Citation Nr: 18146117 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-34 225 DATE: October 30, 2018 REMANDED Entitlement to service connection for a menstrual disorder is remanded. Entitlement to service connection for a bilateral foot disorder is remanded. Entitlement to service connection for diverticulitis, claimed as secondary to service-connected irritable bowel syndrome (IBS) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1985 to August 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2012 and August 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). Remand is required for adequate examinations. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Further, when the Veteran has provided lay testimony of an in-service event, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). Specific reasons for remand will be addressed by issue. 1. Entitlement to service connection for a menstrual disorder In an October 2012 statement, the Veteran alleged that her menstrual disorder was an undiagnosed illness, or a qualifying chronic disability for which service connection is warranted on the basis of the Veteran being a Persian Gulf veteran. In her July 2016 VA Form 9, the Veteran attributed her claimed menstrual disorder to her service in Saudi Arabia. She emphasized that she had no unusual bleeding or cycles prior to her service in Saudi Arabia and received inoculations. The Board notes that the Veteran’s STRS show her of a history of having a change in her menstrual pattern on her June 1991 Report of Medical History for her separation from active duty. Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (e). For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317 (a)(1). There are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that VA determines in regulations warrants a presumption of service connection. 38 C.F.R. § 3.317 (a)(2). An undiagnosed illness is a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1). A medically unexplained chronic multisymptom illnesses is defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that VA determines meets the criteria in paragraph 3.317(a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). The Veteran’s claim has thus far been denied on the basis that a menstrual disorder has been attributed to diagnoses that have occurred following her separation from active duty. At a May 2012 VA Gynecological examination, the Veteran was diagnosed with a history of polycystic ovarian syndrome and fibroids, both occurring after her service. On clinical interview, she reported starting an overseas tour in Saudi Arabia in November 1990. From December 1990 to August 1991, she ceased having a period, which she attributed to an inoculation received for her deployment. She resumed having her period after her deployment. The Veteran reported having an ablation in 2009 for fibroids, after which she had more heavy bleeding and cramping. Thereafter, she underwent an abdominal hysterectomy in 2010, but her ovaries were not removed. Symptoms reportedly present at that time were stress incontinence. The examiner opined that the Veteran’s menstrual condition was less likely as not incurred in or caused by service. The examiner explained that the Veteran had a period of amenorrhea in service, which was likely due to stress. The examiner noted that she later began having menstrual periods which were irregular, at which time she was found to have polycystic ovarian syndrome. In 2009, after having heavy periods, the Veteran was diagnosed with fibroids, which was treated with hysterectomy in 2010. Based on this evidence, the Veteran’s hysterectomy and fibroids were less likely as not caused by service. In an August 2013 addendum, a VA examiner noted that the Veteran had diagnoses of fibroids and polycystic ovarian syndrome and that these conditions were known to cause menstrual irregularities. They were not causally related to the Veteran’s travel to Southwest Asia, opined the examiner. According to medical sources, the main contributing factors to polycystic ovarian syndrome included obesity, premature adrenarche, heredity, certain ethnic backgrounds, and some anti-seizure medications. The examination and opinions rendered are inadequate to adjudicate the Veteran’s claim. The Veteran has consistently described undergoing irregular menstral cycles during her military service and having the onset of heavy menstrual periods after her return from the Southwest Theater of operations. At that time, prior to 1993, she did not have a diagnosis of polycystic ovarian syndrome or fibroids. That is, it is debatable as to whether symptoms manifested by irregular or heavy menstrual periods are attributable to a diagnosed condition. The Board finds that remand is warranted to address the Veteran’s claim that she experienced menstrual symptoms during service, to include an opinion as to whether the symptoms are a qualifying chronic disability, that is, an undiagnosed illness or medically unexplained chronic multi-symptom illness. 2. Service connection for a bilateral foot disorder The Veteran asserts she has bilateral plantar fasciitis that had onset during service. In the July 2016 VA Form 9, the Veteran alleged she had a diagnosis of plantar fasciitis and had received treatment in the form of injections and physical therapy for this condition. She described having plantar fasciitis during her military service and ignoring the symptoms. She reportedly had been suffering from bilateral fasciitis for years, only first seeking treatment for a foot disorder in 2003. She specifically attributed her bilateral plantar fasciitis to wearing combat boots daily for six years, participating in road marches, and running four times per week during service. On VA examination in May 2012, the examiner found mild tenderness at the bilateral plantar fascia. The examiner opined that the Veteran’s plantar fasciitis was less likely than not incurred in or caused by the Veteran’s service, explaining that there was no evidence of plantar fasciitis found in service or on separation examination. On VA examination in August 2013, the Veteran was again diagnosed with plantar fasciitis. The examiner noted an annotation in the Veteran’s STRs showing foot pain in February 1988 after the Veteran had been out in the cold. The examiner also noted that the Veteran had been found to not have a cold weather injury at that time and that the Veteran’s exit examination showed no ongoing foot pain. Explaining that the Veteran’s record did not show a diagnosis of plantar fasciitis and that no specific injury was diagnosed in the STRs, it was less likely than not that the Veteran’s plantar fasciitis was due to her service. The May 2012 and August 2013 opinions are inadequate because the opinions fail to account for the Veteran’s credible lay statements describing bilateral foot pain during service. In addition, the Veteran has described instances of wear and tear on her feet that could satisfy the in-service element of service connection. Absent an opinion that addresses the Veteran’s statements and this theory of entitlement, the Board is unable to adjudicate this claim. Remand is thus warranted for an opinion. 3. Service connection for diverticulosis In the July 2016 VA Form 9, the Veteran alleged she had a present diagnosis of diverticulosis that was secondarily related to her service-connected IBS. She has consistently attributed her claimed disorder to her service-connected IBS. See e.g. November 2011 statement. Private treatment records from December 2009 and January 2010 show the Veteran underwent a colonoscopy after an evaluation for reported changes in bowel habits and abdominal pain. She had experienced a four-year history of constant bloating, -constipation, and a recent change in bowel habits. The colonoscopy revealed sigmoid diverticulosis. A present disability is shown. At a May 2012 VA examination, the examiner opined that the Veteran’s diverticulosis was less likely as not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner explained that many people have small pouches, or diverticula, in the lining of the colon that bulge outward through weak spots. This condition, called diverticulosis, affected about 10 percent of Americans older than 40 years. The condition becomes more common as people age, and diverticula are most common in the sigmoid portion of the large intestine, which is where the Veteran’s diverticula are located. This opinion is inadequate. It addresses the Veteran’s claim on a direct theory of entitlement. However, the Veteran attributes the development of her diverticulosis of the sigmoid colon to her service-connected IBS. In a June 2013 addendum opinion, a VA examiner opined that the Veteran’s diverticulosis is less likely as not proximately due to or the result if IBS. The examiner provided the same discussion of diverticulosis as was provided in the May 2012 examination report, noting that IBS has not been documented as a cause of diverticulosis. This opinion is inadequate. First, there is no detailed rationale to support a finding that diverticulosis is not proximately due to or the result of IBS. Second, the examiner failed to address whether the Veteran’s service-connected IBS has aggravated the Veteran’s diverticulosis. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. Contact the Veteran and afford her the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of her gynecological disorder. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. The examiner must elicit a full history from the Veteran of her claimed symptoms, to include the onset thereof. An explanation for all opinions expressed must be provided. The Veteran is competent to attest to factual matters of which she has first-hand knowledge. The examiner must elicit a full history from the Veteran and consider the lay statements of record. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must provide a fully reasoned explanation. a. The examiner must opine as to whether it is at least as likely as not (a 50 percent probability or more) that any current gynecological disorder is causally or etiologically related to service. The examiner must address the Veteran’s statements and records showing that she had irregular periods in service. b. The examiner must provide an onset date for any currently diagnosed disorder. c. The examiner must also determine whether any of the Veteran’s complaints is due to an (A) an undiagnosed illness; or (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of her bilateral plantar fasciitis. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral plantar fasciitis had onset in, or is otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of an in-service bilateral foot pain and that pain existing ever since service. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of her diverticulosis. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the diverticulosis had onset in, or is otherwise related to, active military service. The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the diverticulosis is caused or aggravated by the service-connected irritable bowel syndrome. The examiner must specifically address the Veteran’s assertions of constipation caused by IBS causing an undue strain on her intestines, causing or aggravating her diverticulosis. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel