Citation Nr: 21030981 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 16-34 210 DATE: May 20, 2021 REMANDED Entitlement to service connection for left leg shin splints is remanded. Entitlement to service connection for right leg shin splints is remanded. Entitlement to service connection for a sexually transmitted disease (STD), to include herpes, is remanded. Entitlement to service connection for a scar status post Cesarean section (C-section) is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety, to include as due to military sexual trauma (MST), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1981 to March 1988. The Veteran testified at a September 2020 Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The Veteran's claim is for entitlement to service connection for PTSD; however, the VA treatment records indicate the Veteran has anxiety. Therefore, the Board will recharacterize the issue of entitlement to service connection for PTSD as entitlement to service connection for any acquired psychiatric disorder, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Remand is required to obtain VA examinations. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the United States Court of Appeals for Veterans Claims indicated that there was a four-part test to determine whether an examination was necessary under 38 C.F.R. § 3.159(c)(4). Id. at 81. Under this test, VA will provide a medical examination or obtain a medical opinion where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence to make a decision on the claim. Id.; see also 38 C.F.R. § 3.159(c)(4). 1. Entitlement to service connection for left leg shin splints is remanded. 2. Entitlement to service connection for right leg shin splints is remanded. Here, the service treatment records (STRs) show that in January 1982, the Veteran complained of bilateral leg pain and was assessed to have bilateral leg shin splints. In a January 2015 lay statement, the Veteran's battle buddy, V.L.B. stated that the Veteran was placed on a physical profile for shin splints during service and remained on crutches for the remainder of basic training. The Veteran testified at September 2020 Board hearing that she experienced bilateral shin splints during bootcamp and was placed on crutches. Board Hearing Transcript (T.) at 10. She stated that she also experienced bilateral leg shin splints in 2018. T. at 8. Therefore, the criteria for McLendon have been met. And as a result, the Board cannot make a fully informed decision on the issue of entitlement to service connection for bilateral leg shin splints because no VA examiner has opined whether the Veteran's bilateral leg shin splints was caused by service. Also, remand is required to obtain the Veteran's military personnel records. It is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim, including making reasonable efforts to obtain military personnel records. 38 C.F.R. § 3.159(c)(1). As the Veteran and V.L.B. stated that the Veteran was placed on a physical profile due to experiencing shin splints, the military personnel records are of interest and should be obtained. 3. Entitlement to service connection for a STD, to include herpes, is remanded. Here, a January 1983 STR indicates the Veteran was diagnosed with and treated for herpes. In a March 2015 lay statement, the Veteran's roommate, C.S., stated that the Veteran told her she was in pain and needed to seek treatment at the hospital. C.S. stated that after the Veteran went to sick call, the Veteran disclosed that she had herpes that was contracted from another soldier. C.S. stated that the Veteran has been traumatized by this incident. At the September 2020 Board hearing, the Veteran testified that she contracted herpes from a personal assault by another soldier. T. at 3-4. Therefore, the criteria for McLendon have been met. And as a result, the Board cannot make a fully informed decision on the issue of entitlement to service connection for a sexually transmitted disease, to include herpes, because no VA examiner has opined whether the Veteran's sexually transmitted disease was caused by service. 4. Entitlement to service connection for a scar status post C-section is remanded. Here, the STRs show the Veteran had a c-section in May 1985 at an Army community hospital. In July 1985, the Veteran complained of incisional irritation due to the C-section. At the September 2020 Board hearing, the Veteran testified that she had a C-section in service and the scar from the C-section is now painful. T. at 5-8. Therefore, the criteria for McLendon have been met. And as a result, the Board cannot make a fully informed decision on the issue of entitlement to service connection for a scar status post C-section because no VA examiner has opined whether the Veteran has a scar from the C-section that was conducted in service. Also, remand is required to obtain the Veteran's military hospital treatment records. It is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim, including making reasonable efforts to obtain military personnel records. 38 C.F.R. § 3.159(c)(1). The STRs indicate in May 1985 that the Veteran was discharged from Darnall Army Community Hospital from admission for a C-section. These records are of interest as they could include information regarding the evaluation, treatment, diagnosis, and residual effects of the Veteran's scar status post C-section. 5. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and anxiety, to include as due to MST, is remanded. In a May 2015 lay statement, C.S. confirmed the Veteran to have been traumatized by a personal assault during service. At the September 2020 Board hearing, the Veteran testified that she was the victim of a personal assault and contracted herpes as a result. T. at 3-4. An October 2010 VA treatment record shows the Veteran is diagnosed with anxiety. As the personal assault is found by the Board to be a verified stressor and the Veteran has a current acquired psychiatric disorder, the criteria for McLendon have been met. And as a result, the Board cannot make a fully informed decision on the issue of entitlement to service connection for an acquired psychiatric disorder because no VA examiner has opined whether the Veteran's acquired psychiatric was caused by service. The matters are REMANDED for the following action: 1. Obtain the Veteran's military personnel records. Document all requests for information as well as all responses in the claims file. 2. Obtain records from any inpatient treatment at Darnall Army Community Hospital from December 1981 to March 1988. Document all requests for information as well as all responses in the claims file. 3. After the above records development, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral shin splints found to be present. The examiner must opine as to whether the disability is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, including in-service January 1982 shin splints and/or physical profiles. The examiner must specifically address the Veteran's and V.L.B.'s lay statements and contentions in the context of any negative opinion. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sexually transmitted disease, to include herpes, found to be present. The examiner must opine as to whether any such disability found to be present at any point during the appeal period is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, including the verified in-service personal assault and a January 1983 herpes diagnosis. The examiner must specifically address the Veteran's lay statements and C.S.'s lay statement and contentions in the context of any negative opinion. 5. After the above records development, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any scar status post C-section found to be present. The examiner must opine as to whether the disability is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, including the in-service May 1985 C-section at Darnall Army Community Hospital and July 1985 complaints of irritation of the incision. The examiner must specifically consider the Veteran's lay statements and contentions in the context of any negative opinion. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD and anxiety, found to be present. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opined whether it is at least as likely as not (50 percent or greater probability) related to the verified in-service stressor of the acknowledged in-service personal assault or the January 1983 herpes diagnosis. If any other acquired psychiatric disorders are diagnosed, to include anxiety, the examiner must opine whether each diagnosed disorder is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, to include the in-service personal assault and the January 1983 herpes diagnosis. The examiner must specifically address the Veteran's lay statements and C.S.'s lay statement and contentions in the context of any negative opinion. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thompson, 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.