Citation Nr: 18143635 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 14-36 173 DATE: October 19, 2018 REMANDED Entitlement to service connection for a bilateral foot disability, to include bone spurs, is remanded. Entitlement to service connection for residuals of a hysterectomy, is remanded. Entitlement to service connection for a bladder disability, to include as a residual of a hysterectomy, is remanded.   REASONS FOR REMAND The Veteran served on active duty from March 1981 to March 1985, with subsequent service with the Army National Guard of Virginia from September 1985 to March 1987 and from September 1996 to February 1998. This case comes before the Board of Veterans’ Appeals (Board) from a March 2010 rating decision, which in pertinent part, denied service connection for bone spurs, a hysterectomy, and a bladder disability. In December 2015, the Veteran testified before a Veterans Law Judge (VLJ) at a Central Office hearing. A copy of the transcript is associated with the record. In February 2017, the Board remanded the claims for additional development, to include obtaining outstanding in-service and post-service treatment records and a VA examination and medical opinion. In a February 2018 letter to the Veteran, VA informed the Veteran that the VLJ who held her hearing was no longer employed at the Board and requested that she respond within thirty days of the letter if she desired another hearing. She was informed that if no response was received, the Board would assume she did not want another hearing and would proceed accordingly. To date, the Veteran has not responded to the letter. The Veteran’s service treatment records are unavailable for review in this case. When service records are unavailable through no fault of a veteran, VA has a heightened duty to assist, as well as an obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). 1. Entitlement to service connection for a bilateral foot disability, to include bone spurs, is remanded. The Board cannot make a fully-informed decision on the issue of service connection for a bilateral foot disability. A May 2017 VA examiner found that although the Veteran reported multiple medical visits in service, there were no service treatment records for review; therefore, it was less likely than not that the Veteran’s bilateral foot disaiblity, to include bone spurs, was incurred in or caused by heavy lifting associated with her duties as a medical supply specialist and the wearing of uncomfortable boots. The opinion is inadequate because it appears to be based solely on the absence of service treatment records and it is unclear whether the examiner considered the 1999 medical record in which the Veteran reported onset of her bone spur eight years prior, only a few years after service separation. Therefore, the Board finds that a remand is warranted in order to obtain an addendum opinion as to the nature and etiology of the Veteran’s bone spurs. 2. Entitlement to service connection for residuals of a hysterectomy is remanded. 3. Entitlement to service connection for a bladder disability, to include as a residual of a hysterectomy, is remanded As issues 2-3 are related, the Board will address them together. Specifically, the Board cannot make a fully-informed decision on the issues of service connection for residuals of a hysterectomy and for a bladder disability, to include as a residual of a hysterectomy. In December 2015, the Veteran’s treating physician indicated that excessive heavy lifting “may have” contributed to her uterine prolapse. The Board finds that this opinion is inadequate, as the opinion did not relate the Veteran’s uterine prolapse to in-service heavy lifting. Furthermore, speculative language such as “may have” does not create an adequate nexus for the purposes of establishing service connection. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor’s statement framed in terms such as “could have been” is not probative). A May 2017 VA examiner found that although the Veteran reported onset of symptoms of uterine prolapse in service, she did not seek treatment until 2003, when her symptoms became more pronounced, to include dysmenorrhea. As there were no service treatment records for review, the examiner opined that it was less likely than not that the Veteran’s prolapsed uterus was incurred in or caused by heavy lifting associated with her duties as a medical supply specialist. As to the Veteran’s bladder disability, the May 2017 VA examiner noted that the Veteran sought treatment in 2002 for stress incontinence, but that there were no records available to show any objective documentation of a chronic urinary or bladder condition during service. The examiner did not opine as to whether the Veteran’s bladder disability was caused or aggravated by residuals of a hysterectomy. The May 2017 VA examiner’s opinions are also inadequate as they appear to be based solely on the absence of service treatment records without regard to the Veteran’s lay testimony regarding her symptoms. Therefore, the Board finds that a remand is warranted for an addendum opinion as to the nature and etiology of the Veteran’s residuals of a hysterectomy and any diagnosed bladder disability. As the claim of service connection for a bladder disability is intertwined with a determination on the claim of service connection for a hysterectomy, the issue must be remanded. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s bilateral foot disability, to include bone spurs, is at least as likely as not related to service, to include heavy lifting as a medical supply specialist and the wearing of uncomfortable boots. The examiner is asked to comment on the Veteran’s credible lay statements concerning onset of her foot pain and the 1999 medical record in which the Veteran reported onset 8 years prior, or several years after service separation. The examiner is asked to explain why her statements make it more or less likely that a current condition started during service. If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran’s recollection of her symptoms during and after service may be inaccurate or not medically supported as the onset or cause of his current diagnosis. Please note, the service treatment records are unavailable for review, and the examiner should not consider the lack of evidence of treatment during service to be negative evidence. Rather, the examiner should only rely on silence in the medical records if it can be explained (a) why the silence in the record can be taken as proof that the symptom did not occur, (b) why the fact would have normally been recorded if present, or (c) why absence in the medical records is medically significant. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hysterectomy is at least as likely as not related to service, to include a prolapsed uterus due to heavy lifting as a medical supply specialist. The examiner is asked to comment on medical record indicating a mild prolapsed uterus, and the December 2015 private opinion stating that heavy lifting could cause a prolapsed uterus. In answering this question, the examiner is asked to consider the statements from the Veteran indicating that heavy menstrual symptoms starting in service in 1997. The examiner is asked to explain why her statements make it more or less likely that a current condition started during service. If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran’s recollection of his symptoms during and after service may be inaccurate or not medically supported as the onset or cause of his current diagnosis. Please note, the service treatment records are unavailable for review, and the examiner should not consider the lack of evidence of treatment during service to be negative evidence. Rather, the examiner should only rely on silence in the medical records if it can be explained (a) why the silence in the record can be taken as proof that the symptom did not occur, (b) why the fact would have normally been recorded if present, or (c) why absence in the medical records is medically significant. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s bladder disability is at least as likely as not related to service. The examiner is asked to comment on the Veteran’s credible lay statements concerning onset of her bladder disability. The examiner is asked to explain why her statements make it more or less likely that a current condition started during service. If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran’s recollection of his symptoms during and after service may be inaccurate or not medically supported as the onset or cause of his current diagnosis. The examiner must also opine on whether the Veteran’s bladder disability is at least as likely as not (1) proximately due to a different disability, or (2) aggravated beyond its natural progression by a different disability. Please note, the service treatment records are unavailable for review, and the examiner should not consider the lack of evidence of treatment during service to be negative evidence. Rather, the examiner should only rely on silence in the medical records if it can be explained (a) why the silence in the record can be taken as proof that the symptom did not occur, (b) why the fact would have normally been recorded if present, or (c) why absence in the medical records is medically significant. C. BOSELY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Owen, Associate Counsel