Citation Nr: 18152534 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 16-45 382 DATE: November 23, 2018 ORDER Entitlement to service connection for dysfunctional uterine bleeding is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a bilateral hearing loss disability is remanded. Entitlement to service connection for gamekeeper’s thumb is remanded. Entitlement to service connection for onychomycosis, bilateral big toes is remanded. Entitlement to a compensable initial rating for right knee strain with degenerative joint disease is remanded. Entitlement to an initial rating in excess of 10 percent for cervical strain with degenerative disc disease is remanded. Entitlement to an initial rating in excess of 10 percent for lumbar strain with degenerative disc disease is remanded. FINDING OF FACT The Veteran’s dysfunctional uterine bleeding had its onset in service and has continued since service. CONCLUSION OF LAW The criteria for service connection for dysfunctional uterine bleeding have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(d) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1978 to July 1983, from February 1991 to June 1991, from November 2001 to November 2002, from January 2003 to January 2004 and from May 2004 to August 2004, with additional periods of Reserve service. This matter came before the Board of Veterans Appeals (Board) on appeal from September 2013 and December 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for dysfunctional uterine bleeding with abnormal pap and anovulatory bleeding The Veteran contends that her dysfunctional uterine bleeding began in service. The Board concludes that the Veteran has dysfunctional uterine bleeding that began in service and has continued since service and that service connection is therefore warranted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. As defined by statute and regulation, active military, naval, or air service includes any period of active duty training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. § 101 (21), (24); 38 C.F.R. § 3.6 (a), (d) (2017). ACDUTRA includes full-time duty performed for training purposes by Reserves. 38 C.F.R. § 3.6 (c)(1). Service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or from an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C. §§ 101 (24), 106 (2017). April 1992 service treatment records indicate that the Veteran was treated for bleeding between periods at Hill Air Force Base while stationed there for 2 weeks of Reserve training. The Board notes that full time Reserve duty for training constitutes ACDUTRA. The Veteran was diagnosed with dysfunctional uterine bleeding, and the provider opined was probably anovulatory. The provider also noted that the Veteran had no prior treatment. June 2003 service treatment records from a period of active duty note bleeding between periods and extra heavy bleeding with clots. December 2003 active duty service treatment records note continued irregular periods and the December 2003 Reserve Component Health Risk Assessment noted irregular periods and an ovarian cyst. A July 2013 VA examination diagnosed anovulatory bleeding and the examiner opined that the Veteran’s gynecological condition was related to service. The examiner noted that the Veteran was found to have ovulatory bleeding and stated that her current conditions were a continuation of those found in service. The Board therefore finds that the competent medical evidence of record indicates that the Veteran has a current disability of dysfunctional uterine bleeding that was incurred during service and has continued since service. April 1992 service treatment records indicate that she was first diagnosed with dysfunctional uterine bleeding while stationed at Hill Air Force Base for two weeks of ACDUTRA and active duty service treatment records from December 2003 and February 2004 note continued menstrual irregularities. Moreover, the July 2013 VA examination found a current diagnosis of anovulatory bleeding and opined that her current condition was a continuation of the one found in service. Service connection is therefore warranted. 38 C.F.R. § 3.303(d). REASONS FOR REMAND 1. Entitlement to service connection for hypertension The Board finds that additional development is required to clarify the onset of the Veteran’s hypertension and her periods of service. The evidence of record is inconsistent regarding the date of the Veteran’s initial hypertension diagnosis. May 2007 service treatment records document a diagnosis of essential hypertension. October 2002 and January 2004 service treatment records contain hypertension evaluations but do not contain a diagnosis of hypertension. However, the July 2013 VA examiner stated that the Veteran was diagnosed with hypertension in 2001. As the examiner did not provide a more precise date of diagnosis the Board is unable to determine whether it occurred during a period of active duty. The July 2013 examiner also did not provide a nexus opinion regarding hypertension. Remand for a new examination to clarify the onset and etiology of the Veteran’s hypertension is therefore required. The Board notes that the Veteran had active service from November 2001 to November 2002, from January 2003 to January 2004 and from May 2004 to August 2004. However, the Board’s review indicates that the claim file does not appear to contain complete service personnel records for her period of service in the Reserve. As they may contain information regarding the Veteran’s dates of service, remand is required to obtain them. The Board also notes that May 2007 service treatment records state that a private doctor managed the Veteran’s blood pressure treatment, but those records have not yet been associated with the claim file. A remand is required to allow VA to obtain authorization and request these records. 2. Entitlement to service connection for a bilateral hearing loss disability As the matter is already being remanded to obtain private treatment records and service personnel records, which may contain information pertinent to the issue on appeal, remand is required. 3. Entitlement to service connection for gamekeeper's thumb A July 2013 VA examination diagnosed gamekeeper’s thumb on the right hand. The examiner noted the Veteran’s reports of increased pain when extending her thumb and tenderness and pain to palpation on the right proximal interphalangeal (PIP) joint. No etiological opinion was provided. An October 2013 addendum opinion from the same provider stated that the Veteran’s thumb disability was not caused by service as there was no objective evidence of gamekeeper’s thumb. The Board notes that the October 2013 opinion is inconsistent with the July 2013 report, which contained a diagnosis of gamekeeper’s thumb. The opinion is therefore inadequate and remand for a new examination and opinion is required. 4. Entitlement to service connection for onychomycosis, bilateral big toes A July 2013 VA examination noted a 2013 diagnosis of onychomycosis of the bilateral great toes and a history of large toenail removal due to onychomycosis in 1982. The Veteran reported flareups of onychomycosis since 1982 and an inability to wear closed shoes. No etiological opinion was provided. An October 2013 addendum opinion from the same provider found that the Veteran’s toe disability was not caused by service as the toe disability was diagnosed after service. The Board notes that the October 2013 opinion is inconsistent with the July 2013 report, which noted a 1982 diagnosis of onychomycosis and associated toenail removal. The opinion is therefore inadequate and remand for a new examination and opinion is required. 5. Entitlement to a compensable initial rating for right knee strain with degenerative joint disease 6. Entitlement to an initial rating in excess of 10 percent for cervical strain with degenerative disc disease 7. Entitlement to an initial rating in excess of 10 percent for lumbar strain with degenerative disc disease VA knee, cervical spine and lumbar spine examinations were provided in July 2013. In each of the reports, the examiner stated that he could not offer an opinion as to functional loss during flare ups as the Veteran was not able to replicate a flare up during the examination. As the examiner declined to offer an opinion as to additional functional loss during flare ups due to a lack of direct observation of function under those circumstances, the examinations are inadequate and a new examination is required upon remand. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board also notes that since the July 2013 VA knee, cervical spine and lumbar spine examinations, the U.S. Court of Appeals for Veteran’s Claims (the Court) has issued the decision in Correia v. McDonald, 28 Vet. App. 158, 166 (2016) concerning the adequacy of VA orthopedic examinations. The Court in Correia held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. The Board’s review indicates that the July 2013 VA joint examinations did not include the testing required under Correia and that remand for new examinations is required. The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete service personnel records, to include all documents pertaining to her service in the Air Force Reserve. Verify all active duty for training and inactive duty training dates for service in the Air Force Reserve. If necessary, a request should be made to the Defense Finance and Accounting Service (DFAS). Document all requests for information as well as all responses in the claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for all private providers who treat her claimed disabilities. Make two requests for the authorized records from all identified providers, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an appropriate VA examination, to determine the etiology of her hypertension. The examiner should review the file and provide a complete rationale for all opinions expressed. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is related to active service. Attention is requested to October 2002 and January 2004 service treatment records documenting blood pressure evaluations and the examiner should provide an opinion indicating whether these records indicate that the Veteran’s hypertension had its onset in service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of her symptoms. 4. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current right thumb disability, to include gamekeeper’s thumb. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current right thumb disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of her symptoms. 5. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current great toe disability, to include onychomycosis. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current great toe disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of her symptoms. 6. Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of her right knee, cervical spine and lumbar spine disabilities. The claim file should be made available to and reviewed by the examiner and the examination report should state a review of the file was completed. All necessary tests should be performed and all findings should be reported in detail. The examiner should identify all right knee, cervical spine and lumbar spine pathology found to be present. The examiner should conduct all indicated tests and studies, to include range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. If pain is noted, the point during range of motion at which pain starts must be clearly indicated. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups she experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 7. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Arnold, Associate Counsel