Citation Nr: 18152508 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 16-19 396 DATE: November 23, 2018 ORDER Service connection for sinusitis is granted. Service connection for irritable bowel syndrome (IBS) is denied. Service connection for anemia is denied. Service connection for left lower extremity radiculopathy is denied. Entitlement to a rating in excess of 10 percent prior to December 19, 2013 for service-connected lumbosacral strain is denied. Entitlement to a rating in excess of 30 percent prior to January 19, 2016 for service-connected posttraumatic stress disorder (PTSD) with major depressive disorder and insomnia is denied. REMANDED Service connection for myomectomy cystic fibroids is remanded. Service connection for plantar fasciitis is remanded. Service connection for hemorrhoids is remanded. Service connection for allergic rhinitis is remanded. Entitlement to a rating in excess of 10 percent for service-connected left foot strain is remanded. Entitlement to a rating in excess of 10 percent from December 19, 2013 and 20 percent from January 19, 2016 for service-connected lumbosacral strain is remanded. Entitlement to a compensable rating prior to January 19, 2016 and in excess of 10 percent thereafter for service-connected right retropatellar pain syndrome with traumatic arthritis is remanded. Entitlement to a compensable rating prior to January 19, 2016 and in excess of 10 percent thereafter for service-connected left retropatellar pain syndrome with traumatic arthritis is remanded. Entitlement to a rating in excess of 50 percent from January 19, 2016 for service-connected PTSD with major depressive disorder and insomnia is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran’s sinusitis is related to military service. 2. The Veteran’s IBS is not related to military service. 3. The Veteran does not have a current diagnosis of anemia. 4. The Veteran’s left lower extremity radiculopathy is unrelated to her service or service-connected back disability and instead results from a nonservice-connected back disability. 5. Prior to December 19, 2013 the Veteran’s service-connected lumbosacral strain was manifested by pain and limitation of motion with flexion greater than 60 degrees, a combined range of motion greater than 120 degrees and was not manifested by muscle spasm, guarding, or localized tenderness resulting in abnormal gait or abnormal spinal contour. 6. Prior to January 19, 2016 the Veteran’s service-connected PTSD with major depressive disorder and insomnia was been manifested by symptomatology demonstrating occupational and social impairment with decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The criteria for service connection for sinusitis have been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for IBS have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for anemia have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for left lower extremity radiculopathy have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. Prior to December 19, 2013 the criteria for a rating in excess of 10 percent for service-connected lumbosacral strain have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5237. 6. Prior to January 19, 2016 the criteria for a rating in excess of 30 percent for service-connected posttraumatic stress disorder PTSD with major depressive disorder and insomnia have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on a period of initial active duty for training from November 1988 to March 1989 and on active duty from January 1998 to September 1998. In August 2016, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The United States Court of Appeals for Veterans Claims (Court) has held that a claim for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits but is instead part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran raised entitlement to TDIU during the August 2016 hearing. As such, the issue of entitlement to a TDIU is properly before the Board of Veterans’ Appeals (Board). The Veteran has not been afforded a Department of Veterans Affairs (VA) examination in connection with her service connection claim for IBS. Generally, a VA examination is necessary prior to final adjudication of a claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the veteran qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). As discussed further below, there is no competent evidence that the Veteran has IBS related to her active service. As such, the Board finds that a VA examination is not necessary to decide the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see also McLendon, 20 Vet. App. at 79. Neither the Veteran nor her representative has raised any other issues with the duty to notify or duty to assist. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Sinusitis. The Veteran asserts that her sinusitis is related to military service. She testified that she received treatment in service for her sinuses and had ear infections, colds, and consistently experienced sinus problems in service. She testified that her sinus problems got worse during active due deployment due to burning and the particles and poor air quality. She testified that she received treatment in service and consistently has been treated for sinus problems after service and has headaches and sinus drainage now. Service treatment records reflect that in June 1998 the Veteran was treated for allergies and muscle aches, had burning itching eyes, sneezing and a cough and ear infection. The Veteran underwent an April 2014 VA examination. The examiner diagnosed chronic sinusitis. The Veteran reported experiencing a sinus condition since 1998 causing respiratory infection and the condition has remained the same with occasional flare-ups. The examiner opined that the Veteran’s sinusitis was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. He reported the Veteran was seen on September 1996 for probable sinusitis and seen on March 2006 for chronic nasal congestion, rhinorrhea, and itchy eyes, and October 2013 for an upper respiratory infection. He explained that sinusitis is an inflammation, or swelling, of the tissue lining the sinuses. He explained normally, sinuses are filled with air, but when the sinuses become blocked and filled with fluid, germs can grow and cause an infection. Conditions that can cause sinus blockage include the common cold, allergic rhinitis, nasal polyps, or a deviated septum. He reported the Veteran first developed sinusitis in service and continues to suffer from it. Given the positive medical opinion of record, the Board finds that the probative evidence of record reflects that the Veteran’s current sinusitis is related to military service. Accordingly, service connection is warranted. 2. IBS. With respect to the Veteran’s service connection claim for IBS, the Veteran testified that she did not receive treatment in service but was told to drink lots of water. In her April 2016 VA Form 9 she asserted that during deployment she experienced being constipated, having diarrhea, having painful cramping in the stomach, blood in the stool difficulty emptying her bowel, and hemorrhoids. She reported her symptoms have occurred since service. She reported being dispensed stool softeners or medication and told to rest and that it was the environment during deployment that was causing problems. She reported receiving follow-up treatment after deployment. Service treatment records are absent complaints related to IBS. At separation in September 1998 clinical evaluation was normal and the Veteran denied problems with the stomach, liver, or intestine. VA treatment records reflect that the Veteran does have intermittent problems with irritable bowel syndrome. However, there is no medical evidence to support that the Veteran’s treatment for IBS is related to active service. Treatment records simply do not indicate any form of connection. The Veteran is competent to attest to things she experiences through her senses. However, the Veteran is not shown to possess any medical expertise; thus, her opinion as to the etiology of IBS is not competent medical evidence. Moreover, whether any symptoms the Veteran experienced in service or following service are in any way related to her current treatment requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999). Further, the Board finds the Veteran’s assertions that her in-service bowel complaints have continued since military service lack credibility as she specifically denied stomach problems at separation and there were no abnormal findings during separation examination. In summary, the preponderance of the evidence is against a finding that the Veteran has IBS that was caused or aggravated by active service. Thus, the claim for service connection is denied. 3. Anemia VA has established certain rules and presumptions for chronic diseases, such as primary anemia. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Veteran testified that she receives VA treatment for anemia and that she had problems in service with anemia due to bleeding and problems related to her myomectomy cystic fibroids. A review of the Veteran’s treatment records is absent current complaints for anemia. The evidence does not reveal the Veteran has symptoms for, or been diagnosed with, anemia during the period on appeal. Her statements that her anemia is related to military service or a service-connected disability does not amount to persistent or recurrent symptoms of a current disability. While the Veteran is competent to report observable symptomatology, she is not competent to provide such as diagnosis without medical expertise. Thus, her statements are not probative as to the existence of a current disability. The Veteran underwent an April 2014 VA examination to determine the existence and etiology of gynecological disabilities. The examiner reported that the Veteran has not been diagnosed with anemia. This is the most probative evidence as to the existence of a current disability and is adverse to the claim. The other medical evidence of record is not in conflict with the finding by the examiner that the Veteran does not currently have a diagnosis for anemia. As the preponderance of the evidence establishes that the Veteran does not have a diagnosis for anemia, the claim must be denied. See Degmetich v. Brown, 104 F.3d 1328 (1997); see also McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). 4. Left lower extremity radiculopathy. The Veteran asserts that she has lumbar radiculopathy related to military service or her service-connected lumbosacral strain. She testified that she experienced radiating pain from her back to her lower extremities in service and that her VA and private treatment providers have told her she has radiculopathy. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Secondary service connection requires: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability which is service connected; and (3) competent evidence of a nexus between the two. Service treatment records reflect that the Veteran had low back pain without radiation. For example, a September 1998 screening note of acute medical care and a September 1998 physical therapy consultation indicate the Veteran had back pain with no radiculopathy. Neurological evaluation and lower extremity evaluation were normal on the Veteran’s September 1998 military separation examination. On a corresponding report of medical history the Veteran denied nerve injury or paralysis. While she reported foot trouble, this was described as pain wearing boots. To the extent the Veteran now alleges onset of radicular symptoms during service in connection with her claim for compensation benefits, the Board finds these statements lack credibility as they are in direct conflict with her statements during service and examination findings made contemporaneous to service for the purpose of identifying disability. VA treatment records reflect that the Veteran was diagnosed with lumbar radiculopathy in October 2013, many years after her active duty service. The Veteran underwent back examinations in October 2013, March 2014, and January 2016. The October 2013 and April 2014 examiners reported that there was no radiculopathy. The January 2016 examiner reported the Veteran had radiculopathy with sciatic nerve involvement bilaterally of moderate severity. Thus, radiculopathy is not shown to be present until many years after the Veteran’s separation from active duty service. Regarding the etiology of the diagnosed radiculopathy, a VA examiner in January 2016 attributed the Veteran’s radiculopathy to nonservice-connected lumbar degenerative disc disease and not service-connected lumbosacral strain. The examiner noted the relevant history, to include the report of generalized low back pain, pain from the low back to scapula, and no reports of radicular symptoms in 1998, and explained that radiating pain from the scapula to low back with generalized low back pain is not a symptom of lumbar radiculopathy but more in line with thoracolumbar and lumbosacral strain/mechanical/muscular back pain. Regarding a lay statement of record noting the Veteran’s complaints of radicular symptoms since 2001, the examiner noted that this was still 3 years after active service and that subsequent EMG testing in 2013 was negative for any findings of radiculopathy or neuropathy. The examiner concluded that the in-service back pain complaints were related to the service-connected lumbosacral strain and not lumbar degenerative disc disease with radicular symptoms that was diagnosed at least 12 years after active duty. This opinion is afforded high probative weight as it was made by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. Moreover, the examiner had knowledge of the pertinent medical history to include through interviewing the Veteran and reviewing lay statements. The findings are also based on a medical history supported by other evidence of record, such as the absence of radiculopathy on separation examination and report of medical history, the absence of radiculopathy on earlier VA examinations years after separation from active duty, and an onset of radicular symptoms after active duty which is in keeping with the Board’s factual findings. To the extent a private physician in May 2016 has opined that various “conditions” the Veteran has been diagnosed with are a direct result of psychological and physical trauma suffered during military service in Bosnia-Herzegovina, the Board finds this opinion to lack any probative value as to the question of service connection for lower extremity radiculopathy. Radiculopathy is not addressed by the physician. Overall, the most probative evidence indicates the onset of the Veteran’s lower extremity radicular symptoms was after her active duty service and is related to a nonservice-connected back disability. The Veteran’s statements as to onset of radicular symptoms during active duty are not credible and the medical evidence contemporaneous to service shows low back pain without radicular symptoms; in fact, neurological and lower extremity evaluation at separation was normal. As the current radicular symptoms are unrelated to service and are not caused or aggravated by the service-connected lumbosacral strain, service connection must be denied. Increased Rating The Veteran asserts that the severity of her service-connected disabilities is more severe than the currently assigned ratings. The issues on appeal stem from her September 2013 claim for increase. 5. Entitlement to an increased rating in excess of 10 percent prior to December 19, 2013 for service-connected lumbosacral strain. Regulations specify that disabilities of the spine should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (Spinal Formula). 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. When intervertebral disc syndrome (IVDS) is present, it is to be evaluated under the Spinal Formula unless it is more favorable to rate under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula). Ratings under the Spinal Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. As relevant to the thoracolumbar spine, the Spinal Formula provides for a 20 percent disability rating when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, when the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is assigned with unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Spinal Formula. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is to 90 degrees and the normal combined range of motion is 240 degrees. Id., Note (2). Associated objective neurologic abnormalities should be rated separately under an appropriate diagnostic code. Id., Note (1). Alternatively, the IVDS Formula provides for rating based on the total duration of incapacitating episodes. 38 C.F.R. § 4.71a, IVDS Formula. Incapacitating episodes are defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id., Note (1). A 20 percent disability rating is assigned with incapacitating episodes having a total duration of at least 2 weeks. Higher ratings are available with incapacitating episodes of greater duration during a 12-month period. In this case, prior to January 19, 2016 IVDS is not shown or alleged. During the appeal period the Veteran underwent VA examination in October 2013. Range of motion testing was performed and showed, at worst, forward flexion to 75 degrees and a combined range of motion no less than 225 degrees. During examination the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. No report suggests that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements. The Veteran has not described a range of motion which would warrant a higher rating. In this regard, during the VA examinations she denied flare-ups which impacted function of the thoracolumbar spine. When asked about pain on use and during flare-ups, the Veteran noted she was having pain during the examination. Thus, the Board finds the examination findings are representative of the severity of the Veteran’s lumbosacral strain during this period. Treatment records do not show greater limitation of motion than the examination findings. Absent indication by the Veteran or other evidence suggesting additional limitation of motion during flare-up or after repetitive use over time there is no reason to suspect range of motion is limited any more than reflected during examination and additional inquiry in this regard is unnecessary. Given the above, a higher rating is not warranted based on limitation of motion. Ankylosis of the spine is not shown by the medical evidence or alleged by the Veteran. The October 2013 examiner reported that the Veteran does not have guarding or muscle spasm of the thoracolumbar spine or incapacitating episodes of IVDS. As discussed above, the Veteran’s lower extremity radicular symptoms are unrelated to her service-connected lumbosacral strain. There are no other neurological symptoms which should be addressed by a separately-assigned disability rating. 6. PTSD with major depressive disorder and insomnia disorder prior to January 19, 2016. The Veteran’s psychiatric disability is evaluated under Diagnostic Code 9411, which assigns ratings based upon the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, recent events. Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory such as, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Here, the Veteran asserts that her combined psychiatric symptoms are more severe than the 30 percent rating prior to January 19, 2016. The Veteran underwent VA examination in April 2014. During examination the VA examiner reported that it was possible to differentiate the symptoms attributable to each to each diagnosis. She reported the Veteran’s PTSD results in memories of traumatic events, avoidance and hypervigilance the Veteran’s depressive disorder results in periods of depression; and the Veteran’s insomnia consists of persistent problems with sleep. She reported the Veteran’s symptoms for each disorder exacerbate each other. The Veteran endorsed symptoms of depressed mood, anxiety, suspiciousness, and chronic sleep impairment. On examination the Veteran was alert and oriented to time and place. Her mood was euthymic with congruent affect. The examiner reported the Veteran was talkative and went on tangents at points in answering questions. The examiner reported that the Veteran’s disability results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routing behavior, self-care and conversation. She reported that it was not possible to differentiate what portion of the occupational and social impairment was caused by each mental health disorder and explained that given the overlap in symptoms that have persisted for years, it is not practical to differentiate the specific impairment due to each diagnosis. VA treatment records are not in significant conflict with findings on examination. While the Veteran testified that the January 2016 examination is more demonstrative of her level of disability, the Board finds the medical evidence, particularly the VA examination report, to be most probative as to the actual level of disability prior to January 2016. The examination was performed to determine the level of disability and the Veteran was an active participant in providing information for the examiner’s consideration. The examination report is certainly most probative as to the level of disability at the time it was performed and clinical records do not show a worsening until the January 2016 examination. While the Board certainly recognizes the Veteran’s mental health condition worsened, her general statement that the January 2016 examination report is more demonstrative of her disability do not alter the findings made during the period addressed in this decision. A rating in excess of 30 percent is not warranted at any point prior to January 19, 2016 when looking at the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. For example, the April 2014 examiner reported symptoms of depressed mood, anxiety, suspiciousness, and chronic sleep impairment, all of which are listed as demonstrative of a 30 percent rating. Id. The evidence does not reflect that the Veteran had a flattened affect (the examiner noted euthymic mood with congruent affect), trouble with speech, panic attacks more than once a week, difficulty understanding complex commands, impaired memory, judgment, or abstract thinking, difficulty in establishing and maintaining effective work and social relationships, or disturbances of motivation or mood not already considered in the 30 percent rating during this period. In fact, the examiner’s responses suggest these symptoms were not present. The Veteran was able to appropriately engage with the examiner and was described as talkative during examination. The examiner explained that the Veteran’s symptoms resulted in occupational and social impairment with decreased work efficiency and intermittent periods of inability to perform occupational tasks, consistent with a 30 percent rating. Id. When taking into account all of the symptomatology of record, social, and occupational impairment was to a lesser degree than reduced reliability and productivity. Thus, a rating in excess of 30 percent is not warranted. Id. In reaching this decision the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against assigning even higher ratings, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Neither the Veteran nor her 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, 369-370 (2017) REASONS FOR REMAND 1. Service connection for myomectomy cystic fibroids. The Veteran asserts that her myomectomy cystic fibroids are related to military service. She testified that she experienced heavy bleeding, blood loss, fatigue, anemia, and cramps in 1998 in Bosnia with follow up treatment after deployment. She testified that the VA diagnosed her cystic fibroids after service in about 1999 and that she had a hysterectomy in 2001, 2008 and 2011. She testified that her friend was aware that she had to use thickened pads and of her in service bleeding. Service treatment records are absent treatment related to myomectomy cystic fibroids and during examination in September 1998 there was no indication that the Veteran’s pelvic or gynecological evaluation was abnormal. During the April 2014 VA examination, the examiner diagnosed myomectomy cystic fibroids. The Veteran reported that her condition began in 1998 and has continued since then. The examiner opined that the Veteran was seen on June 2000 for uterine fibroids and December 2000 for a routine examination of the pelvis that showed enlarged uterus with multiple intramural lesions which are non-specific but consistent with uterine fibroids. He reported that the Veteran was diagnosed April 2014 with status post myomectomy cystic fibroid. The examiner reported that the Veteran had fibroids in service resulting in myomectomy. He reported the claimed disability was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The Board notes that the April 2014 medical opinion is based, at least in part, on an inaccurate factual premise. The evidence does not reflect that the Veteran had fibroids in service and the treatment for uterine fibroids in June and December 2000 did not occur during a period of active duty service. As such, the Board finds remand is necessary to obtain a supplemental medical opinion as to whether the Veteran’s current fibroid disability is related to active service. 2. Service connection for plantar fasciitis. With respect to the Veteran’s plantar fasciitis the Veteran testified that her doctor told her that her plantar fasciitis is related to service. Service treatment records reflect that the Veteran complained of foot pain related to her boots. She underwent VA examination in January 2016. The examiner diagnosed bilateral plantar fasciitis and reported that the Veteran has had heel injections due to this disability. The Veteran reported having tender heels as far back as she can remember. A VA medical opinion has not been provided with respect to the etiology of the Veteran’s current plantar fasciitis. Accordingly, remand is warranted to obtain a supplemental medical opinion. 3. Service connection for hemorrhoids. With respect to the Veteran’s service connection claim for hemorrhoids, the Veteran testified that she had hemorrhoids in service and received treatment after military service. In a September 1998 report of medical history the Veteran reported having hemorrhoids treated with medication. The April 2014 examiner diagnosed hemorrhoids. He reported that the Veteran began to notice internal and external hemorrhoids since 1998 and that the condition has remained the same over time. He opined the Veteran’s medical records are silent for any hemorrhoids. Accordingly, the Board finds remand is necessary to obtain a supplemental medical opinion with a clear rationale as to the etiology of the Veteran’s current hemorrhoids. 4. Service connection for allergic rhinitis. The Veteran underwent an April 2014 VA examination and was diagnosed with allergic rhinitis. While the examiner opined this condition was incurred during service, the examiner did not address the fact that this condition predated the Veteran’s entry onto active duty. Notably, the Veteran was diagnosed with allergic rhinitis at least as early as August 1994, and a June 1998 treatment record indicates her report of a history of allergies for 7 years. Thus, the relevant question is whether the preexisting allergic rhinitis was aggravated during active duty. No opinion addressing this question is of record and remand is therefore necessary. 5. Increased rating for service-connected left foot strain. During the August 2016 hearing the Veteran testified that her service-connected left foot strain has worsened since the most recent examination. As the Veteran reported increased symptoms, the Board finds that remand is necessary to afford the Veteran an additional VA examination to determine the current severity of her service-connected left foot strain. 6. Increased rating for service-connected lumbosacral strain. As noted above, the Veteran underwent back surgery in December 2013. The Veteran was denied a temporary total evaluation for hospitalization due to her service-connected back disability. The issue of the temporary total evaluation is the subject of a separate appeal and is currently undergoing development. Accordingly, the Board finds that the issue of entitlement to increased rating for service-connected lumbosacral strain from the period of the Veteran’s back surgery is inextricably intertwined with the outcome of the separate appeal addressing the temporary total rating. As such, the instant appeal must be remanded pending resolution of the appeal regarding the temporary total evaluation. See Harris v. Derwinski, 1 Vet. App. 180 (1991). 7. Increased rating for left and right retropatellar pain syndrome with traumatic arthritis. The Veteran has made allegations that the record before VA has not been properly developed. She testified that she fell as a result of her bilateral knee disabilities and reported her falls to her private treatment provider Dr. C. The record contains treatment records from Dr. C pertaining to her service-connected back disability, but is absent treatment records for her bilateral knee disabilities. On remand, the Veteran should be provided the opportunity to provide additional authorization for VA to obtain any missing records. The Veteran is advised that authorization is required to obtain private records and VA will not be able to obtain any records for which she does not submit the required authorization form, which must be completed in its entirety. 8. Increase rating for PTSD with major depressive disorder and insomnia disorder from January 19, 2016. During the August 2016 hearing the Veteran testified that her PTSD symptoms have increase in severity since the January 2016 VA examination. As the Veteran reported increased symptoms, the Board finds that remand is necessary to afford the Veteran an additional VA examination to determine the current severity of her service-connected PTSD. 9. TDIU. The Board finds that entitlement to a TDIU has been reasonably raised by the record and is inextricably intertwined with the issues of entitlement to increased ratings for service-connected PTSD, left foot strain, back disability, and bilateral knee disabilities. See Harris, 1 Vet. App. 183. Therefore, they must be addressed before the Board can adjudicate the TDIU issue on appeal. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to her increased rating claims to specifically include records from Dr. C. regarding falls due to her knee disabilities. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current myomectomy cystic fibroids are related to an in-service injury, event, or disease. In offering the opinion, the examiner is asked to consider the Veteran’s lay statements that she had heavy bleeding, blood loss, fatigue, anemia, and cramps in 1998 in Bosnia with follow up treatment after deployment and lay statements that she used thickened pads during deployment. For reference, the Veteran was on active duty from January 1998 to September 1998. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 3. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current hemorrhoid disability is related to an in-service injury, event, or disease. In offering the opinion, the examiner is asked to consider the Veteran’s lay statements that she experienced hemorrhoids in service. For reference, the Veteran was on active duty from January 1998 to September 1998. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 4. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current plantar fasciitis is related to an in-service injury, event, or disease. In offering the opinion, the examiner is asked to consider the Veteran’s lay statements and service treatment records that reflect the Veteran had foot pain in service when wearing boots. For reference, the Veteran was on active duty from January 1998 to September 1998. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 5. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s preexisting allergic rhinitis increased in disability beyond natural progression as a result of the Veteran’s active duty service. For reference, the Veteran was on active duty from January 1998 to September 1998. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 6. After records development is completed, schedule the Veteran for a VA mental health examination to determine the current symptoms, level of severity, and functional impairment associated with her service-connected psychiatric disorders. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. 7. After records development is completed, schedule the Veteran for a VA foot examination to determine the current symptoms, level of severity, and functional impairment associated with her service-connected left foot strain. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. 8. Provide the Veteran with appropriate notice regarding how to substantiate her claim for entitlement to a TDIU and request that she submit a VA Form 21-8940. Any necessary development as a result of the Veteran’s submission of a VA Form 21-8940 should be undertaken. 9. After records development is completed, the Agency of Original Jurisdiction should determine if additional examinations are necessary for the service-connected lower back and knee disabilities. E.g., if the record suggests any of these disabilities has worsened since last examination a new examination would be appropriate. (Continued on the next page) 10. Following a final disposition of the Veteran’s appeal regarding the temporary total evaluation for back surgery, and any other development deemed necessary, readjudicate the instant appeal based on the entirety of the evidence. If any benefit sought on appeal is not granted to the fullest extent, issue the Veteran and her representative a supplemental statement of the case and provide a reasonable opportunity to respond before the case is returned to the Board for further appellate review. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Gonzalez, Associate Counsel