Citation Nr: 0812176 Decision Date: 04/11/08 Archive Date: 04/23/08 DOCKET NO. 00-23 972 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for pelvic inflammatory disease, the residuals of a left salpingo-oopherectomny, and benign hemorrhagic follicular cyst. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to service connection for a left foot disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant and her mother ATTORNEY FOR THE BOARD Simone C. Krembs, Associate Counsel INTRODUCTION The veteran served on active duty from November 1979 to December 1982. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) that denied the veteran's claims for service connection for PTSD, pelvic inflammatory disease, the residuals of a left salpingo-oopherectomny and benign hemorrhagic follicular cyst, and for left knee and foot disabilities. The veteran testified before the Board at a June 2004 hearing that was held at the RO. The Board remanded the claims for additional development in July 2001 and in January 2005. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. REMAND Additional development is needed prior to further disposition of the claims. The veteran asserts that she first experienced difficulties with pelvic inflammatory disease, a benign hemorrhagic follicular cyst, and left knee and foot disabilities during her period of active service. A review of the veteran's service medical records reflects that in January 1980 she reported to sick call with complaints of left lower quadrant abdominal pain that had persisted for the past 12 hours. She stated that she had completed her menses four days earlier and that she had been slightly constipated since that time. Physical examination revealed low grade point tenderness of the left lower quadrant. The assessment was rule out left oopheritis and/or fallopian salpingitis. In April 1980 the veteran again complained of left lower quadrant abdominal pain. The assessment again was rule out left oopheritis and/or fallopian salpingitis. The veteran next reported to sick call in June 1980 with complaints of pain in the region of her left ovary. The assessment again was rule out left oopheritis and/or fallopian salpingitis. On follow up evaluation she additionally reported symptoms consisting of malodorous vaginal discharge. Pelvic examination revealed a three to four cm cystic mass that was very tender to palpation. The impression was adnexal mass, probable ovarian cyst. Pelvic inflammatory disease was noted to be a possibility although that was not felt to be likely, as she had a normal body temperature and laboratory testing revealed a normal white blood cell count. Approximately one week later the veteran was noted to be beginning her menses. Pelvic examination at that time was unremarkable. The assessment was resolving ovarian cyst. In August 1980, however, the veteran again complained of left lower quadrant abdominal pain, this time associated with dysuria and urgency. The assessment was urinary tract infection. In September 1980, the veteran complained of vaginal itching and incontinence, particularly at the time of her menstrual period. Pelvic examination at that time was normal. The impression was cystitis. In December 1980, the veteran complained of pain in her ovaries for the past two days. Finally, in November 1980 the veteran again complained of pelvic pain. It was determined that the veteran was not pregnant. Post-service clinical records demonstrate frequent treatment for vaginitis and a large left ovarian cystic mass that was surgically removed in February 1995. Next, with respect to the veteran's left knee, her service medical records reflect that in September 1981 she reported to sick call with complaints of left knee pain that had persisted for the past two weeks, and was worsened with running. Physical examination of the knee revealed tenderness to palpation of the infrapatellar region but stable ligaments. X-ray examination of the knee revealed no fracture or other abnormality. The assessment was rule out chondromalacia patella. She was placed on a limited duty profile for one week and was referred to physical therapy. At her first physical therapy appointment she denied a history of trauma to her left knee. Examination resulted in an assessment of chondromalacia. She was scheduled for in- office physical therapy for one week, to be followed by a home program for one week. The next record of treatment related to the left knee is dated in January 1982. At that time, the veteran again reported to sick call with complaints of left knee pain. Physical examination revealed mild tenderness to palpation of the left retropatellar region and moderate laxity of the lateral and medial ligaments. The assessment was acute knee strain. Finally, on examination in November 1982, prior to separation from service, the veteran complained of recurrent knee problems. Physical examination, however, revealed "nothing significant." Post-service clinical records show that in September 1995 the veteran reported a history of recurrent left knee dislocations since her left knee injury in service. The diagnosis at that time was left knee dislocation secondary to old trauma. With respect to the left foot, the veteran's service medical records reflect that on examination in September 1979, prior to entry into service, the veteran was found to have mild asymptomatic pes planus that was not considered to be disabling. In December 1979 she reported to sick call with complaints of bilateral Achilles tendonitis. In May 1980 she complained of callus build-up on both feet for the past six months. The calluses were trimmed. She was again seen in August 1980 and September 1981 for trimming of her calluses, particularly on the left. In December 1981 she was seen for complaints of left foot pain that had persisted for the past two weeks. Physical examination revealed tenderness to palpation of the little tendon and mild swelling. The assessment was sore dorsal area of left foot. In March 1982 and June 1982 the veteran was again seen for removal of callous build-up. Post-service clinical records demonstrate that the veteran was seen in December 2002 for treatment of painful bilateral calluses. In February 2003 she complained of a painful left heel that had been present for the past 21 years. Examination resulted in an assessment of metatarsalgia and left plantar fasciitis. She was prescribed orthotic inserts. In July 2003 she again sought treatment for painful calluses which she related to improperly fitted shoes when in the military. She additionally complained of a painful left heel. Heel spurs were suspected. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) (2007); Robinette v. Brown, 8 Vet. App. 69 (1995). With respect to the veteran's claim for service connection for pelvic inflammatory disease, the residuals of a left salpingo-oopherectomny, and benign hemorrhagic follicular cyst, the veteran has been afforded a VA examination. However, the examiner did not address whether the veteran's gynecological disorders were related to her period of active service. The Board finds that because the veteran's service medical records and post-service clinical records demonstrate treatment for gynecological problems including a left ovarian cyst, and it remains unclear to the Board whether these gynecological problems are related to the problems for which she was treated in service, a remand for an examination and etiological opinion is necessary in order to fairly address the merits of her claim. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the claim for service connection for a left knee disability, the veteran has been afforded a VA examination of her left knee. However, the examiner did not address whether the veteran's left knee disability was related to her period of active service. The Board finds that because the veteran's service medical records and post- service clinical records demonstrate treatment for left knee problems, and it remains unclear to the Board whether her current left knee problems are related to the problems for which she was treated in service, a remand for an examination and etiological opinion is necessary in order to fairly address the merits of her claim. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). . With respect to the claim for service connection for a left foot disability, the veteran has not yet been afforded a VA examination. The Board finds that because the veteran's service medical records and post-service clinical records demonstrate treatment for left foot problems, and it remains unclear to the Board whether her current left foot problems are related to the problems for which she was treated in service, a remand for an examination and etiological opinion is necessary in order to fairly address the merits of her claim. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, in correspondence received from the veteran's representative in March 2008, the representative indicated that there were additional records available from the VAMC in Bay Pines, Florida, pertaining to the veteran's pending appeal. As the most recent clinical records of record are dated in February 2005, it appears that additional treatment records remain outstanding. Because these may include records that are pertinent to the veteran's claims, they are relevant and should be obtained. 38 C.F.R. § 3.159(c)(2) (2007); Bell v. Derwinski, 2 Vet. App. 611 (1992). Finally, the Board observes that the claims folder includes a power-of-attorney form (VA Form 23-22) in which the veteran appointed the American Legion as her representative. However, in a February 2008 letter, the veteran stated that she had changed her representative to the Disabled American Veterans (DAV). The DAV subsequently submitted a Memorandum in support of the veteran's claims dated in February 2008. The veteran did not, however, submit an additional VA Form 23-22 officially changing her power of attorney. In light of the need to remand the claims for further development anyway, on remand the veteran's desire as to her representation should also be clarified. Accordingly, the case is REMANDED for the following actions: 1. Contact the veteran to clarify which organization she wants to have as her service representative in this case. If the veteran indicates that any agency other than the American Legion is now her chosen representative, a power of attorney from the veteran should be obtained and the file forwarded to that agency for review of the claim and preparation of a VA Form 646. 2. Obtain and associate with the claims file records from the VAMC in Bay Pines, Florida dated from February 2005 to the present. 3. Schedule the veteran for a gynecological examination for the purpose of ascertaining whether any current gynecological disorder is related to her period of active service. The physician should review the record and render an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current gynecological disorder first manifested in service or is related to the gynecological problems for which she received treatment in service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should indicate in the examination report that the claims file was reviewed and discuss the private and VA medical records of treatment relating to gynecological disorders. The rationale for all opinions must be provided. 4. Schedule the veteran for an orthopedic examination for the purpose of ascertaining whether any current left knee disability is related to her period of active service. The physician should review the record and render an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current left knee disability is related to the left knee problems for which she received treatment in September 1981 and January 1982. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should indicate in the examination report that the claims file was reviewed and discuss the private and VA medical records of treatment relating to the left knee. The rationale for all opinions must be provided. 5. Schedule the veteran for a podiatric examination for the purpose of ascertaining whether any current left foot disability is related to her period of active service. The physician should review the record and render an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current left foot disability is related to the left foot problems for which she received treatment in service. Additionally, the examiner should specifically comment as to whether it is at least as likely as not (50 percent probability or greater) the veteran's pre-existing pes planus was aggravated or permanently worsened as a result of her active service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should indicate in the examination report that the claims file was reviewed and discuss the VA medical records of treatment relating to the left foot. The rationale for all opinions must be provided. 6. Then, readjudicate the claims for service connection for PTSD, pelvic inflammatory disease, the residuals of a left salpingo-oopherectomny, and benign hemorrhagic follicular cyst, and for left knee and foot disabilities. If the decisions remain adverse to the appellant, issue a supplemental statement of the case and allow the appropriate opportunity for response. Thereafter, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). _________________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).