Citation Nr: 18160398
Decision Date: 12/26/18	Archive Date: 12/26/18

DOCKET NO. 18-15 976
DATE:	December 26, 2018
REMANDED
Entitlement to service connection for a cervical spine disorder (claimed as neck pain) is remanded.
Entitlement to service connection for bilateral hip disorders (claimed as bilateral hip pain) is remanded.
Entitlement to service connection for bilateral ankle disorders (claimed as bilateral ankle pain) is remanded.
Entitlement to service connection for a bilateral foot disorder, to include bilateral plantar fasciitis and a disorder of the left fifth toe, is remanded.
Entitlement to service connection for vertigo is remanded.
Entitlement to service connection for urticaria is remanded.
Entitlement to service connection for headaches is remanded.
Entitlement to service connection for temporomandibular joint dysfunction (TMJ) is remanded.
REASONS FOR REMAND
The Veteran served on active duty from May 1997 to May 2001.  These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina.  
Initially, the Board notes that the most recent treatment records in the claims file are dated in October 2015.  As it appears that the Veteran has undergone relevant ongoing treatment since that time, the Board finds that, on remand, any outstanding private medical records and VA medical records should be obtained and added to the record.  See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016) (where the Veteran “sufficiently identifies” other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information); Bell v. Derwinski, 2 Vet. App. 611 (1992).
Turning to the Veteran’s contentions in this case, she has contended that she has “camel neck” as a result of work and military exercises while on active duty.  She has reported that this condition had a “gradual onset.”  The Veteran has also reported current neck pain.  
She has also contended that she injured her right ankle in basic training.  Service treatment records reflect that she suffered a sprained ankle.  See September 1997 service treatment record.  She alleges that she continued to re-injure her right ankle while in service but did not seek further treatment.  She has argued that, due to favoring her injured right ankle, she began experiencing pain in the left ankle and her hips.  She has reported that she continues to experience pain in her ankles and hips.  
Regarding her bilateral feet claims, she has contended that she has a current bilateral foot disorder related to service.  She has argued that when she entered the service, she had a dermatological condition of both feet that cleared up in May 1997, but came back in boot camp and never left again.  She indicated that she currently has severe scarring and skin pigmentation, and that she continues to experience blisters between her toes intermittently.  A March 2007 VA medical record shows that the Veteran reported that she had a rash on her feet that began in at least 2000 and has continued since then.  On examination, the Veteran’s feet had diffuse scaling “moccasin feet” and thickened and yellow toenails.  
Additionally, the Veteran contends that, while on active duty, she experienced hives, edema in her lips and chin, and the sensation that her throat was closing after eating a meal ready to eat (MRE).  She was given a shot of Benadryl and prednisone.  She reported that the hives have been present intermittently since service as random periods of edema in her face, eyes, lips, hands, feet or toes.  She indicated that she sought treatment from an allergist and was diagnosed with chronic idiopathic urticaria.  VA medical records reflect idiopathic urticaria on her problem list dated in January 2014.  
Furthermore, the Veteran has contended that she began having headaches in service, and that they have continued since service.  She has also contended that her headaches are caused by TMJ.  A January 2014 VA medical record reflects headache syndrome on her problem list. 
The Board reflects that VA examinations of the foregoing claimed disorders are necessary at this time; a remand is necessary in order for such to be accomplished.  See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).
Finally, regarding the Veteran’s TMJ, the Veteran has contended that she began having jaw pain during service and that she currently has TMJ.  Service treatment records from her reserve duty show that, in March 2005, the Veteran was seen for jaw pain, and given a provisional diagnosis of TMJ.  She argues that her pain has continued, and that she has current TMJ which is worsening with time.
It is unclear from the record what type of Reserve duty—active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA)—the Veteran was on in March 2005.  This is significant, as service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing ACDUTRA or injury incurred or aggravated by INACDUTRA.  38 U.S.C. §§ 101(24), 106, 1131.  For a member of a Reserve component, ACDUTRA means full-time duty performed by Reserve service members for training purposes.  INACDUTRA means duty (other than full-time) prescribed for Reserve service members under section 206 of title 37 of the United States Code or any other provision of law.  Thus, on remand, it should be determined whether the Veteran was serving on ACDUTRA or INACDUTRA in March 2005.  
In addition, the Board finds that the Veteran should be provided with a VA examination to determine whether she has current TMJ that is related to the March 2005 notation.  See McLendon, supra.  
The matters are REMANDED for the following action:
1. Obtain any and all VA treatment records not already associated with the claims file from any VA medical facility that may have treated the Veteran and associate those documents with the claims file.
2. Obtain any and all Tricare treatment records not already associated with the claims file from Armed services medical facility that may have treated the Veteran since her discharge from service and associate those documents with the claims file.
3. Ask the Veteran to identify any private treatment that she may have had for her claimed disorders, which is not already of record.  After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file.  If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that she can make an attempt to obtain those records on her own behalf.
4. Determine whether the Veteran was serving on ACDUTRA and INACDUTRA and any other type of Reserve service in March 2005.  The AOJ should provide a list of the specific and exact dates of such service and the types of service for those dates; the AOJ is reminded that merely providing a retirement points report that does not indicate the exact dates and types of service is not adequate to comply with this remand directive.  The AOJ must document all steps taken to make this determination. 
5. Ensure that the Veteran is scheduled for a VA examination in order to determine whether her cervical spine disorder is related to service.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner must opine whether any cervical spine disorder found at least as likely as not (50 percent or greater probability) began in or is otherwise related to her miliary service.  The examiner must address the Veteran’s contentions that she has had a gradual onset of “camel neck” as a result of work and military exercises while on active duty.
In addressing the above, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
6. Ensure that the Veteran is scheduled for a VA examination in order to determine whether her bilateral hip and ankle disorders are related to service.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner must opine whether any bilateral hip and ankle disorders found at least as likely as not (50 percent or greater probability) began in or is otherwise related to her miliary service, to include the noted treatment for her right ankle during military service.  
If and only if the examiner finds that the Veteran’s right ankle is related to service, then the examiner should also opine whether the left ankle and bilateral hip disorders at least as likely as not are (a) caused by; or, (b) aggravated (i.e., chronically worsened) by the Veteran’s right ankle disability, to include any abnormal gait or weightbearing as a result of that disabilities.  The examiner is reminded that he or she must address both prongs (a) and (b) above.
In addressing the above, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
7. Ensure that the Veteran is scheduled for a VA examination in order to determine whether her bilateral foot disorders, to include any skin disorder of the feet, bilateral plantar fasciitis, and/or a disorder of the left fifth toe, are related to service.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner must opine whether any cervical spine disorder found at least as likely as not (50 percent or greater probability) began in or is otherwise related to her miliary service, to include any treatment for a skin disorder during military service.
In addressing the above, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
8. Ensure that the Veteran is scheduled for a VA examination in order to determine whether urticaria or disorder manifested by urticaria is related to service.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner must opine whether any cervical spine disorder found at least as likely as not (50 percent or greater probability) began in or is otherwise related to her miliary service.  
The examiner must address the Veteran’s contentions that, while on active duty, she experienced hives, edema in her lips and chin, and the sensation that her throat was closing after eating an MRE, was given a shot of Benadryl and prednisone, and that the hives had been present intermittently since service as random periods of edema in her face, eyes, lips, hands, feet or toes.  The examiner must also address the January 2014 VA medical record showing idiopathic urticaria.
In addressing the above, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
9. Ensure that the Veteran is scheduled for a VA examination in order to determine whether her TMJ is related to service.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner must opine whether any cervical spine disorder found at least as likely as not (50 percent or greater probability) began in or is otherwise related to her miliary service.  
In particular, the examiner must address the March 2005 reserve service treatment records reflecting that she was seen for jaw pain, and given a provisional diagnosis of TMJ, and her contentions that she began having jaw pain during service and that she currently has TMJ.  With respect to this noted reserve service treatment, the examiner must opine whether it is at least as likely as not that the disability was (1) incurred or aggravated (i.e., chronically worsened) in the line of duty in March 2005, or (2) the result of an injury incurred in or aggravated in the line of duty in March 2005.
In addressing the above, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
10. Ensure that the Veteran is scheduled for a VA examination in order to determine whether her headaches are related to service or secondary to her claimed TMJ.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner must opine whether any headache disorder found at least as likely as not (50 percent or greater probability) began in or is otherwise related to her miliary service.  
Next, if the examiner finds that the Veteran’s headaches are not directly related to service, the examiner should also opine whether the headache disorder at least as likely as not is (a) caused by; or, (b) aggravated (i.e., chronically worsened) by the Veteran’s claimed TMJ disorder.  The examiner is reminded that he or she must address both prongs (a) and (b) above.
In addressing the above, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
 
MARTIN B. PETERS
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Harrigan Smith

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