Citation Nr: 22051184 Decision Date: 09/08/22 Archive Date: 09/08/22 DOCKET NO. 17-66 556 DATE: September 8, 2022 REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a right hand disability, to include residuals of a broken thumb, is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a staph infection (also known as Methicillin-resistant Staphylococcus aureus (MRSA)) is remanded. Entitlement to service connection for a right leg disability, to include a right hamstring disability, is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an eye disability is remanded. Entitlement to service connection for an acquired psychiatric disability, to include depression and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1972 to September 1974. This matter comes to the Board of Veterans' Appeals (Board) on appeal from January 2017 and November 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a virtual hearing before the undersigned Veterans Law Judge of the Board in December 2021. A transcript of that hearing has been associated with the claims file. In a February 2022 statement, the Veteran reported he missed a virtual hearing at VA; however, as noted above, his virtual Board hearing was held in December 2021. Therefore, there is no prejudice to the Veteran in proceeding with this appeal. 1. Service Connection for a Right Shoulder Disability 2. Service Connection for a Low Back Disability 3. Service Connection for a Right Hand Disability, to Include Residuals of a Broken Thumb 4. Service Connection for a Right Ankle Disability 5. Service Connection for a Staph Infection (MRSA) disability 6. Service Connection for a Right Leg Disability, to include a Right Hamstring Disability 7. Service Connection for a Neck Disability In regard to the claims for service connection for low back, neck, right shoulder, right hand, right leg, and right ankle disabilities, the Board observes that the Veteran testified at the December 2021 Board hearing that he sustained injuries to the back, neck, right shoulder, right hand, right leg and right ankle when he was attacked and put in a wrestling hold during his service in the United States (U.S) National Guard in 1986. He also testified he had symptoms in the back, neck, right shoulder, right hand, right leg and right ankle since that time. In addition, he testified he contracted a staph infection during his service in the U.S. National Guard and has had the infection show up in blood testing that has been performed since that time. As the Veteran reported these disabilities occurred during his service in the U.S. National Guard, following his active service, the Board must first determine whether these occurred during a period of active duty for training (ADT) or inactive duty for training (IDT). The Veteran has unverified periods of ADT and IDT from his service in the U.S Army Reserves and U.S. National Guard. Therefore, a remand of the claims for service connection for a low back disability, neck disability, right shoulder disability, right hand disability, right leg disability, right ankle disability and staph infection (MRSA) for further development by the RO is necessary to obtain any outstanding military personnel records and information to verify the Veteran's IDT and ADT service dates as well as the Veteran's duty assignments and locations. The RO should contact the National Personnel Records Center (NPRC), the Defense Finance Accounting Service (DFAS) and/or any other appropriate source to verify any period of ADT or IDT and associate any responses with the record. The RO is also requested to obtain a copy of the Veteran's Master Military Pay Account (MMPA) to determine the exact dates of his IDT and ADT. Service treatment records (STRs) reflect that the Veteran has also been treated for the low back, right hand, right leg and right ankle during the Veteran's period of active service. STRs demonstrate treatment for the right ankle in October 1972 and June 1973, a right thumb injury in March 1974 with x-rays within normal limits in June 1974 and low back pain, diagnosed as lumbosacral strain, in August 1974. STRs also demonstrate the Veteran was treated for a right leg injury and right leg pain in August 1973 and reported having a history of trick or locked knee in the September 1974 Report of Medical History at separation from active service. VA outpatient treatment reports reflect that the Veteran has current treatment and diagnoses for the low back, neck, right shoulder, right hand and right ankle during the period of the appeal. These medical records also reflect treatment for the right leg in 2001 and 2003. VA outpatient treatment reports also reflect that the Veteran was treated for a staph infection (MRSA) during the pendency of the appeal. In light of the above, the Board finds that VA examinations and opinions are necessary to determine whether it was at least as likely as not that any currently diagnosed low back, neck, right shoulder, right hand, right leg and right ankle and staph infection (MRSA) disabilities were incurred in or are otherwise related to the Veteran's active service or any periods of ADT or IDT. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Locklear v. Nicholson, 20 Vet. App. 410 (2006); see Waters v. Shinseki, 601 F.3d 1274, 1276 (2010). Although a VA examination and opinion was provided for the right hand in November 2017, considering the additional testimony and remand instructions to determine the dates of IDT and ADT, a new VA examination is warranted for the right hand. 8. Service Connection for Sinusitis 9. Service Connection for Headaches 10. Service Connection for an Eye Disability With respect to the claims for service connection for headaches, an eye disability, and sinusitis, the Board observes these disabilities were reported in the STRs from the Veteran's active service. In the September 1974 Report of Medical History, the Veteran reported a history of frequent or severe headaches, eye trouble and sinusitis. At a December 2021 virtual hearing, the Veteran testified he was attacked during his active service while stationed in Germany, which caused his headache and eye problems and he has continued to have problems since that time. He also testified that he developed sinusitis in service which has continued since that time. VA outpatient treatment reports reflect the Veteran has been treated for sinusitis and headaches during the period of the appeal. Accordingly, new VA examinations and opinions are necessary to determine whether it was at least as likely as not that any currently diagnosed headache, eye or sinusitis disabilities were incurred in or are otherwise related to the Veteran's active service, including a consideration of the Veteran's reports of a continuity of symptoms his active service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Locklear v. Nicholson, 20 Vet. App. 410 (2006); see Waters v. Shinseki, 601 F.3d 1274, 1276 (2010). 11. Service Connection for an Acquired Psychiatric Disability, to Include Depression and PTSD With regard to the claim for an acquired psychiatric disability, to include depression and PTSD, the STRs demonstrate the Veteran reported symptoms of excessive depression or worry in the September 1974 Report of Medical History at separation. He also reported in an April 2017 statement regarding his PTSD stressor that his initial trauma arose from an incident during his active service wherein he was attacked and an incident where he was attacked during his service in the U.S. National Guard. In a September 2017 statement, the Veteran reported his stressor included an assault in 1973 while on active duty in Germany, which he also claimed during his December 2021 virtual hearing. In addition, VA outpatient treatment records reflect the Veteran has been treated for and diagnosed with adjustment disorder and depression. A February 2019 private physician's letter reflects the Veteran was also diagnosed with PTSD. Accordingly, the Board finds that a VA examination and opinion is necessary to determine whether it was at least as likely as not that any currently diagnosed psychiatric disability, to include depression and PTSD, was incurred in or was otherwise related to the Veteran's active service or any periods of ADT or IDT. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Locklear v. Nicholson, 20 Vet. App. 410 (2006); see Waters v. Shinseki, 601 F.3d 1274, 1276 (2010). The matters are REMANDED for the following action: 1. Obtain any outstanding military personnel records and contact the National Personnel Records Center (NPRC) in order to verify the Veteran's inactive duty for training (IDT) and active duty for training (ADT) service dates and duty assignments and locations. 2. Contact the Defense Finance and Accounting Service (DFAS) and request that they review the Veteran's pay records, if possible, to determine the dates and types of all military service performed by the Veteran. That is, the Defense Finance and Accounting Service must determine all service periods when the Veteran was paid from an account designated to pay for ADT, and what periods were paid from an account designated to pay for IDT. 3. Obtain a copy of the Veteran's Master Military Pay Account (MMPA) from his periods of Reserve and National Guard service, including from 1986, the year he indicated he was attacked, to determine the exact dates of the Veteran's IDT and ADT, as well as for any other dates deemed necessary. 4. Obtain any outstanding STRs from the Veteran's service in the U.S. Army Reserves and U.S. National Guard. 5. After completing Steps 1 to 4, determine if the Veteran was on active duty, IDT, or ADT during the periods he indicated he was treated for and/or diagnosed with a low back disability, neck disability, right shoulder disability, right hand disability, right leg disability, right ankle disability and staph infection (MRSA). 6. Obtain and associate with the claims file all pertinent VA and private medical records the Veteran adequately identifies. 7. Upon receipt of all additional records, schedule the Veteran for VA examinations to determine the current nature and etiology of his low back, right shoulder, neck, right ankle, right hand, and right leg disabilities. The examination report is to contain a notation that the examiner reviewed the claims file. A full examination should include all testing necessary, including X-rays. PLEASE REVIEW AND ADDRESS: (1) the service treatment reports (STRs) demonstrating treatment for the low back, right ankle, right hand and right leg during active service; (2) the service personnel records (SPRs); (3) the verified periods of active duty for training (ADT) and inactive duty for training (IDT); (4) the post-service medical evidence demonstrating treatment for the low back, right shoulder, neck, right ankle, right hand and right leg AND (2) the Veteran's hearing testimony that his low back, right shoulder, neck, right ankle, right hand and right leg were injured during his service in the National Guard and that symptoms have continued since his active service. PLEASE NOTE: the Veteran is competent to attest to any lay observable symptoms and past treatment. The examiner is asked to answer the following: (a) Whether it is at least as likely as not that any currently diagnosed low back, right shoulder, neck, right ankle, right hand or right leg disability had its onset during the Veteran's (1) period of active service, OR (2) during a period of ADT OR IDT while in the U.S. Army Reserves or National Guard; OR, (b) Whether it is at least as likely as not that any currently diagnosed low back, right shoulder, neck, right ankle, right hand or right leg disability was caused by any incident or event that occurred during such period, to include the competent lay statements of being attacked in 1986 and having symptoms of low back, right shoulder, neck, right ankle, right hand and right leg problems since that time. It is essential the examiner provide explanatory rationale for opinions on these determinative issues, citing to specific evidence in the file supporting conclusions. 8. Upon receipt of all additional records, schedule the Veteran for a VA examination to determine the current nature and etiology of his staph infection (MRSA). The examination report is to contain a notation that the examiner reviewed the claims file. A full examination should include all testing necessary, including lab testing for a staph infection (MRSA). PLEASE REVIEW AND ADDRESS: (1) the service treatment reports (STRs); (2) the service personnel records (SPRs); (3) the verified periods of active duty for training (ADT) and inactive duty for training (IDT); (4) the post-service medical evidence demonstrating treatment for a staph infection (MRSA); AND (2) the Veteran's hearing testimony that his staph infection (MRSA) initially occurred during his service in the National Guard and that it was detected in blood tests since that time. PLEASE NOTE: the Veteran is competent to attest to any lay observable symptoms and past treatment. The examiner is asked to answer the following: (a) Whether it is at least as likely as not that any currently diagnosed staph infection (MRSA) had its onset during the Veteran's (1) period of active service, OR (2) during a period of ADT OR IDT while in the U.S. Army Reserves or National Guard; OR, (b) Whether it is at least as likely as not that any currently diagnosed staph infection (MRSA) was caused by any incident or event that occurred during such period of active service, ADT or IDT, to include the Veteran's testimony that this infection occurred during his service in the U.S. National Guard. It is essential the examiner provide explanatory rationale for opinions on these determinative issues, citing to specific evidence in the file supporting conclusions. 9. Upon receipt of all additional records, schedule the Veteran for a VA examination to determine the current nature and etiology of his sinusitis, headaches and eye disabilities. The examination report is to contain a notation that the examiner reviewed the claims file. A full examination should include all testing necessary. PLEASE REVIEW AND ADDRESS: (1) the service treatment reports (STRs) demonstrating September 1974 Report of Medical History that reflects the Veteran reported a history of frequent or severe headaches, eye trouble and sinusitis; (2) the service personnel records (SPRs); AND (3) the Veteran's hearing testimony that he was attacked in Germany during his active service and had headaches and eye problems since that time and that he developed sinusitis in service and symptoms had continued since that time. PLEASE NOTE: the Veteran is competent to attest to any lay observable symptoms and past treatment. The examiner is asked to answer the following: (a) Whether it is at least as likely as not that any currently diagnosed sinusitis, headaches or eye disability had its onset during the Veteran's period of active service; OR, (b) Whether it is at least as likely as not that any currently diagnosed sinusitis, headaches or eye disability, was caused by any incident or event that occurred during such period, to include the competent lay statements of having these disabilities since active service. It is essential the examiner provide explanatory rationale for opinions on these determinative issues, citing to specific evidence in the file supporting conclusions. 10. Upon receipt of all additional records, schedule the Veteran for a VA examination to determine the current nature and etiology of his acquired psychiatric disability. The examination report is to contain a notation that the examiner reviewed the claims file. PLEASE REVIEW AND ADDRESS: (1). the service treatment reports (STRs) demonstrating September 1974 Report of Medical History reflects the Veteran reported a history of depression or excessive worry; (2) the service personnel records (SPRs); (3) the verified dates of active duty for training (ADT) and inactive duty for training (IDT); (4) the Veteran's statements in April 2017 that his initial trauma arose from the incident where he was attacked during his active service and also during service in the U.S. National Guard and that he was assaulted in 1973 while on active duty in Germany, which he also claimed during his December 2021 virtual hearing; AND (5) the post-service VA treatment records reflecting psychiatric symptoms and the February 2019 private physician's letter that he has a PTSD diagnosis. PLEASE NOTE: the Veteran is competent to attest to any lay observable symptoms and past treatment. The examiner is asked to answer the following: (a). Clearly identify each psychiatric disorder found on examination; (b). The examiner must opine whether the evidence of record, including the Veteran's lay statements, other lay statements of record, and service records or other information, corroborate the claim that a personal assault occurred in service. (c). If the examiner finds that the evidence indicates that a personal assault occurred during the Veteran's military service, to include any verified periods of ADT and IDT in the U.S. Army Reserves and National Guard, the examiner must opine whether it is at least as likely as not that any PTSD is related to the in-service personal assault. (d). If the examiner finds that the evidence does not indicate that a personal assault occurred during the Veteran's military service, including any verified periods of ADT and IDT in the U.S. Army Reserves and National Guard, the examiner must opine whether it is at least as likely as not that any PTSD diagnosis is related to another verified in-service stressor. (e). If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently diagnosed psychiatric disability had its onset during the Veteran's period of active service, or is at least as likely as not related to an in-service incident, disease or injury, to include consideration of the report of depression or excess worry in the September 1974 Report of Medical History. (f). If a diagnosis of a psychiatric disability was not provided, please discuss the Veteran's reported psychiatric symptoms and whether any disorder diagnosed during the period of the appeal, to include depression or PTSD, and explain why the noted evidence does not establish a chronic diagnosis. IF PTSD IS NOT FOUND, the VA examiner should discuss the February 2019 private physician's letter that the Veteran has a diagnosis of PTSD. (g). In providing the requested opinions, the examiner must determine whether there is evidence of behavior changes demonstrated by the Veteran; and if so, if said changes are consistent with the expected reaction or adjustment of a person who has been subjected to an assault. It is essential the examiner provide explanatory rationale for opinions on these determinative issues, citing to specific evidence in the file supporting conclusions. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Saira Spicknall, 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.