Citation Nr: 1752876 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 14-07 082 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a right hip disability. 3. Entitlement to service connection for a migraine disability. 4. Entitlement to service connection for a gynecological and/or genitourinary disability. 5. Entitlement to service connection for depression. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Orie, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from April 1987 to January 1990. These matters come before the Board of Veterans' Appeals on appeal from a June 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In June 2016, the Veteran testified before the undersigned Veterans Law Judge at a Board hearing via videoconference. A copy of that transcript is of record. The issues of entitlement to service connection for a low back disability, a right hip disability, a right knee disability, migraines, and a gynecological/ genitourinary disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT At the June 2016 Board hearing, the Veteran, through her representative, indicated that she wished to withdraw her appeal as it pertained to her claim for service connection for depression. CONCLUSION OF LAW The criteria for withdraw of the Veteran's service connection claim for depression have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2014); 38 C.F.R. § 20.204 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION An appellant, or his authorized representative, may withdraw an appeal or any issues therein, on the record at a hearing or in writing; such a withdrawal is effective when received. 38 C.F.R. § 20.204. At the June 2016 Board hearing, the Veteran's representative indicated that the Veteran no longer wanted to pursue her claim for service connection for depression. The Veteran also submitted a written statement, expressing her intent to withdraw the claim for service connection for depression. See Statement in Support of Claim dated June 20, 2016. Accordingly, the Board finds that the Veteran's withdrawal of the claim was well-informed; thus, the Board no longer has jurisdiction to review the issue and the appeal, as it pertains to depression, is dismissed. 38 U.S.C. § 7105(b)(2). ORDER The issue of entitlement to service connection for depression is dismissed. REMAND Missing Service Records The Veteran contends that her orthopedic injuries, specifically her low back, right hip and right knee injuries are related to a fall she had during annual training while she was in the Reserves. The Veteran's treatment records from her period of time in the Reserves demonstrate that she slipped and fell on concrete steps in August 1995. As a result of that fall, the Veteran injured her knee. See Service Treatment Records dated August 4, 1994. Although x-rays were negative at that time, subsequent treatment records demonstrate that the Veteran continued to have pain and swelling in her right knee. See Service Treatment Records dated August 5, 1995, August 6, 1995, August 7, 1995, and August 8, 1995. In addition, the Veteran also sought physical therapy for a low back injury in 1993. Available records do not specify the etiology of the Veteran's injury, nor was a specific diagnosis provided. It is unclear from available records whether the Veteran was on active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA) when these injuries occurred. Upon remand, the AOJ is asked to verify the Veteran's periods of active duty for training, inactive duty for training, and active duty service. Missing Treatment Records In addition, the Veteran contends that she received treatment during service at several military hospitals in different locations, to include Fort Gordon and Fort Hood. She also contends that she sought treatment from a civilian gynecologist familiar with her medical history. Upon remand, the AOJ should contact the Veteran and verify all locations of her medical treatment during service and upon discharge from service. Upon receipt of the names and dates of the Veteran's treating physicians and any necessary authorizations, the AOJ should verify that all pertinent service and post-service treatment records are in the claims file; any outstanding records should be obtained. VA Examinations The Veteran's service treatment records document the Veteran's numerous complaints of headaches, back pain, right knee pain, and right hip pain. To date, the Veteran has yet to be afforded an adequate VA examination with nexus opinion. Upon remand, the AOJ should schedule the Veteran for VA examinations in relation to her claims for migraines, low back, right knee, and right hip. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and her representative and request the dates and locations of the Veteran's in-service hospitalizations. Once that information and any necessary authorizations are received, contact the named hospitals, NPRC and any other appropriate facility and attempt to obtain the missing records from the hospitals in Frankfurt, Germany, Fort Lee, Virginia, and Fort Knox, Kentucky. All attempts to secure the missing records must be documented in the claims file. If no additional records are available or further attempts to secure them would be futile, a response to that effect should be documented in the claims file. 2. Contact the Veteran and her representative and request that the Veteran complete, sign, and return a VA Form 21-4142, Authorization and Consent to Release Information to allow VA to request the Veteran's complete records from the civilian doctors who treated the Veteran for her claimed disabilities since her return from service. 3. Take additional action to verify the dates of the Veteran's ACDUTRA and INACDUTRA and any other type of Reserve service by contacting the Defense Finance and Accounting Service (DFAS) and requesting the Veteran's Master Military Pay Account (MMPA). The AOJ must document all steps taken to obtain this record. 4. Upon completion of the above, schedule the Veteran for a VA joints examination to determine the nature and etiology of the Veteran's right knee and right hip disabilities. The entire claims file must be made available to the individual designated to examine the Veteran and the designated examiner must review the entire claims file in conjunction with the examination. All necessary tests and studies should be performed. The examiner should determine: a) Whether it is at least as likely as not the Veteran's right hip disability, if any, was caused by or is otherwise etiologically related to her period of service? OR b) Whether it is at least as likely as not the Veteran's right hip disability, if any, was caused or aggravated by her service-connected left knee disability? AND c) Whether it is at least as likely as not the Veteran's right knee disability was caused by or otherwise etiologically related to her period of service? OR d) Whether it is at least as likely as not the Veteran's right knee disability was caused or aggravated by her service-connected left knee disability? All opinions should be supported by adequate rationale. In providing the opinions, the examiner is asked to consider and discuss the significance of the following: * September 18, 1987: V reports right knee pain after falling. Assessed with MCL strain. * Any knee injuries associated with confirmed periods of ACDUTRA and INACDUTRA service. 5. Schedule the Veteran for a VA spine examination to determine the nature and etiology of the Veteran's lumbar spine disability. The entire claims file must be made available to the individual designated to examine the Veteran and the designated examiner must review the entire claims file in conjunction with the examination. All necessary tests and studies should be performed. The examiner should determine: a) Whether it is at least as likely as not the Veteran's lumbar spine disability was caused by or is otherwise etiologically related to the Veteran's period of service? OR b) Whether it is at least as likely as not the Veteran's lumbar spine disability was caused or aggravated by her service-connected left knee disability? All opinions should be supported by adequate rationale. In providing the opinions, the examiner is asked to consider and discuss the significance of the following: * August 1988: lumbar spinal tap. * December 12, 1989: Veteran reports low back pain on the right side; diagnosed with muscle strain. * Any back injuries associated with confirmed periods of ACDUTRA and INACDUTRA service 6. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's migraine disability. The entire claims file must be made available to the individual designated to examine the Veteran and the designated examiner must review the entire claims file in conjunction with the examination. All necessary tests and studies should be performed. The examiner should determine whether it is at least as likely as not the Veteran's current migraines are etiologically related to her documented in-service headaches. All opinions should be supported by adequate rationale, to include a comparison between the Veteran's current symptoms and aggravating factors and those endorsed during service. In providing the opinions, the examiner is asked to consider and discuss the significance of the following: * May 10, 2988: Veteran assessed with possible migraine. * May 20, 1988: Veteran reports headaches along with nausea, vomiting, and diarrhea. * September 24, 1988: Veteran assessed with migraine. * July 7, 1989: Veteran reports headaches, along with nausea and vomiting. CT scan of head yielded normal results. * July 30, 1988: Veteran's complaints of headaches, along with dizziness and stiff trapezius; CT scan of head performed. Veteran assessed with migraine headache verses muscle tension. * August 1, 1988: V reports headaches. * September 8, 1989: Veteran assessed with migraine. * September 24, 1989: Veteran reports headaches, nausea, and vomiting. History of migraine headaches noted. Veteran assessed with recurrent migraine headaches. * September 25 and 28, 1989: Veteran noted to have unresolved migraine headache. * November 14, 1989: Veteran reports headaches every 2-3 months, occasionally associated with nausea and vomiting. 7. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's gynecological disability. The entire claims file must be made available to the individual designated to examine the Veteran and the designated examiner must review the entire claims file in conjunction with the examination. All necessary tests and studies should be performed. The examiner should determine whether it is at least as likely as not the Veteran's current gynecological and/or genitourinary disability is related to her period of service, to include residuals of a dilation and curettage and a C-section. All opinions should be supported by adequate rationale, to include a comparison between the Veteran's current symptoms and aggravating factors and those endorsed during service. In providing the opinions, the examiner is asked to consider and discuss the significance of the following: * May 19, 1987: Veteran reports pelvic/groin pain. * June 8, 1987: Veteran reports groin pain. * July 10, 1987: Veteran reports groin pain. Assessed with chronic right pelvis pain of unknown etiology. * July 15, 1989: Veteran assessed with pelvic discomfort of unknown etiology. * June 21, 1988: V reports chronic pelvic pain; normal pelvic ultrasound. * September 5, 1989: Veteran assessed with pelvic pain of unknown etiology. * December 12, 1989 Report of Medical History: Veteran reports having female pain. 8. After completing the requested actions, and any additional action deemed warranted, to include obtaining an additional opinion if deemed necessary based on evidence obtained in response to the above, the AOJ should readjudicate the claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. See 38 U.S.C. §§ 5109B, 7112 (2014). ______________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs