Citation Nr: 21031364 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 17-20 981 DATE: May 21, 2021 REMANDED Entitlement to service connection for nose fracture is remanded. Entitlement to service connection for sinus problems is remanded. Entitlement to service connection for a right shoulder injury is remanded. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome, right upper extremity is remanded. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome, left upper extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1986 to May 2006. In March 2021, the Veteran testified at a Board hearing before the undersigned. 1. Entitlement to service connection for nose fracture is remanded. 2. Entitlement to service connection for sinus problems is remanded. The Veteran's service treatment records (STRs) show that the Veteran was involved in an automobile accident in August 2001, during service. According to the emergency discharge instructions the Veteran was informed that based on examination he had a bruise or minor fracture of his nose. He was also informed that x-rays were not taken because a minor fracture of the nose bone (no parts out of place) was treated the same as a contusion (bruise to the nose). The injury was said to take 1-4 weeks to heal with no additional treatment. During the March 2021 Board hearing, the Veteran reported that he has had sinus issues since the accident where at times it is difficult to breathe and difficult to smell. He also stated that he receives a nasal spray to help with breathing that is prescribed by a private physician. As there is evidence the Veteran had a nose injury in service, he currently has symptoms of a disability, and there is an indication those symptoms may be associated with the Veteran's service, the Board finds that a VA examination is necessary to determine whether the Veteran has residuals from the in-service nose injury, to include sinus problems. McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Additionally, on remand, an attempt should be made to obtain the Veteran identified private treatment records for his sinus condition. 3. Entitlement to service connection for a right shoulder injury is remanded. During the March 2021 Board hearing, the Veteran testified that in 1991 he injured his right shoulder playing softball when he ran into the first baseman. He stated that his shoulder hurt so bad he had to leave the game and seek medical attention. The incident occurred in Washington, D. C. and he was treated at an off-base location. The Veteran testified that he had issues with his right shoulder and bicep after the injury. He stated he was unable to do physical training such as pushups or pullups because he couldn't stick his arm straight out or hold it up. The Veteran's STRs show he was diagnosed with tendinitis of the right bicep. He also testified that he has continued to have right shoulder pain since service. As there is evidence the Veteran had a right shoulder injury in service, he currently has symptoms of a disability, and there is an indication those symptoms may be associated with the Veteran's service, the Board finds that a VA examination is necessary to determine whether the Veteran has a shoulder condition that is related to the in-service injury. McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Additionally, on remand, an attempt should be made to obtain the private treatment records for the 1991 right shoulder injury. 4. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. The Veteran contends that his PTSD symptoms are worse than the currently assigned 30 percent disability rating would suggest. During the March 2021 Board hearing, the Veteran testified that he reported more symptoms at the July 2016 VA PTSD examination than were documented. Additionally, the Veteran described his current symptoms which at the very least show that the Veteran's PTSD disability has likely worsened since the July 2016 VA examination. In light of the Veteran's worsening PTSD symptoms, the Board finds that a new VA examination is necessary to determine the current severity of his PTSD disability. 5. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome, right upper extremity is remanded. 6. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome, left upper extremity is remanded. The Veteran contends that his right and left upper extremity carpal tunnel disabilities warrant a rating higher than the 10 percent they are currently assigned. Specifically, the Veteran testified that his disabilities have worsened, and he has increased pain and range of motion limitations in his wrists when lifting items such as groceries or carrying trash bags. In light of the Veteran's worsening carpal tunnel syndrome, the Board finds that a new VA examination is necessary to ascertain the severity of his right and left upper extremity disabilities. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify all private medical providers who have treated him for his right shoulder and sinus conditions. For each provider identified, the Veteran should be requested to complete and sign a separate VA Form 21-4142, Authorization and Consent to Release Information to VA, and arrangements should thereafter be made to obtain the Veteran's treatment records from these facilities. A response, negative or positive, should be associated with the claims file. 2. Thereafter, schedule the Veteran for a VA nose/sinus examination. The examiner must review the claims file and must note that review in the report. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. The examiner should consider the Veteran's reports of his in-service injuries and subsequent symptoms. The examiner should provide the following information: (a) Diagnose any nose or sinus disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any current nose or sinus disability is due to the Veteran's service, to include the 2001 in-service motor vehicle accident. 3. Thereafter, schedule the Veteran for a VA shoulder examination. The examiner must review the claims file and must note that review in the report. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. The examiner should consider the Veteran's reports of his in-service injuries and subsequent symptoms. The examiner should provide the following information: (a) Diagnose any right shoulder or right bicep disability found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any current right shoulder or right bicep disability is due to the Veteran's service, to include the 1991 softball injury and the 2001 in-service motor vehicle accident. 4. Thereafter, schedule the Veteran for a VA carpal tunnel examination to ascertain the current severity of his right and left upper extremity carpal tunnel disabilities. 5. Thereafter, schedule the Veteran for a VA PTSD examination to ascertain the current severity of his PTSD disability. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Mitchell, 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.