Back to BVA DecisionsMIXEDService Branch ARMY Special Benefit NO SPECIAL BENEFIT Docket No. 18-42 721A
IRRITABLE COLON SYNDROME (SPASTIC COLITIS MUCOUS COLITIS)
RAY BARTO SLABBEKORN, JR. · 2023 · Case ID: 23015636
Summary
The veteran, who served in the U.S. Army from April 1985 to January 1986, appeals the denial of service connection for bilateral hearing loss, tinnitus, right and left shoulder disabilities, right and left lower extremity neuropathy/radiculopathy, GERD, ulcer disability, irritable bowel syndrome, sleep impairment disorder, and an acquired psychiatric disorder. The Board denied claims for hearing loss and tinnitus due to a lack of evidence of a current diagnosis, citing Brammer v. Derwinski. Claims for shoulder and lower extremity conditions were denied due to no evidence of current diagnosis or nexus to service, noting the lack of lay statements and the negative findings on a December 2017 VA lumbar spine examination which found no radiculopathy. The Board remanded claims for right and left knee disabilities, GERD, ulcer disability, irritable bowel syndrome, sleep impairment disorder, and acquired psychiatric disorder. For the knee claims, the Board noted the in-service diagnosis of patellofemoral joint syndrome and post-service arthroscopy, requiring a VA examination to determine etiology and nexus to service or secondary connection to service-connected bilateral ankle disability. For GERD, ulcer, and IBS, the Board noted current diagnoses and a history of indigestion and ulcers, requiring a VA examination. For sleep impairment, the Board noted a history of sleep difficulty and a current diagnosis of obstructive sleep apnea, requiring a VA examination to determine service connection. For the psychiatric disorder, the Board noted current diagnoses of major depressive disorder and anxiety, along with service complaints of depression and nervous trouble, also requiring a VA examination.
Rationale
Current diagnosis of irritable bowel syndrome; Remanded for VA exam
Full Decision Text
Citation Nr: 23015636 Decision Date: 03/15/23 Archive Date: 03/15/23 DOCKET NO. 18-42 721A DATE: March 15, 2023 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected lumbosacral strain, is denied. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected lumbosacral strain, is denied. Entitlement to service connection for neuropathy/radiculopathy of the left lower extremity, to include secondary to service-connected lumbosacral strain is remanded. Entitlement to service connection for neuropathy/radiculopathy of the right lower leg, to include as secondary to service-connected lumbosacral strain is remanded. REMANDED Entitlement to service connection for a right knee disability, to include as secondary to service-connected bilateral ankle disability, is remanded. Entitlement to service connection for a left knee disability, to include as secondary to service-connected bilateral ankle disability, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for an ulcer disability is remanded. Entitlement to service connection for irritable bowel syndrome is remanded. Entitlement to service connection for a sleep impairment disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that the Veteran has a diagnosis of bilateral hearing loss. 2. The evidence of record persuasively weighs against finding that the Veteran has a diagnosis of tinnitus. 3. The evidence of record persuasively weighs against finding that the Veteran has a right shoulder disability. 4. The evidence of record persuasively weighs against finding that the Veteran has a left shoulder disability. 5. The evidence of record persuasively weighs against finding that the Veteran has neuropathy/radiculopathy of the right lower extremity. 6. The evidence of record persuasively weighs against finding that the Veteran has neuropathy/radiculopathy of the left lower extremity. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 3. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 5. The criteria for service connection for neuropathy/radiculopathy of the right lower extremity have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 6. The criteria for service connection for neuropathy/radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1985 to January 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal of a January 2018 rating decision. The Veteran requested and was scheduled for a Board hearing but subsequently cancelled the request. Service Connection In order to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). 1. Entitlement to service connection for bilateral hearing loss 2. Entitlement to service connection for tinnitus The Veteran claims that service connection for bilateral hearing loss and tinnitus is warranted as he was exposed to acoustic trauma during service. The first . Service Connection In order to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). 1. Entitlement to service connection for bilateral hearing loss 2. Entitlement to service connection for tinnitus The Veteran claims that service connection for bilateral hearing loss and tinnitus is warranted as he was exposed to acoustic trauma during service. The first element of service connection requires a current disability. The Veteran has not identified or submitted any private treatment records noting a current diagnosis of bilateral hearing loss or tinnitus. The Board understands that there is a certain subjective nature to a finding of tinnitus, however, there is nothing in this record indicating these problems other than the claim itself. As there is no evidence of record showing a current diagnosis of bilateral hearing loss or tinnitus, the claims of entitlement to service connection for bilateral hearing loss and tinnitus are denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 3. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected lumbosacral strain 4. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected lumbosacral strain 5. Entitlement to service connection for neuropathy/radiculopathy of the left lower extremity, to include as secondary to service-connected lumbosacral strain 6. Entitlement to service connection for neuropathy/radiculopathy of the left lower extremity, to include as secondary to service-connected lumbosacral strain The Veteran has not provided any lay statements regarding his shoulder disabilities or neuropathy/radiculopathies of the lower extremities, to include theories as to the cause of these conditions. In a November 2022 Appellate Brief, the Veteran's representative contended that the Veteran's shoulder disabilities and neuropathy/radiculopathy of the lower extremities was caused by his military service. The representative also indicated that radiculopathy of the lower extremities was secondary to the Veteran's service-connected lumbosacral strain. However, aside from a brief and conclusory statement that service-connection is warranted for these claimed disabilities, no lay statements have been offered in support of these claims. The Veteran's service treatment records do not show complaint, treatment, or diagnosis for a disability of either shoulder or either lower extremity. Moreover, the Veteran has not submitted any post-service treatment records relating to a disability of either shoulder or relating to neuropathy/radiculopathy of either lower extremity. Moreover, current medical treatment records fail to show treatment or diagnosis of a right or left shoulder disability or a disability of either lower extremity. Notably, on VA examination of the lumbar spine in December 2017, the examiner reported that the Veteran did not have evidence of radicular pain or any other signs or symptoms due to radiculopathy. As there is no competent evidence of a current diagnosis of a disability of the right and left shoulders and of the right and left lower extremities, there is no basis on which the claims for service connection for any of these disorders may be granted. See Brammer, 3 Vet. App. at 225. Accordingly, the appeal on these issues is denied. REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability, to include as secondary to service-connected bilateral ankle disability is remanded. 2. Entitlement to service connection for a left knee disability, to include as secondary to service-connected bilateral ankle disability is remanded. The Veteran contends that a bilateral knee disability was incurred during service. In the alternative, he claims that his knee conditions are secondary to his service-connected bilateral ankle disability. The Veteran's service treatment records show that the Veteran was treated and diagnosed with patellofemoral joint syndrome. Post-service medical records indicate that in December 2018, the Veteran underwent knee arthroscopy (right or left knee was not specified). Therefore, the Board finds that a VA examination and medical opinion are needed to determine the nature and etiology of any current disability of the right and left knee. In addition, the private treatment records pertaining to the knee arthroscopy should be obtained. 3. Entitlement to service connection for GERD is remanded. 4. Entitlement to service connection for an ulcer disability is remanded. 5. Entitlement to service connection for irritable bowel syndrome is remanded. The Veteran . The Veteran's service treatment records show that the Veteran was treated and diagnosed with patellofemoral joint syndrome. Post-service medical records indicate that in December 2018, the Veteran underwent knee arthroscopy (right or left knee was not specified). Therefore, the Board finds that a VA examination and medical opinion are needed to determine the nature and etiology of any current disability of the right and left knee. In addition, the private treatment records pertaining to the knee arthroscopy should be obtained. 3. Entitlement to service connection for GERD is remanded. 4. Entitlement to service connection for an ulcer disability is remanded. 5. Entitlement to service connection for irritable bowel syndrome is remanded. The Veteran has current diagnoses of GERD, hiatal hernia and moderate gastritis. Moreover, in a May 2017 private treatment record, it was noted that the Veteran had a past medical history of stomach ulcers. In a Report of Medical History, in conjunction with service discharge, the Veteran complained of frequent indigestion. The Veteran has not been provided with a VA examination with respect to his claimed disabilities. Thus, a remand is warranted for VA examination. 6. Entitlement to service connection for a sleep impairment disorder is remanded. The Veteran contends that a current sleep impairment disorder is related to service. In a Report of Medical History, in conjunction with service discharge, the Veteran complained of difficulty sleeping. In a November 2020 sleep study, he was diagnosed as having obstructive sleep apnea. The Board finds that a remand is necessary to provide the Veteran with a VA examination and medical opinion as to whether a sleep impairment disorder, to include sleep apnea, is related to service. 7. Entitlement to service connection for an acquired psychiatric disorder is remanded. The medical evidence of record shows current diagnoses of major depressive disorder and anxiety. In a Report of Medical History, in conjunction with service discharge, the Veteran indicated that he had "depression or excessive worry" and "nervous trouble." A remand is warranted for a VA examination to resolve this claim. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain private treatment records pertaining to the knees from Doctors Hospital at Renaissance. 2. Schedule the Veteran for an appropriate VA examination for his claimed right and left knee disability. The claims file, including a copy of this REMAND, should be provided to the examiner. (a) After reviewing the Veteran's claims file, the examiner is asked to opine whether it is at least as likely as not that any current disability of the right and left knee had an onset in service or is otherwise related to service. (b) If the response to the above is negative, the examiner should opine as to whether it is at least as likely as not that a right and left knee disability is caused or proximately due to his service-connected bilateral ankle disability. (c) If the response to the above is negative, the examiner should opine as to whether it is at least as likely as not that a right and left knee disability is chronically aggravated by his service-connected bilateral ankle disability. A complete rationale must be provided for each opinion rendered. In addition to the diagnosis of patellofemoral joint syndrome during service, the examiner is asked to consider the lay statements of the Veteran. 3. Schedule the Veteran for appropriate VA examinations for his claimed GERD, ulcer disability and irritable bowel syndrome. The claims file, including a copy of this REMAND, should be provided to the examiner(s). After reviewing the Veteran's claims file, and with regard to the disability appropriate for each examiner, the examiner is asked to opine whether it is at least as likely as not that any current disability(ies) had an onset in service or is otherwise related to service. A complete rationale must be provided for each opinion rendered with regard to the disability appropriate for each examiner. In addition to the Veteran's report of frequent indigestion at service discharge, the examiner is asked to consider the lay statements of the Veteran. 4. Schedule the Veteran for an appropriate examination for his claimed sleep impairment disorder. The claims file, including a copy of this REMAND, should be provided to the examiner. After reviewing the Veteran's claims file, the examiner is asked to opine whether the examiner is asked to opine whether it is at least as likely as not that any current sleep impairment disorder, to include sleep apnea, had an onset in service or is otherwise related to service. A complete rationale must be provided for any opinion rendered. In addition to the Veteran's report of frequent trouble sleeping at service discharge, the examiner is asked to consider the lay statements of the Veteran. A complete rationale for any opinions expressed should be set forth. 5. Schedule the Veteran for a VA examination to determine the nature and for his claimed sleep impairment disorder. The claims file, including a copy of this REMAND, should be provided to the examiner. After reviewing the Veteran's claims file, the examiner is asked to opine whether the examiner is asked to opine whether it is at least as likely as not that any current sleep impairment disorder, to include sleep apnea, had an onset in service or is otherwise related to service. A complete rationale must be provided for any opinion rendered. In addition to the Veteran's report of frequent trouble sleeping at service discharge, the examiner is asked to consider the lay statements of the Veteran. A complete rationale for any opinions expressed should be set forth. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of any acquired psychiatric disorder. The claims file, including a copy of this REMAND, should be provided to the examiner. After reviewing the Veteran's claims file, the examiner is asked to opine whether the examiner is asked to opine whether it is at least as likely as not that any current psychiatric disorder had an onset in service or is otherwise related to service. A complete rationale must be provided for any opinion rendered. In addition to the Veteran's reports of depression or excessive worry and nervous trouble at service discharge, the examiner is asked to consider the lay statements of the Veteran. RAY BARTO SLABBEKORN, JR. Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Henriquez, 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.