Citation Nr: A20015744 Decision Date: 10/19/20 Archive Date: 10/19/20 DOCKET NO. 191212-49538 DATE: October 19, 2020 ORDER Readjudication of the claim for service connection for migraine headache is warranted. Readjudication of the claim for service connection for bilateral knee pain is warranted. REMANDED The issue of service connection for migraine headaches is remanded. The issue of service connection for bilateral knee and leg pain, to include as secondary to service-connected lumbosacral strain, is remanded. The issue of service connection for a bilateral ankle pain, to include as secondary to service-connected lumbosacral strain, is remanded. The issue of service connection for bilateral pelvic pain, to include as secondary to service-connected lumbosacral strain, is remanded. FINDINGS OF FACT 1. New evidence was received after the December 2002 denial that is relevant to the issue of entitlement to service connection for migraine headaches. 2. New evidence was received after the December 2002 denial that is relevant to the issue of entitlement to service connection for bilateral knee pain. CONCLUSIONS OF LAW 1. The criteria for readjudicating the claim for service connection for migraine headaches have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 3.156(d)). 2. The criteria for readjudicating the claim for service connection for bilateral knee pain have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 3.156(d)). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 2000 to December 2002. The claim is before the Board on a December 2019 Direct Review Request pursuant to the Appeals Modernization Act (2019) (“AMA”). 84 Fed. Reg. 138, Pub. L. No. 115-55, § 5104 (to be codified as amended in 38 U.S.C.), 131 Stat. 1105 (2017). Readjudication of the claims for service connection for migraine headaches and bilateral knee pain is warranted. The Veteran contends that she has submitted new and relevant evidence to readjudicate claims for service connection for migraine headaches and bilateral knee pain. VA will readjudicate a claim if new and relevant evidenced is presented or secured. 38 C.F.R. § 3.156(d). "Relevant evidence" is evidence that tends to prove or disprove a matter in issue. 38 C.F.R. § 3.2501(a)(1)). The Board finds the Veteran submitted new evidence after the December 2002 rating decision. Service treatment records were associated with the file, which indicate a history of recurrent bilateral frontal headache and a history of recurrent bilateral knee pain. Post-discharge VA medical records were also associated with the file, which indicate a diagnosis of migraine headaches and complaints of bilateral knee pain. These records were not already of record and may prove or disprove the nexus element of the claims for service connection for migraine headaches and bilateral knee pain. Readjudication of the claims is warranted. REASONS FOR REMAND Service connection for migraine headaches is remanded. Service connection for bilateral knee and leg pain, to include as secondary to service-connected lumbosacral strain, is remanded. Service connection for a bilateral ankle pain, to include as secondary to service-connected lumbosacral strain, is remanded. Service connection for bilateral pelvic pain, to include as secondary to service-connected lumbosacral strain, is remanded. The matter is REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The issue of service connection for migraine headache is remanded to correct a duty to assist error that occurred prior to the November 2018 rating decision on appeal. The Agency of Original Jurisdiction (AOJ) did not obtain a VA examination regarding whether the Veteran's headaches are related to her service (i.e., was caused by an in-service injury, event, or illness). The Board finds that a VA examination is required to make this determination. Remand of the issues of service connection for bilateral knee and leg pain, bilateral ankle pain, and bilateral pelvic pain, to include as secondary to service-connected lumbosacral strain, is necessary to obtain VA examinations and opinions. The Veteran has no current diagnoses of bilateral knee, leg, ankle, or pelvic disabilities. However, the record indicates that the Veteran experiences bilateral knee, leg, ankle, and pelvic pain. VA examinations and opinions are, therefore, necessary as to whether the pain caused functional impairment for which service connection could be granted. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of her migraine headaches. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinion: * Identify whether the Veteran's migraine headaches incurred in service or were caused by an in-service injury, event or illness. The examiner must review the entire record in conjunction with rendering the requested opinion. In addition to any records that are generated because of this Remand, the VA examiner's attention is drawn to the following: * A September 2000 service treatment record indicates that the Veteran was evaluated for headache lasting two to three days. No known allergies were indicated. * In the July 2002 Medical Evaluation Board (MEB) Narrative Summary, the examiner noted a history of bilateral frontal headaches over the preceding eight months. * In the July 2002 report of medical history for the purpose of MEB, the Veteran reported frequent or severe headache. Specifically, the Veteran reported headache when looking at things too long. The examiner noted recurrent frontal headache over the preceding eight months. * In a November 2002 Compensation and Pension Examination Report, the examiner noted that the Veteran’s headaches began in July 2002. Headaches were noted to occur two to three times per week with a duration of up to one hour. Photophobia, nausea, and vomiting were denied. The examiner noted a diagnosis of tension headaches. However, no etiological opinion was provided. * An August 2019 VA medical record indicates that the Veteran was evaluated for migraine headaches. The examiner noted that the Veteran has a relevant past medical history of migraines. Migraine headaches were noted to occur with a frequency of three times per month. It was noted that the Veteran treats her symptoms with Sumatriptan, which was noted to decrease the severity of the migraines. 3. Schedule the Veteran for a VA examination to obtain an opinion as to the nature and etiology of any right and/or left knee/leg disorders or pain, to include as secondary to service-connected lumbosacral strain. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Whether each identified right knee/leg disorder, or right knee/leg pain which causes functional impairment, was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (b.) Whether each identified left knee/leg disorder, or left knee/leg pain which causes functional impairment, was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (c.) Whether each identified right knee/leg disorder, or right knee/leg pain which causes functional impairment, was caused by the service-connected lumbosacral strain. (d.) Whether each identified left knee/leg disorder, or left knee/leg pain which causes functional impairment, was caused by the service-connected lumbosacral strain. (e.) Whether each identified right knee/leg disorder, or right knee/leg pain which causes functional impairment, was aggravated by the service-connected lumbosacral strain. (f.) Whether each identified left knee/leg disorder, or left knee/leg pain which causes functional impairment, was aggravated by the service-connected lumbosacral strain. 4. Schedule the Veteran for a VA examination to obtain an opinion as to the nature and etiology of any right and/or left ankle disorders or pain, to include as secondary to service-connected lumbosacral strain. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Whether each identified right ankle disorder, or right ankle pain which causes functional impairment, was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (b.) Whether each identified left ankle disorder, or left ankle pain which causes functional impairment, was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (c.) Whether each identified right ankle disorder, or right ankle pain which causes functional impairment, was caused by the service-connected lumbosacral strain. (d.) Whether each identified left ankle disorder, or left ankle pain which causes functional impairment, was caused by the service-connected lumbosacral strain. (e.) Whether each identified right ankle disorder, or right ankle pain which causes functional impairment, was aggravated by the service-connected lumbosacral strain. (f.) Whether each identified left ankle disorder, or left ankle pain which causes functional impairment, was aggravated by the service-connected lumbosacral strain. 5. Schedule the Veteran for a VA examination to obtain an opinion as to the nature and etiology of any right and/or left pelvic disorders or pain, to include as secondary to service-connected lumbosacral strain. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Whether each identified right pelvic disorder, or right pelvic pain which causes functional impairment, was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (b.) Whether each identified left pelvic disorder, or left pelvic pain which causes functional impairment, was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (c.) Whether each identified right pelvic disorder, or right pelvic pain which causes functional impairment, was caused by the service-connected lumbosacral strain. (d.) Whether each identified left pelvic disorder, or left pelvic pain which causes functional impairment, was caused by the service-connected lumbosacral strain. (e.) Whether each identified right pelvic disorder, or right pelvic pain which causes functional impairment, was aggravated by the service-connected lumbosacral strain. (f.) Whether each identified left pelvic disorder, or left pelvic pain which causes functional impairment, was aggravated by the service-connected lumbosacral strain. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed, and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Timothy T. Emmart The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.