Citation Nr: 21013756 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-47 909 DATE: March 10, 2021 REMANDED Entitlement to service connection for migraines is remanded. Entitlement to service connection for a bilateral eye disability is remanded. Entitlement to service connection for allergies is remanded. Entitlement to service connection for a jaw disability, to include temporomandibular (TMJ), is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a bilateral leg disability is remanded. Entitlement to service connection for a hernia disability is remanded. Entitlement to service connection for bilateral foot disability is remanded. Entitlement to service connection for a bilateral elbow disability is remanded. Entitlement to service connection for a bilateral wrist disability is remanded. Entitlement to service connection for a bilateral ankle disability is remanded. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) due to military sexual trauma, is remanded. REASONS FOR REMAND The Veteran had active naval service from June 2010 to March 2011. She also had periods of active duty for training (ACDUTRA) with the United States Navy Reserve, including from June 10, 2012, to June 26, 2012, and from March 10, 2013, to June 21, 2013. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. This case was previously before the Board in December 2018, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. For the reasons discussed below, there has not been substantial compliance with the remand directives and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for migraines. 2. Entitlement to service connection for a bilateral eye disability. 3. Entitlement to service connection for allergies. 4. Entitlement to service connection for a jaw disability, to include TMJ. 5. Entitlement to service connection for a neck disability. 6. Entitlement to service connection for hypertension. 7. Entitlement to service connection for a low back disability. 8. Entitlement to service connection for a bilateral leg disability. 9. Entitlement to service connection for a hernia disability. 10. Entitlement to service connection for bilateral foot disability. In December 2018, the Board remanded this case, in part, so that the AOJ could “request that the appropriate authority certify the completeness (DD Form 2963) of the Veteran’s service treatment records”. In April 2020 the AOJ associated the Veteran’s service treatment records with the record. However, the record does not contain certification from an appropriate authority that the service treatment records in the claims folder are complete. As such a remand is necessary to ensure substantial compliance with the prior remand directives. 11. Entitlement to service connection for a bilateral elbow disability. A June 2018 VA treatment record documents the Veteran’s reports that her elbow pain started in 2010 while she was in the military. She reported noticeable pain with movement of the elbow and lifting. Service treatment records dated in March 2013 demonstrate she sought treatment for elbow pain, and the provider noted she had overuse syndrome due to a recent increase in physical activity. As such there is evidence of peristent symptoms of a disability and an in-service event, injury, or disease. Considering the credible lay evidence reporting problems with the Veteran’s elbows since service, coupled with VA treatment records showing medical care for reports of elbow pain, she should be afforded a VA examination with opinion on this issue. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 12. Entitlement to service connection for a bilateral wrist disability. An August 2016 VA treatment record documents the Veteran’s reports of complaining of pain in her wrist joints for the prior three to four years. This suggests a possible onset of wrist pain during the Veteran’s service as well as a continuity of symptoms since then. She also reported experiencing wrist pain during pushups during physical training (PT). See March 2016 Notice of Disagreement. Considering the credible lay evidence reporting problems with the Veteran’s wrists since service, coupled with VA treatment records showing medical care for reports of wrist pain, she should be afforded a VA examination with opinion on this issue. 13. Entitlement to service connection for a bilateral ankle disability. Service treatment records dated in March 2013 show the Veteran had ankle pain for several weeks that worsened with running. An August 2016 VA treatment record documents the Veteran’s reports of pain in her ankle joints for the prior three to four years, which could correspond with her periods ACDUTRA. Considering the credible lay evidence reporting problems with the Veteran’s ankles since service, coupled with VA treatment records showing medical care for reports of ankle pain, she should be afforded a VA examination with opinion on this issue. 14. Entitlement to service connection for a psychiatric disorder, to include PTSD due to military sexual trauma, is remanded. An October 2019 VA treatment record documents the Veteran’s report of a trauma history including a military sexual assault (MST) in 2012 that likely served as an index event. The provider stated that the Veteran exhibited the full range of PTSD symptoms secondary to the index trauma. VA treatment records show the Veteran has been diagnosed with PTSD, anxiety, and depression. As such, there is evidence of a current diagnosis. Considering the credible lay and medical evidence of record, remand is needed to afford the Veteran an examination on this issue. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2021 to the present. 2. Ensure that a complete copy of the Veteran’s service treatment and personnel records have been associated with the claims file and request that the appropriate authority certify the completeness (DD Form 2963) of the Veteran’s service treatment records. 3. Arrange to have the Veteran scheduled for a VA upper extremity examination. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has a right elbow, left elbow, right wrist, or left wrist disability that had an onset in, or is otherwise attributable to, her period of active service, including her periods of ACDUTRA. In so doing, the examiner should discuss the medical significance, if any, of the March 2013 service treatment records, the June 2018 report by the Veteran that her elbow pain began while she was in the military, the Veteran’s reports of wrist pain while performing physical training in the military, and her August 2016 report of wrist pain starting three to four years prior. A complete medical rationale for all opinions expressed must be provided. 4. Arrange to have the Veteran scheduled for a VA ankle examination. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has a right or left ankle disability that had an onset in, or is otherwise attributable to, her period of active service, including her periods of ACDUTRA. In so doing, the examiner should discuss the medical significance, if any, of the March 2013 and June 2013 service treatment records as well as the August 2016 report that her symptoms began three to four years prior. A complete medical rationale for all opinions expressed must be provided. 5. Attempt to corroborate the Veteran’s in-service stressor based on personal assault. If more details are needed, contact the Veteran to request the information. 6. After the Veteran’s reported stressors have been developed, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of any acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). If the Veteran is diagnosed with PTSD, 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. The examiner must opine whether the evidence of record, including the Veteran’s lay statements, and the Veteran’s service records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304 (f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran’s active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. (Continued on the next page)   If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. Jack S. Komperda Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Smith, Associate 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.