Citation Nr: 22015772 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 19-03 162A DATE: March 18, 2022 REMANDED The issue of service connection for a lumbar spine disorder is remanded. The issue of service connection for a cervical spine disorder is remanded. The issue of service connection for a chest keloid is remanded. The issue of service connection for a right leg keloid is remanded. The issue of service connection for a left foot disorder is remanded. The issue of service connection for bilateral pes planus is remanded. REASONS FOR REMAND The Veteran served in the U.S. Army from January 1966 to January 1969. He served in the Republic of Vietnam and his military decorations include the Combat Infantryman's Badge. In October 2021, the Veteran was afforded a hearing before the undersigned Veterans Law Judge. 1. The issue of service connection for a lumbar spine disorder is remanded. 2. The issue of service connection for a cervical spine disorder is remanded. 3. The issue of service connection for a chest keloid is remanded. 4. The issue of service connection for a right leg keloid is remanded. 5. The issue of service connection for a left foot disorder is remanded. 6. The issue of service connection for bilateral pes planus is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran has not been afforded VA examinations for cervical spine, keloid, left foot, and pes planus disorders. The April 2018 VA medical opinion regarding the lumbar spine is inadequate because the negative opinion is based solely on the lack of in-service treatment after an in service injury. The examiner did not address whether the in-service injury caused the Veteran's current lumbar spine disorders. Additionally, the VA examination report stated that the Veteran's lumbar disorder began in 1966 in service. This conflicts with the opinion stating the disorder did not begin in service. Therefore, remand is necessary. The RO adjudicator is advised that the Veteran served in combat. Under the law, the Veteran's account of in-service events that relate to these disabilities IS PRESUMED CREDIBLE. The RO adjudicator should ensure that any VA medical examiners are advised that the absence of service treatment records documenting the claimed in-combat service injuries is NOT A BASIS TO DENY THE CLAIMS. Remand is also necessary to attempt to obtain any private treatment records. The record indicates that the Veteran had private treatment for several of his disorders. THE REMAND DIRECTIVES FOLLOW. 2. Advise the Veteran that he may submit any additional medical and non-medical evidence relating to his claimed disorders that is not already in VA's possession. Specifically request authorization to obtain: *Private treatment records from any providers who have treated the Veteran for his claimed disorders, including Dr. Jones or his successor. *Physical examination records from the Veteran's former employer, American Can Company. *Private physical therapy records for the Veteran's lumbar spine treatment. *Records from a 1975 surgery to repair chest scars. *Private treatment for foot complaints, including pes planus. 3. Return the matter of the cause of the lumbar spine disorder to the examiner who conducted the April 2018 examination for a file review. If the examiner is not available, have the record reviewed by an equally qualified examiner. (a.) Ask the examiner to review the evidence and to provide a fully-explained opinion as to whether each identified lumbar spine or low back disorder was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (b.) If the examiner determines that the Veteran does not have a diagnosed lumbar spine or low back disorder, the examiner is asked to provide an opinion as to (1) whether the Veteran has low back pain which causes functional impairment and, if so, (2) whether the low back pain was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. If necessary, the examiner or the RO may schedule the Veteran for another VA medical examination or appropriate clinical testing. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The Veteran served in the U.S. Army from January 1966 to January 1969. He was in combat in Vietnam, and was awarded the Combat Infantryman Badge. Under the law, the Veteran's account of factual occurrences during combat service is CREDIBLE. On the Veteran's December 1965 physical examination for service entrance, his spine was normal. On his report of medical history at that time, the Veteran indicated that he did not have arthritis or rheumatism, or bone, joint, or other deformity. No notation of any spine complaints was made. In October 1967, the Veteran was in a motor vehicle accident. He had complaints of back pain which radiated from his cervical to lumbar spine. It was noted that he had acute muscle spasms and pain; the pain became less acute over time. On his December 1968 physical examination for service separation, the Veteran's spine was normal. On his report of medical history at that time, the Veteran indicated that he did not have arthritis or rheumatism, or bone, joint, or other deformity. The examiner noted a 1967 back injury and stated that the Veteran had "no problem now." A June 2017 VA treatment record states that the Veteran had low back pain for many years. An X ray study indicated chronic low back pain and degenerative changes. The Veteran was diagnosed with mechanical low back pain and lumbar spondylosis. An April 2018 VA examination report states a diagnosis of lumbosacral strain which began in 1966. The Veteran reported back pain that began in service because of carrying heavy equipment and has continued intermittently since that time. May and September 2018 VA treatment records indicate that the Veteran had complaints of low back pain that radiated into his right hip and both buttocks. The record states that the onset of symptoms was in service, although the Veteran had no acute inciting trauma or event. 2018 VA treatment records indicate private and VA physical therapy for the lumbar spine. A July 2020 VA treatment record states a diagnosis of chronic low back pain. At his October 2021 Board hearing, the Veteran reported having to carry personal gear and mortar while in Vietnam, which caused back pain in service. 4. Schedule the Veteran for a VA examination to determine the cause of each identified cervical spine or neck disorder. (a.) Ask the examiner to review the evidence and to provide a fully-explained opinion as to whether each identified cervical spine or neck disorder was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (b.) If the examiner determines that the Veteran does not have a diagnosed cervical spine or neck disorder, the examiner is asked to provide an opinion as to (1) whether the Veteran has neck pain which causes functional impairment and, if so, (2) whether the neck pain was caused by any in service event, injury, disease, or disorder, or in any way originated during service. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The Veteran served in the U.S. Army from January 1966 to January 1969. He was in combat in Vietnam, and was awarded the Combat Infantryman Badge. Under the law, the Veteran's account of factual occurrences during combat service is CREDIBLE. On the Veteran's December 1965 physical examination for service entrance, his spine was normal. On his report of medical history at that time, the Veteran indicated that he did not have arthritis or rheumatism, or bone, joint, or other deformity. No notation of any spine complaints was made. In October 1967, the Veteran was in a motor vehicle accident. He had complaints of back pain which radiated from his cervical to lumbar spine. It was noted that he had acute muscle spasms; the pain became less acute over time. On his December 1968 physical examination for service separation, the Veteran's spine was normal. On his report of medical history at that time, the Veteran indicated that he did not have arthritis or rheumatism or bone, joint, or other deformity. The examiner noted a 1967 back injury and stated that the Veteran had "no problem now." June 2017 and April 2018 VA treatment records indicate that the Veteran had neck pain. At his October 2021 Board hearing, the Veteran reported having to carry personal gear and mortar while in Vietnam, which caused neck pain in service. 5. Schedule the Veteran for a VA examination to determine the cause of chest and right leg keloids. (a.) Ask the examiner to review the evidence and to provide a fully-explained opinion as to whether a (1) chest and/or (2) right leg keloid was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (b.) Ask the examiner to review the evidence and to provide a fully-explained opinion as to whether a chest and/or right leg keloid is an extension of or was caused by or is part of the Veteran's service connected right shoulder keloid. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The Veteran served in the U.S. Army from January 1966 to January 1969. He was in combat in Vietnam, and was awarded the Combat Infantryman Badge. Under the law, the Veteran's account of factual occurrences during combat service is CREDIBLE. On his December 1965 physical examination for service entrance, the Veteran's skin was normal, and he had no identifying body marks or scars. The Veteran did not indicate any scars or marks on his skin on his report of medical history at that time. On his December 1968 physical examination for service separation, a right shoulder keloid was noted, but he was otherwise normal. The Veteran did not indicate any scars or marks on his skin on his report of medical history at that time. The Veteran has reported post-service treatment for keloids in 1975-1976, and in the early 1980s. November 2011 and May 2012 private treatment records state that the Veteran had keloids on his chest. In a May 2012 Decision Review Officer (DRO) hearing, the Veteran reported VA treatment for keloids in the chest area and right shoulder beginning shortly after service separation. He stated that they had been spreading. A July 2012 VA examination report noted a keloid of the right shoulder only. The examiner stated that it was caused by contact with metal wire while in combat in Vietnam. The examiner did not discuss the Veteran's reports of right leg and chest keloids but indicated that there were no scars anywhere other than the right shoulder. A June 2017 VA treatment record states that the Veteran had surgery in 1975 to repair scars on his chest, and that he had scarring on his chest and shoulders from getting caught in wire in Vietnam. A May 2018 VA treatment record also indicates that the Veteran got caught in razor wire in service, which caused skin damage to both shoulders and which required surgery to repair. At his October 2021 Board hearing, the Veteran reported that he was cutting bamboo in Vietnam when he tried to escape sniper fire and got caught in wire that caused the keloids on the right shoulder, right leg, and chest. He stated that they had grown over time. 6. Schedule the Veteran for all necessary VA examinations to determine the cause of pes planus and any other identified left foot disorder(s). Ask the examiner to review the evidence and to provide a fully-explained opinion as to whether (1) pes planus and/or (2) any other identified left foot disorder(s) was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The Veteran served in the U.S. Army from January 1966 to January 1969. He was in combat in Vietnam, and was awarded the Combat Infantryman Badge. Under the law, the Veteran's account of factual occurrences during combat service is CREDIBLE. On his December 1965 physical examination for service entrance, the Veteran's feet were normal. There was a notation of a recent fracture of one metatarsal. On his report of medical history from that time, he indicated that he had foot trouble. It was noted that he had a small left toe fracture in the past but there were no sequelae. In September 1967, he was treated for pain in the left foot near the small toe. The service treatment record stated that no X-ray study was needed because the Veteran had fallen arches. In October 1968 he requested arch supports for flat feet and was prescribed a #9 shoe. On his December 1968 physical examination for service separation, the Veteran's feet were normal. On his report of medical history from that time, the Veteran originally indicated that he had foot trouble but then crossed it out and indicated he did not have foot trouble. A December 2015 VA treatment record indicates that the Veteran had foot and ankle impairment that limited his ability to exercise. A June 2017 VA treatment record states that the Veteran fractured his left little toe in 1965. December 2019, February 2020, and July 2020 VA treatment records indicate pain in both feet; a normal left foot X-ray study; treatment for left foot pain; and a diagnosis of left foot posterior tibial tendon dysfunction. At his October 2021 hearing, the Veteran reported having pes planus in service, and that he had private and VA treatment since service separation. He also reported injuring his left foot while in service and that he first noticed symptoms after he returned from Vietnam. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. E. Miller, Counsel The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.