Citation Nr: 18152653 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 14-34 757 DATE: November 23, 2018 ORDER Entitlement to service connection for a bilateral hip disorder, diagnosed as trochanteric bursitis, is granted. Entitlement to service connection eczema is granted. Entitlement to service connection for a disability manifested by dizziness and vertigo, to include as secondary to service-connected sinusitis, is granted. The appeal as to the issue of entitlement to an evaluation for unspecified depressive disorder with anxiety disorder in excess of 30 percent prior to January 23, 2017, and in excess of 50 percent on or after January 23, 2017, is dismissed. REMANDED Entitlement to service connection for right lower extremity radiculopathy is remanded. Entitlement to service connection for a skin disorder other than eczema is remanded. Entitlement to service connection for a bilateral wrist disorder is remanded. Entitlement to a bilateral foot disorder other than left foot hallux valgus status post bunionectomy is remanded. Entitlement to service connection for a left knee disorder is remanded. FINDINGS OF FACT 1. The Veteran has a current bilateral hip disorder, diagnosed as trochanteric bursitis, that manifested during her active service. 2. The Veteran has a current diagnosis of eczema that manifested during her active military service. 3. The Veteran has a current disability manifested by vertigo and dizziness that had its onset during her active service and that is related to her service-connected sinusitis. 4. During the March 2018 hearing, prior to the promulgation of a decision in the appeal, the Veteran indicated that she wanted to withdraw her appeal with respect to the issue of entitlement to increased evaluations for her service-connected unspecified depressive disorder with anxiety disorder. CONCLUSIONS OF LAW 1. A bilateral hip disorder, diagnosed as trochanteric bursitis, was incurred in active service. 38 U.S.C. §1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. Eczema was incurred in active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. Resolving any reasonable doubt in the Veteran’s favor, a disorder manifested by vertigo and dizziness was incurred in active service and is proximately due to or the result of her service-connected sinusitis. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. The criteria for withdrawal of an appeal by the Veteran and her representative have been met for the issue of entitlement to an evaluation for unspecified depressive disorder with anxiety disorder in excess of 30 percent prior to January 23, 2017, and in excess of 50 percent on or after January 23, 2017. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1998 to June 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2011 and September 2015 rating decisions. The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2018. A transcript of that proceeding is associated with the record. The Board notes that, in an April 2018 rating decision, the RO characterized an issue on appeal as a claim for service connection for radiculopathy (previously claimed as right hip with pain radiating down leg). In light of the procedural history of this case, the evidence of record, and the Veteran’s contentions, the Board has bifurcated the claim into two separate issues. See Locklear v. Shinseki, 24 Vet. App. 311 (2011) (bifurcation of a claim generally is within VA’s discretion); Tyrues v. Shinseki, 23 Vet. App. 166, 178-79 (2009), aff’d, 631 F.3d 1380 (Fed. Cir. 2011) (VA is free to dismember a claim and adjudicate it in separate pieces). Given the decision below to grant service connection for the Veteran’s right hip disorder, no prejudice has resulted from the Board’s action in this regard. The Board notes that evidence, including VA medical records, have been associated with the claims file since the most recent statements of the case. However, in August 2018, the Veteran’s representative submitted a waiver of initial consideration by the Agency of Original Jurisdiction (AOJ). Law and Analysis Given the favorable disposition to grant the Veteran’s claims for service connection for bilateral hip, eczema, and vertigo disorders, the Board finds that all notification and development actions needed to fairly adjudicate this aspect of the appeal have been accomplished. There is no prejudice to the Veteran. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2017). 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. 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), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted where a disability is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). I. Bilateral Hip In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection for a bilateral hip disorder is warranted. The Veteran has contended that she has a current bilateral hip disorder that had its onset during service and has continued since that time. She has also asserted that that her bilateral hip disorder is a result of running during service. The Veteran’s March 1998 enlistment examination showed a normal clinical evaluation of the musculoskeletal system and lower extremities, and she denied having any relevant symptoms on an associated report of medical history. In a September 2000 health record, the Veteran reported that she injured her right hip during military training when she was dragged while pretending to be casualty. At that time, a military physician provided an assessment of a right hip contusion, and the Veteran was placed on a physical profile. In September 2005, the Veteran reported having right hip pain following a motor vehicle collision. In April 2007, the Veteran reported having a history five to six-year history of bilateral hip pain. At that time, a physician provided an assessment of bilateral hip joint pain, and he noted that the Veteran did a lot of running. In May 2007, the Veteran reported that she had bilateral hip pain approximately seven years earlier that was brought on by running. In an April 2008 report, a radiologist indicated that x-ray findings were negative for a fracture, but he also advised that a scintography should be performed due to a persistent clinical concern for a stress fracture. In June 2008, a physician noted that a physical examination of the Veteran revealed bilateral tenderness on palpation of the trochanteric bursa, and he provided an assessment of trochanteric bursitis. Thereafter, an April 2009 radiology report noted that the Veteran reported having hip pain for the past several months. The post-service medical records also document complaints of bilateral hip pain and diagnoses of chronic recurrent trochanteric bursitis. See, e.g., January 2015 and February 2015 VA medical records. In support of her claim, the Veteran submitted statements from several service members. In particular, in a March 2018 statement, B.N. (initials used to protect privacy) recounted that the Veteran received a physical profile for her hip during service. He also stated that the Veteran required the assistance of crutches on several occasions and that she experienced difficulty climbing stairs. The Veteran is competent to report her bilateral hip symptoms in service in thereafter. Layno v. Brown, 6 Vet. App. 465 (1994). There is also no reason to doubt the credibility of her statements other than a lack of contemporaneous evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Indeed, the Veteran’s statements have been consistent throughout the appeal and are supported by the evidence of record, including the medical records that document complaints of bilateral hip pain and diagnoses of trochanteric bursitis. The Board acknowledges that a June 2010 VA examiner concluded that there was no pathology on physical examination to render a diagnosis for the Veteran’s bilateral hip pain. However, the examiner did not address whether the Veteran’s trochanteric bursitis resolved or was incorrectly diagnosed. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Indeed, he indicated that no specific diagnosis was provided for the Veteran’s bilateral hip pain during her prior treatment. However, as discussed above, the Veteran’s treatment records note diagnoses of trochanteric bursitis. Therefore, the opinion has limited probative value. The Board has also considered that a June 2010 VA examination reported noted that the Veteran was aware of her right hip condition since November 1988, which may suggest a history of a right hip disorder prior to service. However, as noted above, the Veteran’s enlistment examination was normal, and no hip disorders were noted. Therefore, the presumption of soundness applies, and there is insufficient evidence to rebut that presumption. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Based on the foregoing, and resolving any reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral hip disorder, diagnosed trochanteric bursitis, is warranted. II. Eczema In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection for eczema is warranted. The Veteran has contended that her eczema had its onset during service and has continued since that time. During the March 2018 Board hearing, the Veteran testified that she received treatment for her skin disorder while she was deployed in Afghanistan. The Veteran acknowledged that there was a lapse in treatment for her skin disorder after her separation from service, but she explained that she continued to self-medicate during that time period. The Veteran’s March 1998 enlistment examination documented that she had several scars, but no other skin disorders were noted. In addition, there is no indication that the Veteran’s scars were caused by a skin disorder. Rather, the enlistment examination report reflects that her scars were attributed to other causes, including a dog bite, a scratch, and chicken pox. Therefore, resolving any reasonable doubt in the Veteran’s favor, the Board finds that the presumption of soundness applies and that there is insufficient evidence to rebut that presumption. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The service treatment records dated after the March 1998 enlistment examination show treatment and diagnoses of skin disorders. See, e.g., treatment records dated July 2000 (atopic dermatitis); June 2002 (eczema of the arms and face); April 2003 (tinea corporis); August 2003 (dermatitis); September 2003 (cellulitis); February 2004 (pityriasis rosea); March 2004 (eczema and tinea corporis); June 2004 (eczema); May 2007 (eczema controlled by topical medication). The Board will address the issue of entitlement to a skin disorder other than eczema in the remand section below. The Veteran was afforded a VA examination in June 2010 prior to her separation from service. During the examination, the Veteran reported having eczema associated with exudation, shedding, itching, and crusting. It was also noted that the Veteran’s skin disorder had been treated with oral and topical prescription medications. The examiner diagnosed the Veteran with focal eczema treated with external steroid application. However, he did not provide an opinion as to the etiology of the Veteran’s eczema. The post-service medical evidence also documents treatment and diagnoses of eczema. For example, a February 2012 medical record noted that the Veteran was prescribed topical medication. In addition, a June 2014 VA medical record noted a diagnosis of eczema of the forearms and face. The Veteran is competent to report observable symptomatology and events, including skin rashes. Layno v. Brown, 6 Vet. App. 465 (1994). There is also no reason to doubt the credibility of her statements other than a lack of contemporaneous evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Indeed, her reports have been consistent throughout the appeal. The Veteran’s statements are also supported by the June 2010 VA examination report that noted a diagnosis of eczema. The Board further notes that there are no medical opinions weighing against the claim. Based on the foregoing, and resolving any reasonable doubt in favor of the Veteran, the Board concludes that service connection for eczema is warranted. III. Vertigo In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection for a disability manifested by dizziness and vertigo is warranted. The Veteran has contended that she has a current disorder characterized by dizziness, vertigo, and balance problems that had its onset during her military service. During the March 2018 Board hearing, the Veteran testified that she was prescribed medication for vertigo while on active duty, including Phenergan and Meclizine. The Veteran’s March 1998 enlistment examination showed a normal clinical evaluation of all relevant body systems. In an accompanying report of medical history, the Veteran denied having a history of dizziness or fainting spells. Thereafter, a May 2004 treatment record noted that the Veteran complained of extreme nausea and that she was prescribed Phenergan. A May 2007 treatment record also indicated that the Veteran experienced intermittent episodes of dizziness during her deployment that had since resolved. In March 2008, the Veteran complained of dizziness and lightheadedness. At that time, a physician stated that there was no evidence of cardiac abnormalities and that a neurological examination was reassuring. It was also noted that the Veteran had some vertigous components and that she was prescribed Meclizine. During a June 2010 VA examination, the Veteran reported having instability and vertigo that had its onset in 2008. The examiner diagnosed the Veteran with vertigo and referred her for an audiologic assessment. In so doing, the examiner stated a physical examination of the Veteran did not show any alteration in the form or function of her central, peripheral, or autonomic nervous systems. He also stated that the Veteran had not been provided a diagnosis or received treatment for her vertigo. However, the examiner did not address the service treatment records that noted treatment for complaints of vertigo and dizziness. During a September 2010 VA examination, the Veteran reported having a history of dizziness for the past eight years. She also reported having vertigo, balance problems, feelings of light headedness, and a staggering gait. In addressing the Veteran’s dizziness, the examiner diagnosed her with recurrent chronic sinusitis with secondary recurrent acute imbalance. He also opined that the Veteran’s disorder had an impact on her usual occupation and daily activities in that she needed to stop activities until her dizziness subsided. In addition, the examiner stated that a physical examination of the Veteran’s ears revealed that her external canal, mastoid, and tympanic membranes were within normal limits. There was also no deformity, aural polyps, middle ear infection, or effusion. The examiner further stated that a physical examination did not reveal ear-related cranial nerve conditions or bone loss, disturbance of balance, a staggering gait, or a cerebellar gait. The post-service medical records also show complaints of dizziness. For example, in a November 2014 private medical record, the Veteran reported having the new onset of dizziness for the last couple of days that was associated with changing positions. In a March 2014 VA medical record, the Veteran reported that she had to leave work because she was feeling dizzy. In addition, an October 2015 private medical record noted that the Veteran complained of dizziness. The Veteran has credibly reported having dizziness and vertigo that causes a functional impairment. See 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Her statements are also supported by the June 2010 VA examination that noted a diagnosis of vertigo. In addition, the Board finds that the most probative evidence of record shows that the Veteran’s current disability manifested by dizziness and vertigo is related to her service-connected sinusitis. There are no contrary opinions of record. Accordingly, service connection is warranted. Withdrawn Claim The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or his authorized representative. Id. During the March 2018 hearing, the Veteran withdrew her appeal as to the issue of entitlement to increased evaluations for unspecified depressive disorder with anxiety disorder. Thus, there remain no allegations of errors of fact or law for appellate consideration with respect to this claim. Accordingly, the Board does not have jurisdiction to review the appeal of this issue, and it is dismissed. REASONS FOR REMAND Entitlement to service connection for right lower extremity radiculopathy The Veteran’s service treatment records include a November 2006 radiology report that noted complaints of lumbago with radicular symptoms. The post-service medical evidence also shows diagnoses of radiculopathy. An August 2015 VA medical record noted an assessment of a muscle strain of the right quadricep based on Veteran’s complaints of right lower extremity pain. The Board further notes that the Veteran is service-connected for a lumbar spine strain with lumbago. For these reasons, a remand is necessary to obtain a VA examination and medical opinion. Entitlement to service connection for a left knee disorder The Veteran’s service treatment records show diagnoses of osteoarthritis and degenerative arthritis of the left knee. However, x-ray reports during service noted negative findings for the left knee. See, e.g., March 2009 radiology report; June 2010 VA examination. In addition, a January 2011 private medical record noted that the Veteran injured her left lower extremity during a fall. Thereafter, the Veteran’s VA medical records show diagnoses of left knee degenerative joint disease, patellofemoral arthritis, and patellofemoral pain syndrome. For these reasons, a remand is necessary to obtain a VA examination and medical opinion. Entitlement to service connection for a skin disorder other than eczema The Veteran has contended that she has skin disorders other than eczema that are related to her military service, including cellulitis and a skin disorder manifested by boils. In support of her claim, the Veteran submitted a medical article that noted methicillin-resistant Staphylococcus aureus (MRSA) infections often causes painful skin boils. Her service treatment records show diagnoses of various skin disorders, including atopic dermatitis, tinea corporis, cellulitis, and pityriasis rosea. A March 2010 treatment record noted an assessment of staphylococcal infection staphylococcus aureus methicillin resistant and that a physical examination of the Veteran revealed multiple skin lesions. The post-service medical records also show assessments of skin hidradenitis, as well as rule out diagnoses of dermatitis and seborrheic keratosis. Therefore, a remand is necessary to obtain a VA examination and medical opinion. Entitlement to service connection for a bilateral wrist disorder The Veteran was afforded a VA examination in June 2010 during which the examiner concluded that there was no current pathology to render a diagnosis for her bilateral wrist pain. However, in so doing, the examiner noted that the Veteran reported having symptoms of pain and weakness, as well as functional impairment. The United States Court of Appeals (Court) has held that pain in the absence of a presently-diagnosed condition can cause functional impairment, which may qualify as a disability for VA purpose. See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). Therefore, a remand is necessary to obtain an additional VA examination and medical opinion. Entitlement to service connection for a bilateral foot disorder other than left foot hallux valgus status post bunionectomy The Veteran was afforded a VA examination in June 2010 during which the examiner diagnosed her with bilateral acquired pes planus. However, the examiner did not provide an opinion regarding the nature and etiology of the Veteran’s bilateral pes planus. The medical evidence of records also reflects that the Veteran has been diagnosed with numerous other bilateral foot disorders. Therefore, a remand is necessary to obtain a VA examination and medical opinion. Lastly, the Board notes that the service treatment records have been associated with the claims file. However, during the March 2018 Board hearing, the Veteran asserted that her service treatment records from her periods of deployment are incomplete. On remand, the AOJ should ensure that proper development has been conducted to obtain the Veteran’s complete service treatment records. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for the disorders on appeal that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records, to include any records from the Fayetteville VAMC and Atlanta VAMC. 2. The AOJ ensure that the Veteran’s complete service treatment records have been associated with the claims file. It is noted that the claims file contains copies of service treatment records; however, it appears that these records may be incomplete. In this regard, the Veteran has contended that her service treatment records are incomplete for her periods of deployment from September 2002 to April 2003; June 2004 to June 2005; and October 2005 and October 2006. 3. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any right lower extremity radiculopathy that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any current disorders manifested by radiating pain in the right lower extremity, including radiculopathy. For each disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service, to include any symptomatology therein. The examiner should also provide an opinion as to whether it is at least as likely as not that the disorder was caused by or aggravated by the Veteran’s service-connected lumbar spine disability. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any left knee disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any current left knee disorders. If any previously diagnosed disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. For each disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service, to include any symptomatology therein. In rendering this opinion, the examiner should consider the following: 1) the Veteran’s in-service medical records that noted complaints of left knee pain and assessments of osteoarthritis. See, e.g., March 2009 radiology report (normal left knee examination); April 2009 (bilateral knee pain suspicious for chondromalacia of the patella); July 2009 (knee osteoarthritis); 2) a June 2010 VA examination report; and 3) a January 2011 private treatment record that noted the Veteran complained of left lower extremity pain after falling. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any skin disorders other than eczema that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any skin disorders other than eczema. If any previously diagnosed disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service, to include any symptomatology therein. In rendering this opinion, the examiner should consider the articles submitted by the Veteran in February 2018 regarding MRSA, staph infection carriers, and skin disorders. He or she should also consider the January 2004 service treatment record that noted the Veteran complained of rash that was deployment-related. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any bilateral wrist disorders that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any current bilateral wrist disorders. If the Veteran does not have a current diagnosis associated with her reported symptoms, the examiner should state this with a fully reasoned explanation. The examiner should also state whether there is any functional impairment caused by the Veteran’s reported pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. For each disorder identified or ay functional impairment resulting from pain, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service, to include any symptomatology therein. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any bilateral foot disorders other than left foot hallux valgus status post bunionectomy. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current bilateral foot disorders other than left foot hallux valgus status post bunionectomy. It should be noted that the presumption of soundness does not apply for pes planus, as it was noted on the Veteran’s March 1998 enlistment examination. With regard to pes planus, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder was aggravated by the Veteran’s military service. For each diagnosis identified other than pes planus, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 8. The AOJ should review the examination reports to ensure compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Wulff, Associate Counsel