Citation Nr: 1113331 Decision Date: 04/05/11 Archive Date: 04/15/11 DOCKET NO. 08-29 125 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a gynecological disorder, to include dysfunctional uterine bleeding. 2. Entitlement to service connection for numbness of the left foot, claimed as accessory navicular left foot. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and her mother ATTORNEY FOR THE BOARD B. Adams, Associate Counsel INTRODUCTION The Veteran served on active duty from May 2004 to February 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In response to that rating decision, the Veteran also initiated appeals with respect to the denial of her claims for service connection for insomnia, gastroenteritis, lumbar strain, and left knee strain and with respect to the disability ratings assigned for her right knee strain and bilateral shin splints. In July 2008, the RO issued a decision review officer decision that granted several of these claims and a statement of the case that addressed the remaining claims. However, the Veteran specifically limited her appeal to the issues listed on the title page in her August 2008 substantive appeal. The Board will limit its consideration accordingly. The Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge in August 2010. A transcript of that proceeding is of record. The issue of entitlement to service connection service connection for numbness of the left foot, claimed as accessory navicular left foot, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. FINDING OF FACT The Veteran's gynecological disability is etiologically related to her active service. CONCLUSION OF LAW A gynecological disability incurred in active duty. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION As a preliminary matter, the Board notes that the Veteran has been provided all required notice, to include notice pertaining to the disability-rating and effective-date elements of her claim for service connection for a gynecological disability. In addition, the evidence of record is sufficient to establish her entitlement to service connection for that disability. Therefore, no further development is required under 38 U.S.C.A. §§ 5103, 5103A (West 2002) or 38 C.F.R. § 3.159 (2010). Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2009); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis The Veteran contends that service connection is warranted for a gynecological disorder because it is related to service. Specifically, she maintains that she developed gynecological problems during service and that those problems have persisted continuously since that time. The Board notes that the Veteran characterized her gynecological disorder as menometrorrhagia in her original claim for compensation received in January 2007. The originating agency addressed gynecological disorders other than menometrorrhagia in the July 2008 statement of the case. At the August 2010 hearing, the Veteran clarified that her claim encompassed not only menometrorrhagia but also other gynecological disorders with which she had been diagnosed, including dysfunctional uterine bleeding, endometriosis, polycystic ovarian syndrome, and dysmenorrhea. Accordingly, the Board has re-characterized the Veteran's claim as a claim of entitlement to service connection for a gynecological disorder, to include dysfunctional uterine bleeding. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Service treatment records show that the Veteran began experiencing gynecological problems during service. No pelvic abnormalities were noted in the November 2002 report of medical examination prepared prior to the Veteran's entrance into active duty, although it is unclear whether a physical examination of her pelvis was conducted at that time. A contemporaneous report of medical history notes the Veteran's report that she began menstruating at age 12 and that she experienced long, heavy periods, but it also notes that she denied experiencing dysmenorrhea. The Veteran first complained of gynecological problems in January 2006, when she was treated for heavy vaginal bleeding and pain. Diagnostic assessments of menorrhagia, suprapubic abdominal pain, and dysfunctional uterine bleeding were rendered in January 2006, and a provisional diagnosis of menometrorrhagia was rendered in May 2006. The pertinent post-service medical evidence of record includes an August 2007 VA examination report, VA treatment records dated from September 2007 to March 2009, and a private surgical record dated in March 2008. The August 2007 VA examiner rendered a diagnosis of dysfunctional uterine bleeding, on treatment, but did not provide a nexus opinion. VA treatment records dated in September 2007, December 2007, January 2008, and March 2009 reflect clinical impressions and diagnostic assessments of endometriosis, abdominal pain due to adhesions, and polycystic ovaries. The March 2008 private surgical record reflects diagnoses including pelvic pain, pelvic adhesions, left tubal adhesions, and endometriosis. At the hearing, the Veteran argued that her gynecological problems began in service, were chronic during service, and have persisted since service. The Board notes that she is competent to report the onset and duration of her observable symptoms, including pelvic pain and abnormal vaginal bleeding. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board also finds that her statements regarding the onset and chronic nature of her gynecological disability are credible since they are supported by both service treatment records and by the post-service medical evidence of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Accordingly, since the preponderance of the evidence is in favor of the claim, service connection for a gynecological disability is warranted. ORDER Service connection for a gynecological disability, to include dysfunctional uterine bleeding, is granted. REMAND The Veteran also contends that service connection is warranted for numbness of her left foot, claimed as accessory navicular left foot. She believes that this disorder was caused by the misapplication of a transcutaneous electrical nerve stimulation (TENS) unit while she was receiving treatment for a tibia fracture and shin splints in service. At the August 2010 hearing, the Veteran indicated that she believes her left foot numbness also may be related to her tibia fracture and shin splints. Service treatment records show that an August 2005 X-ray study revealed a left os naviculare, or an accessory navicular bone in the left foot. They also show that the Veteran was prescribed TENS treatment for other joint problems in September 2005, October 2005, and November 2005. A November 2005 record notes her complaint of pain along her left shin and "some tingling" in her foot and toes with prolonged standing. The post-service medical evidence does not address the nature and etiology of the Veteran's alleged left foot numbness. VA treatment records dated through March 2009 do not reflect any treatment or diagnosis related to her left foot. An August 2007 VA examination report notes the Veteran's complaint of left foot pain and reflects a diagnosis of left foot strain, but it does not include an opinion regarding the etiology of that diagnosis. More importantly, it does not address the issue of left foot numbness. The Veteran is competent to report that she experienced numbness in her left foot during service and that she has continued to experience left foot numbness since her separation from service. See, again, Jandreau, 492 F.3d 1372. However, since none of the medical evidence of record adequately addresses the nature and etiology of that claimed condition, the Board finds that a remand is necessary so that the Veteran may be afforded a new VA examination. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Moreover, since this claim was adjudicated to include an accessory navicular bone in the left foot, the examiner also should address the nature and etiology of that condition. While this case is in remand status, additional evidentiary development should be undertaken. Because the Veteran is claiming that her left foot numbness may be related to her service-connected left lower extremity disabilities, she should be provided with appropriate notice regarding the elements necessary to establish entitlement to service connection for that disability on a secondary basis. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Efforts also should be undertaken to obtain any outstanding private and VA treatment records since they may be pertinent to the claim. See 38 C.F.R. § 3.159(c). Accordingly, the case is REMANDED for the following actions: 1. Provide the Veteran with notice that sets forth the evidence necessary to establish service connection for left foot numbness, claimed as accessory navicular left foot, on a secondary basis. 2. Undertake appropriate development to obtain a copy of any outstanding records pertaining to treatment or evaluation of the Veteran's left foot, to include all records of treatment and hospitalization received at the VA medical facility in Jacksonville, Florida, and in other parts of the North Florida/South Georgia Veterans Health System since June 2008. 3. Schedule the Veteran for a VA neurological examination by a physician with appropriate expertise to address the nature and etiology of her left foot numbness. The claims folder must be made available to and reviewed by the examiner. Indicated tests, if any, should be performed. Based upon the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent or better probability) that the Veteran's left foot numbness, accessory navicular, or any other left foot disability diagnosed on examination is etiologically related to an in-service event, injury, or disease, to include the TENS treatment documented in the service treatment records. The examiner also should provide an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent or better probability) that the Veteran's left foot numbness, accessory navicular, or any other left foot disability diagnosed on examination was caused or chronically worsened by her service-connected left knee strain or her service-connected left shin splints. A thorough rationale must be provided for all opinions expressed. If the examiner is unable to provide any requested opinion, a supporting rationale must be provided concerning why the opinion cannot be given. 4. Following the completion of the above, readjudicate the Veteran's claim for service connection for left foot numbness, claimed as accessory navicular left foot, based on a de novo review of the record. If any benefit sought on appeal is not granted, the Veteran and her representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond before the case is returned to the Board for further appellate action. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. 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. 2010). ______________________________________________ TARA L. REYNOLDS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs