Citation Nr: 18149081 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-16 976 DATE: November 8, 2018 ISSUES 1. Entitlement to service connection for a right shoulder disability. 2. Entitlement to service connection for a lower back disability. 3. Entitlement to service connection for a right ankle disability. 4. Entitlement to service connection for a right heel disability. 5. Entitlement to service connection for a right calf disability. 6. Entitlement to service connection for bronchial asthma. 7. Entitlement to service connection for chronic headaches. ORDER Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a lower back disability is denied. Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a right heel disability is denied. Entitlement to service connection for a right calf disability is denied. Entitlement to service connection for bronchial asthma is denied. REMANDED Entitlement to service connection for chronic headaches is remanded. FINDINGS OF FACT 1. A right shoulder disability was not manifest in service or within one year of separation, and has not otherwise been shown to be etiologically related to service. 2. A lower back disability was not manifest in service or within one year of separation, and has not otherwise been shown to be etiologically related to service. 3. The Veteran is not shown to have any current disability related to the right ankle that is diagnosed or otherwise etiologically related to service. 4. The Veteran is not shown to have any current disability related to the right heel that is diagnosed or otherwise etiologically related to service. 5. The Veteran is not shown to have any current disability related to the right calf that is diagnosed or otherwise etiologically related to service. 6. Bronchial asthma was not manifest in service. Bronchial asthma is not otherwise attributable to service. CONCLUSIONS OF LAW 1. A right shoulder disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. A lower back disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 3. A right ankle disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. A right heel disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 5. A right calf disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 6. Bronchial asthma was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1982 to February 1996. This matter is before the Board of Veterans Appeals (Board) on appeal from an August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection To establish service connection a Veteran must generally show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, 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.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). As with all claims for service-connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for a right shoulder disability 2. Entitlement to service connection for a lower back disability The Board incorporates its discussion from the sections above by reference. By way of background, an October 27, 1989 Service Treatment Record (STR) shows that the Veteran presented with complaints of lower back pain. A January 1990 STR shows reports of lower back pain. The most recent August 1991 Report of Medical History disclosed a clinically normal evaluation of the upper extremities, spine, other musculoskeletal system, and neurologic system. An April 6, 1993 STR shows that the Veteran injured his right shoulder playing sports. It was tender, but there was not swelling. Next, private treatment records from Scott & White show that the Veteran presented with right shoulder pain on December 24, 2009. He reported pain and limited motion for the past two months. He denied having any history of chronic medical conditions. The Veteran filed his initial claim for service connection for the issues currently on appeal in February 2014. Next, the Veteran was afforded several May 2014 VA examinations with medical opinions. They have been fully considered and will be addressed below. Regarding the lower back, the VA examination shows that the Veteran provided the following medical history: The Veteran states that in ~1986 he was putting up an antenna when he fell and felt sudden pain in right low back. He states he received pain medication at that time, but no other treatment and that thereafter the pain would recur with road marches and was always treated with ibuprofen. Since then he has recurrent pain with lifting heavy weight with his back and has sudden 8/10 sharp right low back pain which he must then stretch out for about 15 minutes. He states this occurs about 2-3x/week. Next, the VA examiner rendered a May 2014 medical opinion. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner provided the following rationale: The veteran has symptoms and TTP over right SI joint consistent with SI joint dysfunction. Note dated 7/24/1989 had the diagnosis of LBP with sciatica but the symptoms were pain on palpation of the right SI joint with radiation to right thigh which based on symptoms was likely right SI joint sprain. There is a note from 1/4/1990 noted 1 day of paraspinal spasm diagnosed as sprain without mention of SI joint symptoms. Another note possibly apparently dated 5/9/96 noted 3 days of LBP without diagnosis or follow-up in indicating a chronic condition. An earlier note dated 10/15/1986 LBP x 1 day with right paravertebral spasm diagnosed as strain again with no follow-up indicating chronic pathology. LBP is quite common and these incidents of back pain, based on the documentation, appear to be acute unrelated episodes, not is there a continuum of documentation of back pathology after separation, therefore based on available objective information, it is less likely than not. Similarly, regarding the right shoulder, the VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned: The Veteran reports a right rotator cuff tear and has symptoms and findings supportive of that diagnosis with no sign of bursitis which the diagnosis noted in 4/93. There are no apparent further complaints noted which would indicate a chronic condition, nor does bursitis cause rotator cuff tear, therefore it is less likely than not VA treatment records are substantially the same, and show impressions of and treatment for lower back and right shoulder pain. In particular, the first documentation of these disabilities was in an October 7, 2015 VA primary care visit note, showing impressions of arthralgia associated with chronic low back pain and right shoulder pain. The Veteran also submitted several buddy statements, which have been considered. The Veteran filed his Notice of Disagreement (NOD) in August 2015. The Veteran perfected his appeal in April 2016. He attached a statement with lay history and lay argument listed for each issue on appeal. The Board has fully reviewed and considered this. First, regarding the back, he reported that his first back problem occurred when on a two-week field training in New York. His back went out when he went to pull ropes to erect an antenna. He was in pain. Next, regarding the right shoulder, his reports include a 1993 incident in service resulting in injury to the right shoulder. He was diagnosed with a torn rotator cuff. The Veteran reported that he would get Motrin from his medic, but did not want to go to sick call. He sucked it up. Treatment providers would only mask the pain with painkillers. In the March 27, 2017 Statement of Accredited Representative in Appealed Case, the Veteran through his representative avers in part, “The statements show the basis for this claim. We request that due consideration be given to the statements and the other evidence in support of the claim.” In a February 2018 letter, the Veteran indicated, “I have enclosed all the remaining information or evidence that will support my claim, or I have no other information or evidence to give VA to support my claim. Please decide my claim as soon as possible.” The Veteran’s central theory of entitlement is that he injured his shoulder and lower back in service, to which his present disability is attributable. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). More specifically, the Veteran is competent to report pain in his shoulder and lower back. He is competent to report experiencing this following various events that he has described in service. The Veteran is competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for the lower back and right shoulder, that he has arthritis, and when related disabilities were first identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran’s own lay opinions as to the diagnosis and cause of a right shoulder and lower back disability are not probative evidence, although the Veteran’s observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran’s lay opinion beyond a description of his symptoms is of limited probative value. The most probative evidence is the contemporaneous treatment records, including the STRs, and the opinion of the May 2014 VA examiner. First, the Report of Medical History from closest to separation is clinically normal for the upper extremities, spine, other musculoskeletal system, and neurologic system. Years later, in December 2009, the Veteran presented with complaints of right shoulder pain that he had been experiencing for two months. Thus, the first documentation of the Veteran having a right shoulder disability after discharge was in December 2009. The first documentation of arthralgia and a lower back disability was in a problem list from October 7, 2015. We have assigned significant probative weight to the contemporaneous treatment records. Second, we have assigned significant probative weight to the detailed opinion of the March 2014 VA examiner. The physician reviewed the entire claims file, and provide detailed reasons and bases. The physician also considered the Veteran’s lay contentions regarding injuries in service, and the resulting pain. The physician opined that both claimed conditions were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner again noted that service treatment records and the VA examination from before discharge are devoid of right shoulder and back pathology. The VA examiner explained, “LBP is quite common and these incidents of back pain, based on the documentation, appear to be acute unrelated episodes, not is there a continuum of documentation of back pathology after separation, therefore based on available objective information, it is less likely than not.” Regarding the right shoulder, the physician highlighted, “There are no apparent further complaints noted which would indicate a chronic condition, nor does bursitis cause rotator cuff tear, therefore it is less likely than not.” The physician provided detailed reasons and bases to support his opinions. Therefore, the Board assigns significant probative weight to the findings of the March 2014 VA examiner. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A right shoulder or lower back disability was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to credibly report right shoulder and lower back pain, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. Although there are some notations of right shoulder and lower back in service, the most probative evidence supports a finding that these were acute, transitory, and resolved. The STRs from shortly after in-service events and resulting claimed injury disclosed clinically normal examinations. When the Veteran presented in 2009, he reported only recent onset of right shoulder pain. Furthermore, we note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The most probative evidence establishes a remote onset of right shoulder and lower back pathology several years after discharge. Consequently, the preponderance of the evidence being against the claims, service connection for a right shoulder and lower back disability is not warranted. There is no doubt to resolve. 3. Entitlement to service connection for a right ankle disability 4. Entitlement to service connection for a right heel disability 5. Entitlement to service connection for a right calf disability The Board incorporates its discussion from the sections above by reference. A March 1989 STR shows that the Veteran complained of pain of the bilateral calf upon running. There are also notations of achilles tendonitis. The most recent August 1991 Report of Medical History disclosed a clinically normal evaluation of the lower extremities, feet, spine, other musculoskeletal system, and neurologic system. A May 15, 2014 VA primary care note shows that the Veteran has low back pain that causes tingling in both legs, with the right leg worse than the left. Next, the Veteran was provided a May 2014 VA examination. The VA examiner rendered a May 2014 medical opinion for the right calf. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner provided the following rationale, “Veteran has complaints of calf pain, although PE is unremarkable therefore no diagnosis can be made based on available information. This is no calf diagnosis at this time to relate to service.” The Veteran perfected his appeal in April 2016. He attached a statement with lay history and lay argument listed for each issue on appeal. The Board has fully reviewed and considered this. Specifically, the Veteran asserts without explanation that the right heel, calf, and ankle need re-evaluation. Regardless, as discussed above, the Veteran later requested that the case be adjudicated based upon his lay statements and the evidence of record. Here, upon considering theories of entitlement of direct and presumptive service connection, the preponderance is against a finding of current disability related to the right heel, calf, and ankle. As noted above, the May 2014 VA examiner found that the Veteran has no current or previous diagnosis of a right calf disability. It was unremarkable. As such, the first necessary element of service connection is not met. Consistently, the May 2014 VA examination and contemporaneous treatment records, including the VA treatment records, do not show results regarding a possible chronic disabling disease entity related to the right heel, calf, and/or ankle. No further evidence has been submitted associated with the Form 9 or otherwise to show the current diagnosis of sinusitis for this Veteran. There is no probative evidence to the contrary. Consequently, in the absence of a present disability, service connection is not warranted as the preponderance of the evidence is against the finding of the disabilities at issue: right heel, calf, and ankle. 38 C.F.R. §§ 3.303, 3.307, 3.309; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is no doubt to resolve. 6. Entitlement to service connection for bronchial asthma The Board incorporates its discussion from the sections above by reference. A November 1987 STR shows that the Veteran was referred for possible inhalation therapy. He was a smoker. He had no history of asthma in the family. He was on the second day of coughing and wheezing. The most recent August 1991 Report of Medical History disclosed a clinically normal evaluation of the nose, sinuses, lungs and chest, heart, and vascular system. A VA treatment record from Central Texas Health Care System (HCS), separately submitted and received by VA in September 2014, shows the results of pulmonary function testing. In particular, in August 2014, a treating physician concluded, “The diffusion capacity is mildly decreased indicative of a mild decrease in the effective surface area for gas exchange.” Several May 5 and 7, 2014 lay buddy statements show that the Veteran was diagnosed with asthma in service. Additional buddy statements have also been considered. The Veteran was afforded an August 2014 VA respiratory examination. The VA examiner identified asthma. The VA examiner noted an April 17, 2014 primary care note showing a diagnostic impression of asthma, with prescription inhaler. The VA examiner reviewed the claims file, examined the Veteran, and rendered a medical opinion. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Regarding the Veteran’s specific contentions, the VA examiner opined: Evidence of record reviewed does not support a diagnosis of asthma during military service. Veteran had an acute episode of reversible airway disease associated with upper respiratory infection in 1987, but there is no indication of follow up for ongoing chronic respiratory problems such as asthma during remaining military service. He had normal clinical examination findings on the physical exam in 1991. Ongoing tobacco smoking contributes to the Veteran’s respiratory symptoms. The Veteran perfected his appeal in April 2016. Specifically, the Veteran asserts that he was ordered to go to sick call for breathing difficulties in 1987. He was diagnosed with asthma and prescribed rescue inhalers. He did not have any symptoms from 1982 to 1987 prior to this. Since then, his breathing has gotten worse and he has to regularly use a rescue inhaler. The Veteran further asserts that the onset of asthma was in service in 1987, because prior to that, he would not have survived the rigors of service, including road marches with a heavy back pack and strenuous activities, if he had experienced such serious asthma. The Veteran contends that he is entitled to service connection for bronchial asthma. The Veteran is competent to report difficulty breathing and needing to use a rescue inhaler to improve breathing. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is competent to report experiencing this following various events that he has described in service. The Veteran is competent to relate what he has been told by a professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran’s own lay opinion as to the diagnosis and cause of current bronchial asthma, while competent and credible, is not probative evidence. First, the most probative evidence is the contemporaneous treatment records and the opinions of the August 2014 VA examiner. The STRs show that the Veteran was a smoker. They disclosed a clinically normal evaluation of the lungs and chest in 1991, after the alleged 1987 event in service. This is during the period in which the Veteran reports that he had asthma. Next, asthma was not identified after discharge until it is shown in VA treatment records from 2014. To the extent there are lay statements showing the Veteran was diagnosed with asthma in service, the Board assigns more probative weight to the contemporaneous treatment records. Second, the August 2014 VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner based this opinion on a review of the medical evidence in the claims file, as well as the Veteran’s lay reporting. The VA examiner considered the Veteran’s contentions, and opined, “It is not likely that this Veteran’s asthma is related to the complaints in service that occurred 11/18/87.” The VA examiner provided detailed reasons and bases to support her conclusions. Here, regarding direct, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. Asthma was not incurred in or aggravated by service, and is not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to credibly report difficulty breathing and treatment with an inhaler, the Veteran’s own lay opinion regarding identifying a potential disease entity, such as asthma, pales in probative weight when compared to the objective medical evidence of record. Although there is evidence of cough, congestion, and respiratory infection in service, the most probative evidence supports a finding that this was acute, transitory, and resolved. The STRs from after the highlighted 1987 in-service events and subsequent August 1991 Report of Medical History disclosed clinically normal examinations of the nose, sinuses, lungs and chest, heart, and vascular system. We note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The most probative evidence establishes a remote onset of asthma several years after discharge. Consequently, service connection for bronchial asthma is not warranted. There is no doubt to resolve. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board finds that the preponderance of the evidence is against each of the claims decided herein. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to service connection for chronic headaches is remanded. The Board incorporates its discussion from the sections above by reference. A remand to the agency of original jurisdiction (AOJ)is necessary for additional development for review and disposition through an Supplemental Statement of the Case (SSOC), pursuant to 38 C.F.R. §§ 19.31 and 19.37(a). By way of background, the most recent August 1991 Report of Medical History disclosed a clinically normal evaluation of the head, face, neck, and scalp, nose, sinuses, heart, neurologic, and vascular system. The Veteran submitted several lay/buddy statements. A November 26, 2014 VA physician note shows that the Veteran presented for a follow-up at the neurology clinic with complaints of headaches. The assessment shows, “Migraine headaches, improved on Topamax, but the patient’s measure of stress has increased in the workplace causing more headaches per month.” The Veteran perfected his appeal in April 2016. Specifically, the Veteran asserts that his headaches “started to occur from 1983 to 1986.” He also asserts, “Stripping floors with strong chemicals, stripping paint from hallways and rooms without proper gear, I started having headaches and dizziness.” An April 26, 2016 VA treatment record shows that the headaches begin at the beginning of the week in the morning. The physician opined, “It appears that these headaches are often associated with work stress.” Recently, a July 10, 2018 VA primary care note shows a history of migraines with a date of diagnosis of April 26, 2016. A November 28, 2018 VA treatment record shows a notation of a history of migraines. Additional VA treatment records are substantially the same. The Veteran contends that he is entitled to service connection for bronchial asthma. The Board observes that the Veteran is competent to report headaches, for which he takes Topamax for relief of symptoms. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Under 38 C.F.R. § 19.31, the AOJ will provide an SSOC to the appellant and his/her representative when there are any material changes in, or additions to, the information included in the SOC or any prior SSOC, to include receipt of additional pertinent evidence. If the pertinent evidence is received from a source other than the appellant or his/her representative prior to transfer of the case to the Board, solicitation of a waiver of AOJ review is not appropriate, and the case must be remanded for a new SSOC. 38 U.S.C. § 7105(e); 38 C.F.R. §§ 19.31, 19.37(a). Here, an April 2016 VA treatment record showed a diagnosis of migraines with possible etiology. July and November 2018 VA treatment records also show possible diagnostic impressions of disability. The AOJ did not issue an SSOC after this evidence was associated with the record. As the relevant April 2016 VA treatment records were received prior to the June 2017 transfer of the case to the Board, the matter must be remanded for AOJ review and issuance of an SSOC. 38 C.F.R. § 20.904(a)(2). Consequently, a remand is warranted. The matter is REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran’s VA treatment records, and associate them with the Veteran’s claims folder. 2. Readjudicate the claim for service connection for chronic headaches based upon the evidence of record. Attention is directed to the VA treatment records from April 2016 showing a diagnosis of headaches and a possible etiology. 3. After completing the above, and any other necessary development, any claim(s) remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefit sought is not granted, issue the Veteran and his representative an appropriate supplemental statement of the case (SSOC). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel