Citation Nr: 1324014 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 10-22 831A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for myofascial pain syndrome. 2. Entitlement to service connection for a disability manifested by urinary incontinence. REPRESENTATION Appellant represented by: Karl A. Kazmierczak, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, the appellant in this matter, served on active duty from December 1997 to December 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, that denied entitlement to service connection for myofascial pain syndrome and urinary incontinence. In October 2012, the Veteran testified at a videoconference hearing before the undersigned. A transcript of that hearing is of record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veterans Claims Assistance Act of 2000 (VCAA), specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d). In accordance with VCAA, VA is obligated to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The Board finds that medical examination is necessary to determine whether the Veteran's claimed myofascial pain syndrome and urinary incontinence first manifested in service or are medically related to injury or another event or incident of active service. Service treatment records show that the Veteran sought medical treatment for myofascial pain in service in January 2001, February 2001, June 2001, July 2001, and September 2001. She reported having pain in the left shoulder area, neck, and upper back. The Veteran also reported having left arm paresthesias. The September 2001 separation examination report indicates that examination of the musculoskeletal system was normal. She separated from service in December 2001. At the October 2012 Board videoconference hearing, the Veteran stated that she still had myofascial pain in the left trapezius, left shoulder, and neck area. The Veteran stated that the pain began in service in 2008 and she had the pain ever since. The Veteran, as a layperson, is competent to report observable symptoms, including symptoms during and since service. Duenas v. Principi, 18 Vet. App. 512 (2004). This is sufficient evidence to warrant an examination, since there is competent evidence of symptoms and treatment in service, current symptoms of disability, and a report of symptoms since service that suggests a possible association to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The record shows that service connection is in effect for residuals of a left trapezius strain and a noncompensable evaluation is assigned from December 15, 2001. The Board finds that medical examination is necessary in this matter to assist in determining whether the claimed myofascial pain syndrome is a manifestation of the service-connected residuals of left trapezius strain or is caused or aggravated by the service-connected residuals of left trapezius strain. The Veteran asserts that she has had urinary incontinence since service. Service treatment records show that the Veteran had symptoms of frequency and urgency in February 1998. She sought treatment for urinary incontinence in January 1999 and October 1999; stress urinary incontinence was diagnosed. The September 2001 separation examination report indicated that the Veteran denied having frequent or painful urination. The genitourinary system was not examined. At the October 2012 Board videoconference hearing, the Veteran stated that she has had urinary incontinence since service. The Board notes that the Veteran is competent to report observable symptoms and report a continuity of symptoms. Duenas; supra. This is sufficient evidence to warrant an examination, since there is competent evidence of current symptoms, symptoms in service, and a report of symptoms since service. See McLendon; supra. Thus, the Board finds that an examination is needed to determine whether the Veteran currently has a disability manifested by urinary incontinence that had its onset in service or is related to active service. The RO should contact the Veteran in order to have her provide sufficient information, and if necessary authorization, to enable the RO to obtain any pertinent VA and/or non-VA records showing treatment of the claimed disabilities since service separation. The RO should make an attempt to obtain any treatment records identified by the Veteran that are not currently associated with the claims file. The Veteran also should be informed that she may submit evidence to support her claims including any evidence of in-service treatment for the claimed disabilities. Accordingly, the case is REMANDED to the RO for the following action: 1. Contact the Veteran in order to obtain all VA and non-VA medical records referable to her treatment of the claimed myofascial pain syndrome and urinary incontinence. The letter should request sufficient information to identify the health care providers, and if necessary, signed authorization, to enable VA to obtain any additional evidence. If the Veteran adequately identifies the health care providers and provides the completed authorizations, request legible copies of all pertinent clinical records that have not been previously obtained, and incorporate them into the Veteran's claims file. The letter should invite the Veteran to submit any pertinent medical evidence in support of her claims. 2. Schedule the Veteran for a VA examination in order to determine the nature and likely etiology of the claimed myofascial pain syndrome and urinary incontinence. The claims folder must be made available to the examiner for review in connection with the examination. All appropriate tests and studies should be accomplished with all results made available to the examiner prior to the completion of his or her report, and all clinical findings should be reported in detail. Regarding the claimed myofascial pain syndrome, the examiner should report all current diagnoses. The examiner should indicate whether the Veteran has a current disability manifested by myofascial pain. After examining the Veteran and reviewing the relevant evidence in the claims file, the VA examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any current myofascial pain syndrome had its onset during service or is otherwise due to or related to injury or other event of the Veteran's periods of active service. Attention is invited to the service treatment records which show treatment for myofascial pain syndrome in 2001. The VA examiner should opine as to whether it is at least as likely as not that any current myofascial pain syndrome is a manifestation of the service-connected left trapezius strain. If the claimed myofascial pain syndrome is separate and distinct from the service-connected left trapezius strain, the VA examiner should opine as to whether it is at least as likely as not that any current myofascial pain syndrome is proximately due to or aggravated by the service-connected left trapezius strain. If the examiner finds that the myofascial pain syndrome is aggravated by a service-connected disability, the examiner should indicate the degree of disability of the disability before it was aggravated and its current degree of disability, to the extent possible. Regarding the claimed urinary incontinence, the examiner should report all current diagnoses pertinent to the genitourinary system. The examiner should indicate whether the Veteran has a current disability manifested by urinary incontinence. After examining the Veteran and reviewing the relevant evidence in the claims file, the VA examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any current disability manifested by urinary incontinence had its onset during service or is otherwise due to or related to injury or other event of the Veteran's periods of active service. Attention is invited to the service treatment records which show treatment for urinary incontinence in 1999. The examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 3. After completing all indicated development, readjudicate all claims remaining on appeal. If any benefit sought on appeal remains denied, the RO should provide the Veteran and his representative with a fully responsive Supplemental Statement of the Case and afford them a reasonable opportunity for response. The appellant has the right to submit additional evidence and argument on the matter or matters 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. 2012). _________________________________________________ THOMAS D. JONES Acting 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) (2012).