Citation Nr: 21031870 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 18-19 940 DATE: May 24, 2021 REMANDED Entitlement to service connection for chronic regional pain syndrome affecting the right side of the face is remanded. Entitlement to service connection for a neck disorder, claimed as myofascial neck pain with trigger points, is remanded. Entitlement to service connection for temporomandibular joint disorder (TMJ) is remanded. Entitlement to a right shoulder disorder, claimed as a torn bicep tendon, is remanded. Entitlement to service connection for a right wrist disorder, claimed as limitation of motion, is remanded. Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a left clavicle disorder is remanded. Entitlement to a rating in excess of 10 percent for scars is remanded. Entitlement to a compensable rating for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2009 to July 2012. In February 2020, the Veteran presented testimony before the undersigned Veterans Law Judge of the Board. A transcript of the hearing has been associated with the claims file. 1. Chronic regional pain syndrome (pain and numbness of the face), myofascial neck pain, TMJ, right shoulder bicep tendon tear, right wrist disorder, and low back disorder During the Veteran's Board hearing, he testified that he suffered a fall due to his service connected right ankle disability, which resulted in injuries to the right side of his face (chronic regional pain syndrome), myofascial neck pain, TMJ, a torn right bicep tendon, a right wrist disorder, and a low back disorder. The Veteran also asserts he suffers from a left clavicle disorder that is due to or aggravated by his service-connected left shoulder disability. The Veteran's post-service VA treatment records note a history of a fall in April 2005, resulting in TMJ and chronic facial pain and numbness. See October 2017 VA Treatment Record. The record also notes instances of complaints of right wrist pain and direct tenderness with stressing of the long head of biceps tendon. See June 2015 VA Treatment Record. Finally, an August 2016 MRI noted mild degenerative changes of lower lumbar spine. However, the Board cannot make a fully-informed decision on these issues because no VA examiner has opined whether the chronic regional pain syndrome, myofascial neck pain, TMJ, a torn right bicep tendon, a right wrist disorder, and a low back disorder are due to the fall in 2005, resulting from the service-connected right ankle disability. As such, a remand is required for VA examinations and opinions. 2. Left clavicle disorder The Veteran also asserts he suffers from a left clavicle disorder that is due to or aggravated by his service-connected left shoulder disability. The Veteran was previously examined by VA in a June 2017 shoulder examination. At that time, the examiner noted tenderness along the acromioclavicular (AC) joint. During the Veteran's February 2020 Board hearing, he reported experiencing grinding and a feeling that it was "loose." See Board Hearing Transcript, pg. 20. However, to date, it is unclear whether the Veteran has a separate and distinct disorder of the left clavicle that is due to or aggravated by his left shoulder disorder. Therefore, as the Board cannot make a fully-informed decision on this issue because no VA examiner has opined whether any impairment of the left clavicle is due to or aggravated by his service-connected left shoulder disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); As such, a remand is required for a VA examination and opinion. 3. Headaches The Veteran is seeking entitlement to a compensable rating for his service-connected headaches disability. In support of his claim, he testified during his February 2020 Bord hearing that he suffers from headaches daily. The Veteran was last examined by VA in September 2017. Therefore, the Board finds that a new VA examination is needed to ascertain the current severity and manifestation of the service-connected headaches disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown,6 Vet. App. 377 (1994). 4. Scars The Veteran is seeking entitlement to a compensable rating for his service-connected scar disability. In support of his claim, he testified during his February 2020 Bord hearing that he has a total of 5 scars associated with surgery on his service-connected left shoulder. He states they are painful and discolored. The Veteran's left shoulder disability was last examined by VA in June 2017. At that time, the examiner only noted the existence of one scar on the left shoulder. Therefore, the Board finds that a new VA examination is needed to ascertain the current severity and manifestation of the service-connected scar disability, and to ascertain the correct number of surgical scars. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown,6 Vet. App. 377 (1994). The matters are REMANDED for the following action: 1. Obtain any available VA or private treatment records not currently associated with the claims folder dated from October 2018 to the present. 2. Schedule the Veteran with a specialist for a VA examination(s) to determine the nature and etiology of the claimed disorders of chronic regional pain syndrome (facial pain and numbness), myofascial neck pain, TMJ, right shoulder bicep tendon tear, right wrist disorder, and low back disorder. A complete rationale for all opinions offered must be provided. The examiner(s) is asked to provide an opinion on the following, with a full rationale: (a.) Confirm diagnoses for the claimed disorders of chronic regional pain syndrome (facial pain and numbness), neck disorder (myofascial neck pain), TMJ, right shoulder bicep tendon tear, right wrist disorder, and low back disorder. If no clinical diagnosis(es) is made, the examiner must ascertain whether the Veteran's claimed disorders constitute a functional impairment of earning capacity. If the Veteran's pain does not reach this threshold, and thus should not be considered a disability, the examiner should so clarify. (b.) For each disorder, the examiner is asked to state the following: 1. whether each disorder is at least as likely as not (a 50 percent or greater probability) related to the Veteran's active service. 2. Whether it is at least as likely as not that each disorder was caused by the service-connected right ankle disability, yes or no? 3. Is it at least as likely as not that the Veteran's disorders underwent any aggravation (incremental increase in disability, regardless of its permanence), due to right ankle disability, yes or no? In answering these questions, the examiner is asked to consider the Veteran's statement that his fall in April 2005 was the result of his service-connected ankle disability and, but-for this disability, he would not have fallen and incurred these disorders. The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. The medical treatise literature provided by the Veteran and his representative in rendering the above requested opinions should also be considered. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Schedule the Veteran for a VA examination(s) with a specialist to determine the nature and etiology of the claimed left clavicle disorder. A complete rationale for all opinions offered must be provided. The examiner is asked to provide an opinion on the following, with a full rationale: (a.) Determine whether the Veteran currently suffers from a left clavicle disorder separate and distinct from the already service-connected left shoulder disorder. (b.) If no clinical diagnosis(es) is made, the examiner must ascertain whether the Veteran's claimed disorder constitutes a functional impairment of earning capacity. If the Veteran's pain of the left clavicle disorder does not reach this threshold, and thus should not be considered a disability, the examiner should so clarify. (c.) The examiner is asked to state the following: 1. whether a diagnosed left clavicle disorder is at least as likely as not (a 50 percent or greater probability) related to the Veteran's active service. 2. Whether it is at least as likely as not that the left clavicle disorder was caused by the service-connected left shoulder disability, yes or no? 3. Is it at least as likely as not that the Veteran's left clavicle disorder underwent any aggravation (incremental increase in disability, regardless of its permanence), due to the left shoulder disability, yes or no? The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. The medical treatise literature provided by the Veteran and his representative in rendering the above requested opinions should also be considered. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Schedule the Veteran for a VA examination to ascertain the severity and manifestations of his service-connected headaches. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is instructed to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Schedule the Veteran for a VA examination to ascertain the severity and manifestations of his service-connected scar disabilities. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is asked to identify the correct number of scars associated with the left shoulder disability, to include all "port" scars, which the Veteran contends is 5 in total. The examiner must then address the Veteran's contentions that these 5 scars are all painful and discolored. The examiner is instructed to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. The AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berry, 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.