the most recent VA examination. Therefore, a remand is required to afford the Veteran a contemporaneous VA examination to determine the current severity of his cluster headaches. The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records from after the issuance of the September 2016 SOC. 2. Schedule the Veteran for a VA examination to determine the nature and likely cause of the Veteran’s foot disabilities. The VA examiner is requested to review all pertinent records associated with the claims file, and in particular, a copy of this remand. The VA examiner is requested to obtain a full recorded history regarding the Veteran’s foot pain prior to, during, and following service. Then, please opine as to the following: a. The examiner should provide an opinion whether the Veteran’s bilateral pes planus is congenital or acquired. The examiner should note that 38 C.F.R. § 4.57 states that “[t]he congenital condition, with depression of the arch, but no evidence of abnormal callosities, areas of pressure, strain or demonstrable tenderness,” is a congenital abnormality. If the pes planus is congenital, the examiner should opine whether the disorder is more properly classified as a congenital disease or a congenital defect. For VA purposes, a defect differs from a disease in that the former is “more or less stationary in nature” whereas the latter is “capable of improving or deteriorating.” If the Veteran’s pes planus is either a congenital disease or acquired, the examiner is asked to answer the remaining questions: b. Did the Veteran’s pre-existing pes planus increase in severity during service? c. If the Veteran’s pes planus increased in severity in service, is it clear and unmistakable the Veteran’s pes planus increased in severity due to a natural progression of the disease? d. Is it at least as likely as not that the Veteran’s diagnosed hallux valgus or plantar fasciitis was incurred in or otherwise due to active service? Please provide rationale considering the Veteran’s competent reports of bilateral arch pain prior to discharge from active service. Please provide a complete rationale for all opinions, including, but not limited to, whether there is a medical reason for accepting or rejecting the Veteran’s lay statements. 3. Schedule the Veteran for a VA examination regarding his service connection claims for bilateral shin splints. The examiner must specifically address whether the claimed symptoms of bilateral shin splints are attributable to a diagnosed condition, including the diagnosed medial plica syndrome shown in service. The examiner must then address whether the condition is at least as likely as not (50 percent probability or greater) the result of disease or injury in active service. The examiner is advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The examination report must include a complete rationale for all opinions provided. 4. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD, depression, and anxiety disorder. If the Veteran is diagnosed with PTSD, then the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If any other acquired psychiatric disorders are diagnosed, then the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include her in-service mental health treatment. The VA examiner is directed to the Veteran’s August 2020 hearing testimony regarding his duties in service guarding combatant detainees while deployed to Iraq. The examiner is advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The examination report must include a complete rationale for all opinions provided. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed hearing loss and tinnitus. The examiner is advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The examination report must include a complete rationale for all opinions provided. (Continued on the next page)   6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected cluster headaches. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Trickey 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.