Citation Nr: 21041540 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 16-61 215 DATE: July 9, 2021 REMANDED Entitlement to service connection for a left wrist disorder (claimed as left wrist sprain) is remanded. Entitlement to service connection for a right wrist disorder is remanded. Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a left and right foot disorder (claimed as foot pain and numbness), to include as secondary to a lumbar spine disorder, is remanded. Entitlement to service connection for depression is remanded. Entitlement to an initial compensable evaluation for a scar of the right wrist and arm is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1978 to August 1982. This case comes before the Board of Veterans' Appeals (Board) on appeal from April 2016, July 2016, August 2016, and December 2017 rating decisions by the Department of Veterans Affairs (VA). A hearing was held before the undersigned Veterans Law Judge in March 2021. A transcript of the hearing is of record. The Veterans Law Judge held the record open for a 60-day period following the hearing to allow for the submission of additional evidence; however, the Veteran did not submit any evidence. The left and right foot disorder claim has been characterized to more accurately reflect the Veteran's contentions, including his testimony during the Board hearing. It is also noted that a request to reopen a claim for service connection for a bilateral foot skin disorder (originally claimed as fungus, now claimed as athlete's foot) was separately denied as tinea pedis in the April 2016 rating decision and not appealed. On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's claims. Specifically, it appears that there may be outstanding VA and non-VA treatment records, as well as Social Security Administration (SSA) records, as detailed in the directives below. Regarding the left and right wrist claims, the April 2016 (left wrist)/November 2016 (right wrist) VA examiner determined that it was less likely than not that the Veteran had wrist problems related to service. In so finding, the examiner indicated that the Veteran had wrist pain without diagnoses. In an April 2016 addendum, the examiner noted that x-rays of the left wrist were unremarkable and confirmed the earlier opinion. On the other hand, VA and private treatment records subsequent to the 2016 VA examinations show that the Veteran does have wrist diagnoses, including x-ray findings of arthritis, as detailed in the directives below. Regarding the lumbar spine claim, the November 2016 VA examiner determined that it was less likely than not that the Veteran's claimed disorder was related to service. In so finding, the examiner indicated that the Veteran was diagnosed with in-service lumbar strain which should have no residual deficits and was a self-limiting injury occurring over 35 years ago, without complaints since that time. Nevertheless, it is unclear if the examiner considered the complete history of the development of the disorder, inasmuch as the Veteran has reported a history of post-service lumbar spine treatment. See March 2021 Bd. Hrg. Tr. and November 2015 completed release for Willis Chiropractic (noting treatment in 1980s). The examiner also did not explain the medical significance of the 35-year time gap. Based on the foregoing, additional VA medical opinions are needed for the claims. Regarding the right wrist and arm scar claim, the Veteran was provided a VA examination in April 2016. His representative indicated in August 2017 and July 2018 written statements that the disability has increased in severity, and the Veteran testified that the VA examination may not accurately reflect the severity of the disability. An additional VA examination is needed. The case is REMANDED for the following actions: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his claimed disorders. This should specifically include the Lexington/Richland Alcohol and Drug Abuse Council (LRADAC) for mental health/depression, any non-VA surgeon for the feet, and Baptist Hospital for the lumbar spine. See March 2021 Bd. Hrg. Tr. at 26, 32 and July 2018 VA treatment record. After acquiring this information and obtaining any necessary authorization, obtain and associate these records with the claims file. The Veteran may also wish to submit or provide additional information for VA to attempt to obtain any treatment records for his lumbar spine from Willis Chiropractic. See February 2016 report of general information (unable to locate facility based on information provided by Veteran and internet search) and Bd. Hrg. Tr. at 8 (Veteran and representative to check for those treatment records); see also February 2016 report of contact and negative response from University of South Carolina/Department of Orthopedic Surgery. 2. Obtain VA treatment records dated from July 2018 to the present from the Columbia VA Medical Center, as well as any records contained in the Computerized Patient Record System (CPRS) Tools/Vista Imaging database. See March 2021 Bd. Hrg. Tr. at 20; May 2016 VA treatment record (noted service records scanned into that database). 3. Obtain a copy of any decision to grant or deny SSA disability benefits to the Veteran and the records upon which that decision was based and associate them with the claims file. See VA treatment records from July 2017 and October 2017 (Veteran reported being in receipt of such benefits after pending claim that same year). If the search for such records has negative results, the claims file should be properly documented as to the unavailability of those records. 4. DO NOT SCHEDULE THE FOLLOWING UNTIL THE ABOVE RECORDS ARE OBTAINED TO THE EXTENT POSSIBLE. 5. Refer the Veteran's claims file to a VA examiner for a clarifying opinion as to the nature and etiology of any current left and right wrist disorder that may be present. An additional examination of the Veteran should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements, as well as the April 2016 and November 2016 VA examination reports. The examiner should identify all current left and right wrist disorders. See, e.g., February 2017 VA x-ray report (impression of mild bilateral first carpometacarpal (CMC) and triscaphe degenerative changes; September 2016 and April 2017 VA EMG reports (conclusions of left and right mild median neuropathy at the wrist as in carpal tunnel syndrome) and July 2018 VA treatment record (assessment including bilateral hand carpal tunnel syndrome (CTS)). For each diagnosis identified, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran's military service, including any injury therein. The Veteran has contended that his current wrist problems may be related to in-service injuries. See, e.g., March 2021 Bd. Hrg. Tr. The service treatment records dated in 1980 show various treatment for both wrists. In providing this opinion, the examiner should discuss medically known or theoretical causes of any currently diagnosed disorder and describe how such a disorder generally presents or develops in most cases, in determining the likelihood that the current disorder is related to in-service events as opposed to another cause. 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. Refer the Veteran's claims file to a VA examiner for a clarifying opinion as to the nature and etiology of any current lumbar spine disorder that may be present. An additional examination of the Veteran should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements, as well as the November 2016 VA examination report. The examiner should identify all current lumbar spine disorders. Then, for each diagnosis identified, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran's military service, including any injury therein. The Veteran has contended that his current lumbar spine problems are the result of a progressive process that began during service. See, e.g., March 2021 Bd. Hrg. Tr. An undated service treatment record shows that the Veteran was treated for lumbosacral strain. He reported a history of recurrent back pain on a July 1981 periodic examination report of medical history, denying it on the June 1982 separation examination report of medical history. His service records show that he worked as a supply specialist. In addition, he has reported a history of post-service lumbar spine treatment beginning after a work injury when he was delivering bread. See March 2021 Bd. Hrg. Tr. and November 2015 completed release for Willis Chiropractic (noting treatment in 1980s). In providing this opinion, the examiner should discuss medically known or theoretical causes of any currently diagnosed disorder and describe how such a disorder generally presents or develops in most cases, in determining the likelihood that the current disorder is related to in-service events as opposed to another cause. 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. 7. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of his service-connected right wrist and arm scar. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should address whether any right wrist symptomatology is a manifestation of the Veteran's scar disability, as opposed to a nonservice-connected disorder, or whether it is not possible to make this distinction. See, e.g., March 2021 Bd. Hrg. Tr. at 13-17 (Veteran indicated unsure whether feeling in right wrist "go[ing] crazy" was from scar or other wrist problems). 8. Consider whether a VA examination or VA medical opinion is needed for the foot and depression claims after receipt of any additional records as requested above. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Postek, 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.