Citation Nr: 21002546 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 17-60 414 DATE: January 14, 2021 ORDER The issue as to whether veteran status has been established based on qualifying active service in the Reserve component is dismissed. Service connection for a bilateral hearing loss disability is denied. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for rheumatoid arthritis is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for edema of the bilateral lower extremities is remanded. Entitlement to service connection for insomnia, to include as secondary to service-connected tinnitus, is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for sciatica of the left leg is remanded. Entitlement to service connection for carpal tunnel syndrome is remanded. Entitlement to service connection for pes planus is remanded. Entitlement to service connection for achilles tendonitis is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for a head injury is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran was honorably discharged following periods of active duty training (ACDUTRA) and inactive duty training (INACDUTRA) in the United States Navy Reserve from February 2001 to February 2009. 2. Based on a February 2020 Board decision, veteran status was established for all periods of active service from February 2001 to February 2009. 3. The Veteran does not have a bilateral hearing loss disability for VA purposes. CONCLUSIONS OF LAW 1. There is no case or controversy as to the issue of whether veteran status has been established based on qualifying active service in the Reserve component, and the claim is dismissed. 38 U.S.C. § 7105; 38 C.F.R. § 20.104. 2. The criteria for entitlement to service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran was honorably discharged following periods of active service in the United States Navy Reserve from February 2001 to February 2009. In April 2020, the United States Court of Appeals for Veterans Claims (Court) granted the Veteran’s and the Secretary’s joint motion for remand (JMR), vacating and remanding a May 2019 Board decision. As a threshold matter, the May 2019 Board decision determined that the Veteran did not have active service based on her Reserve service for purposes of VA compensation benefits. See 38 U.S.C. § 101(22), (24); 38 C.F.R. § 3.6(a). As such, the May 2019 Board decision denied the Veteran’s claim for entitlement to service connection for: a bilateral hearing loss disability; a right shoulder disability; a left shoulder disability; rheumatoid arthritis; fibromyalgia; edema of the bilateral lower extremities; insomnia; migraine headaches; a low back disability; sciatica of the left leg; carpal tunnel syndrome; pes planus; Achilles tendonitis; obstructive sleep apnea; a head injury; a psychiatric disorder manifested by a head injury; and entitlement to a TDIU. The JMR noted that the Board erred by failing to adequately address the Veteran’s contentions regarding injuries incurred during basic training and other periods of active duty training (ACDUTRA) during her service in the Navy Reserve from February 2001 to February 2009. The JMR noted the failure to address the question of additional periods of service was prejudicial because the record contains conflicting information on this matter. Specifically, the Veteran reported she incurred injuries during periods of ACDUTRA and inactive duty training (INACDUTRA), and provided evidence documenting such service, which were not considered or identified in the Board’s May 2019 decision. For the reasons discussed below, the issue as to whether the Veteran has qualifying active service based on her Reserve service for purposes of VA compensation benefits is dismissed. Veteran Status In order to establish basic eligibility for VA disability compensation benefits, a claimant must first establish “veteran” status. The term “veteran” means a person who had active service, and who was discharged under conditions other than dishonorable. 38 U.S.C. § 101(2). The term “active service” includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 101(22), (24); 38 C.F.R. § 3.6 (a). As it pertains to this appeal, subsequent to the May 2019 Board decision that is the subject of the April 2020 JMR, the Veteran was awarded service connection by the Board for tinnitus. Although the Board determined in its February 2020 decision that it was at least as likely as not that the Veteran’s tinnitus was incurred during a period of service, the Board did not identify a specific period of ACDUTRA or INACDUTRA during which tinnitus began. Rather, the Board found probative the Veteran’s assertions of in-service exposure to acoustic trauma during the training periods throughout her career, and her observation of tinnitus as a result. In light of these findings and the unique facts of this case, the Board must resolve all doubt in the Veteran’s favor and conclude that the tinnitus award was based on noise injury sustained in all periods of ACDUTRA and INACDUTRA during her Reserve service from February 2001 to February 2009. See February 2020 Board decision. In this connection, the threshold issue of entitlement to veteran status has been resolved because veteran status has been established for all periods of ACDUTRA and INACDUTRA, to include any of the periods of service indicated in the April 2020 JMR, by dint of the Board’s February 2020 decision. There is therefore no case or controversy for the Board to resolve as to this issue, and the appeal for entitlement to veteran status is dismissed. 38 U.S.C. § 7105(d)(5). With respect to the Veteran’s periods of active service, the Veteran enlisted in the Navy Reserve in February 2001 and was honorably discharged after completing her eight-year military service obligation in February 2009. See DD Form 4; see also DD Form 256. During her first year of service in the Navy Reserve, from February 16, 2001 to February 15, 2002, the Veteran earned 60 INACDUTRA points, the equivalent of 30 calendar days, for attendance at inactive duty or equivalent training. See Statement of Service certified on July 22, 2014; see also DoD Instruction 1215.07, Service Credit for Non-Regular Retirement. As noted in the April 2020 JMR, although not documented on the Statement of Service certified by Navy Personnel Command, service records confirm the Veteran had ACDUTRA from August 2-16, 2001 (15 days) to attend a Non-prior Service Accession Course (or “bootcamp”). From February 16, 2002 to February 15, 2003, the Veteran earned 44 INACDUTRA points, the equivalent of 22 calendar days, for attendance at inactive duty training or equivalent training. For this entire anniversary year through to December 14, 2003 of the following anniversary year, the Veteran was placed in a “temporarily not physically qualified (TNPQ) in a drill status.” See DD Form 2766 (TNPQ status from February 9, 2002 to December 14, 2003); see also January 2002 private provider’s prescription (limiting Veteran from prolonged standing, and frequent back bending or twisting). Navy Reservists not in a duty status who are injured or develop a potential physically disqualifying condition are categorized as TNPQ or physically disqualified. See BUPERSINST 1001.39F. Despite being in a TNPQ drill status, the Veteran had ACDUTRA from May 2-16, 2002 (15 days) aboard the USS Harry S. Truman. In a May 15, 2002 letter, the Commanding Officer, USS Harry S. Truman, reported the Veteran was assigned as the Supply Response Section Clerk during the annual training from May 2-16, 2002. While the Veteran indicated she carried out labor-intensive work during her 15 days of ACDUTRA in May 2002, the Commanding Officer reported the Veteran was responsible for processing requisitions, validating information system mailboxes for material requirements, and performing technical research on equipment requisitions. See also August 2019 correspondence from the Veteran. From February 16, 2003 to February 15, 2004, the Veteran earned 22 INACDUTRA points, the equivalent of 11 calendar days, for attendance at inactive duty training or equivalent training. See also Annual Retirement Point Record (dates of INACDUTRA listed as March 15-16, 19-20, 2003, April 12-13, 2003, May 17-18, 2003, June 14-15, 2003, and July 18, 2003). The evidence of record indicates the Veteran did not have any ACDUTRA during this anniversary year. As noted above, the Veteran was in a TNPQ in a drill status through December 14, 2003. In an April 2003 Annual Certificate of Physical Condition, the provider reported the Veteran was not physically qualified for full duty. Additionally, it appears the Veteran excused from any Reserve participation from August 2003 through February 2004. See December 2003 correspondence from the Veteran (indicating that she had requested a six-month leave of absence in July 2003 and desired to return to a drilling status in February 2004). From February 16, 2004 to February 15, 2005, the Veteran earned 52 INACDUTRA points, the equivalent of 26 calendar days, for attendance at inactive duty training or equivalent training (including attendance at a course from August 6-8, 2004). The Veteran completed an Annual Certificate of Physical Condition in May 2004, in which she reported that she had no physical or mental defects that might restrict her performance on active duty. The Veteran had ACDUTRA from July 18-30, 2004 (13 days) to attend military occupational specialty training in supply. From February 16, 2005 to February 15, 2006, the Veteran earned 41 INACDUTRA points, the equivalent of approximately 21 calendar days, for attendance at inactive duty training or equivalent training (including attendance at courses in April 15-17, 2005, and May 6-8, 2005). The Veteran had ACDUTRA from May 15-27, 2005 (13 days) to attend school without field duty. The Veteran completed an Annual Certificate of Physical Condition in June 2005, in which she reported that she had no physical or mental defects that might restrict her performance on active duty. The Veteran’s physical readiness testing was waived in September 2005. The Veteran was placed in a temporarily not physically qualified status from October 18, 2005 to November 28, 2005 following voluntary cosmetic surgery in September 2005. From February 16, 2006 to February 15, 2007, the Veteran earned 41 INACDUTRA points, the equivalent of approximately 21 calendar days, for attendance at inactive duty training or equivalent training. See also August 2007 IDT Detail Review (noting dates of INACDUTRA included July 8-9, 2006, September 9-10, 2006, October 14-15, 2006, and November 4-5, 2006). In a periodic performance evaluation covering the period from June 2005 to June 2006, the Veteran’s duties included coordinating and presenting classroom training, and creating a spreadsheet to streamline the tracking of unit activities. The Veteran had ACDUTRA from May 14-19, 2006 (6 days) to attend a leadership course, and ACDUTRA from June 6-16, 2006 (11 days). The Veteran submitted a schedule of tasks and events for the annual training from June 6-16, 2006, which involved physical training in the morning and administrative duties throughout the day. In a September 2006 Periodic Health Assessment, the Veteran was found fit for duty. The Veteran was transferred to the Individual Ready Reserve (IRR) in December 2006. See September 2007 memorandum (removing record of unsatisfactory Reserve participation in December 2006). From February 2007 to February 2008, the Veteran earned 20 INACDUTRA points, the equivalent of 10 calendar days, for nonpaid inactive duty training while assigned to a Voluntary Training Unit. See also August 2007 IDT Detail Review (dates of INACDUTRA listed as April 14-15, 2007, May 5-6, 2007, June 2-3, 2007, July 7-8, 2007, and August 4-5, 2007). In August 2007 correspondence from the Veteran, she requested to return to a [paid] drilling status in September 2007. In a September 2007 Periodic Health Assessment, the Veteran was found fit for duty. In December 2007, the Veteran was granted a waiver for physical readiness testing. The Veteran had no ACDUTRA during this anniversary year. In January 2008, the Veteran’s ACDUTRA was canceled, and she was placed in a TNPQ status “until further notice.” See January 2008 Annual Training Release or Cancellation Request. From February 16, 2008 to February 15, 2009, the Veteran earned 8 INACDUTRA points for attendance at inactive duty training or equivalent training, the equivalent of 4 calendar days (including March 15-16, 2008). While the Veteran reported in January 2016 correspondence that she performed INACDUTRA in August 2008, the Board notes that the Veteran’s request for transfer to the IRR was approved effective April 1, 2008. Service records contain no indication that she returned to a drilling status at any time from April 1, 2008 until her honorable discharge from the Navy Reserve in February 2009. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). With respect to the Veteran’s service-connected disability claims currently on appeal, the Board notes that the Court has held that once a claimant has achieved veteran status for a single disability incurred or aggravated during a period of ACDUTRA, as here where the Veteran was granted service connection for tinnitus based on all periods of active service, that status applies to all disabilities claimed to have been incurred or aggravated during that period of active service. Hill v. McDonald, 28 Vet. App. 243, 252 (2016). Bilateral Hearing Loss Disability The Veteran seeks entitlement to service connection for a bilateral hearing loss disability. See October 2016 VA Form 21-526EZ. For VA purposes, impaired hearing shall be considered a disability when the thresholds for the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In an August 2016 private audiological evaluation, the Veteran reported good hearing overall. The audiologist noted “excellent hearing bilaterally.” In an August 2018 private audiological evaluation, the Veteran reported good hearing. The audiologist reported the Veteran’s hearing acuity was within normal limits at all frequencies bilaterally, and results of the Maryland CNC Test were 100 percent at 40 decibels in each ear. The Veteran was afforded a VA hearing loss examination in August 2019. The Veteran reported military noise exposure from bombing simulations during boot camp, fire fight training simulation, flight operations, and from the shipyard container terminal. The Veteran reported hearing protection was only provided at the shipyard. On the August 2019 VA audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 10 20 25 LEFT 15 10 10 15 5 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 94 percent in the left ear. During the period on appeal, the evidence of record is against a finding that the Veteran’s bilateral hearing impairment meets the criteria to be considered a disability for VA purposes. 38 C.F.R. § 3.385. The Veteran has not alleged that her bilateral hearing acuity has diminished since the August 2019 VA audiological evaluation. The evidence of record does not indicate, and the Veteran has not asserted, that the August 2019 VA audiological evaluation produced test results that were invalid or did not sufficiently address the Veteran’s bilateral hearing impairment. As the preponderance of the evidence is against a finding that the Veteran has a current bilateral hearing loss disability for VA purposes, the claim for entitlement to service connection for a bilateral hearing loss disability is denied. REASONS FOR REMAND Right & Left Shoulder In this case, the Veteran’s report of symptoms upon entry into service include a history of painful or trick shoulder. See January 2001 Report of Medical History; see also June 1999 Claim for Disability Insurance Benefits – Doctor’s Certificate (indicating a diagnosis of calcific tendinitis of the right shoulder). In Hill, the Court held that once a claimant has achieved veteran status for a period of active service, the claimant is then entitled to the presumption of aggravation with respect to a different, preexisting disability shown to have worsened during the same period of active service. Hill, 28 Vet. App. at 252. Under the presumption of aggravation, a preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153. However, to take advantage of the presumption of aggravation, the claimant must submit evidence that, together with the rest of the record, evidences both a baseline severity of a preexisting condition prior to the period of ACDUTRA and a permanent increase in disability during a period of ACDUTRA. Id at 255. In correspondence submitted by the Veteran in January 2016, she indicated that she injured her right shoulder during fire fighter training at the 15-day Non-prior Service Accession Course in August 2001, and while moving large missiles, missile casings, cargo, and equipment during her ACDUTRA (in a TNPQ drill status) aboard the USS Harry S. Truman in May 2002. Additionally, in April 2018 correspondence from the Veteran, she indicated the physical demands of the military, including hauling heavy boxes and equipment, and physical training, and weapons training, aggravated, weakened, and re-injured her preexisting right shoulder condition. With respect to the Veteran’s assertions concerning injury to her right shoulder during periods of active service, service treatment records are silent for any report of injury to the right shoulder during a period of ACDUTRA or INACUDTRA. The Board observes that while the Veteran was in a drilling status (prior to attending the 15-day Non-prior Service Accession Course in August 2001) the Veteran was waived from doing push-ups due to her previous right shoulder surgery. See May 2001 service treatment record. With respect to the Veteran’s assertion that she injured her right shoulder moving large missiles, missile casings, cargo, and equipment during her ACDUTRA (in a TNPQ drill status) aboard the USS Harry S. Truman in May 2002, the Veteran’s post-service description of activities performed during her ACDUTRA in May 2002 is not consistent with the contemporaneous evidence of record. As discussed above, the May 2002 letter from the Commanding Officer, USS Harry S. Truman, described in detail the type administrative duties the Veteran performed as a Supply Response Section Clerk, including processing requisitions, validating information system mailboxes for material requirements, and performing technical research on equipment requisitions. Additionally, the Veteran completed an Annual Certificate of Physical Condition in May 2004 and June 2005, in which she reported that she had no physical defects that might restrict her performance on active duty. Until August 2007, private treatment records associated with the claims file are also silent for complaints related to the Veteran’s right shoulder condition. In an August 2007 private treatment record, the Veteran presented for evaluation of right shoulder pain, which she reported had onset approximately two to three months earlier. The Veteran described experiencing right shoulder pain at night, as well as with activities. Dr. A.Y.L. indicated an impression of right shoulder probable focal rotator cuff tear, and right cervical strain. As discussed in detail above, with respect to the Veteran’s August 2007 report of onset of right shoulder pain two to three months earlier, the Board notes the Veteran’s most recent period of ACDUTRA was more than one year earlier in May and June of 2006. With respect to INACDUTRA, the Veteran was assigned to the IRR in December 2006. The Veteran performed a total of 10 days of nonpaid INACDUTRA with a Voluntary Training Unit on April 14-15, 2007, May 5-6, 2007, June 2-3, 2007, July 7-8, 2007, and August 4-5, 2007. The Veteran requested to return to a paid drilling status effective September 2007. In November 2007 Dr. A.Y.L. prescribed physical therapy to treat the Veteran’s diagnosis of right shoulder impingement. On December 1, 2007, the Veteran was granted a waiver for physical readiness testing. The Veteran was placed in a TNPQ drill status for tendinitis in the right shoulder, with a note that the Veteran’s private treatment provider indicated no physical activities through March 14, 2008. December 2007 service treatment records document that the Veteran was limited from heavy lifting, limited use of effected limb, no use of ladders/stairs, and no physical fitness test. The Veteran’s ACDUTRA was canceled in January 2008 due to her TNPQ status. On March 25, 2009, Dr. A.Y.L. performed a right shoulder diagnostic arthroscopy with a postoperative diagnosis of right shoulder impingement syndrome. The Veteran was transferred to the IRR effective April 1, 2008, with no evidence of further ACDUTRA or INACDUTRA prior to her separation from service on February 15, 2009. In an April 2016 private medical opinion, Dr. M.R.N. reported he had been treating the Veteran since August 2014. Based on a review of the Veteran’s medical records and history, Dr. M.R.N. indicated that the Veteran’s current diagnosis of right shoulder tendinitis/impingement was a result of injuries to her right shoulder during the 15-day Non-prior Service Accession Course in August 2001, while performing ACDUTRA (in a TNPQ drill status) aboard the USS Harry S. Truman in May 2002, and INACDUTRA support operations in 2008. Dr. M.R.N. opined the Veteran’s physical trauma in service “caused, contributed to and aggravated her totally disabling condition(s)…” Although Dr. M.R.N. indicated his August 2016 medical opinion was based on his treatment of the Veteran (since August 2014) and a review of her medical records and history, his positive nexus opinion does not include any discussion of the Veteran’s June 1999 diagnosis of right shoulder tendinitis, and is not supported with a clinical explanation or rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is factually accurate, fully articulated, and sound reasoning for the conclusion). To date, a VA medical opinion has not been obtained with respect to the Veteran’s claim for entitlement to service connection for a right shoulder disability. In order to fulfill VA’s duty to assist, the Board finds remand is necessary to obtain a medical opinion. With respect to the Veteran’s claim for entitlement to service connection for a left shoulder disability, the Veteran indicated her left shoulder condition is secondary to her right shoulder condition. See April 2018 correspondence from the Veteran; see also August 2014 private treatment record (indicating a diagnosis of left shoulder impingement syndrome). The Veteran reported overuse of her left shoulder to compensate for her right shoulder condition, which resulted in a torn left tendon in her left shoulder. As the Veteran’s claim for entitlement to service connection for a left shoulder disability is inextricably intertwined with her service connection claim for a right shoulder disability, it must be remanded as well. Rheumatoid Arthritis, Fibromyalgia, Edema of the Bilateral Lower Extremities, Insomnia, Migraine Headaches In reviewing the evidence of record. it appears the Veteran’s claims for entitlement to service connection for rheumatoid arthritis, fibromyalgia, edema of the bilateral lower extremities, insomnia, and migraine headaches, are substantially intertwined as it appears the symptoms and diagnoses overlap. See November 2014 VA Fibromyalgia Disability Benefits Questionnaire (signs and symptoms attributable to the Veteran’s fibromyalgia included: widespread musculoskeletal pain, stiffness, muscle weakness (Veteran was unable to stand, sit, or walk for long periods of time), fatigue, sleep disturbances, paresthesias, headache, depression, anxiety, irritable bowel syndrome, and Raynaud’s-like symptoms); see also November 2011 progress note by Dr. J.A. The Board observes that prior to the Veteran’s enlistment in the Navy Reserve, Dr. G.R.C. indicated the Veteran reported fatigue, loss of energy, difficulty sleeping, leg swelling, and sensitivity of hands and feet to temperature changes. See May 2000 private treatment record. In June 2000, prior to the Veteran’s enlistment, Dr. G.R.C. reported the Veteran’s back trigger point left suprascapular area and left trapezius muscle body were tender to palpation. See June 2000 private treatment record. In Dr. G.R.C.’s assessment, he questioned whether such symptoms were fibromyalgia syndrome evolving. In a November 2001 private treatment record, approximately 11 weeks following the Veteran’s completion of the 15-day Non-prior Service Accession Course in August 2001, the Veteran reported poor energy for the previous four to six weeks without associated symptoms. Dr. G.R.C. indicated the Veteran’s energy loss was secondary to sleep deprivation and poor/limited quality of sleep. In a May 2003 private treatment record, Dr. S.H.Z. indicated the Veteran was being evaluated for the complaint of multiple joints causing significant pain. An August 2019 hearing loss examiner referenced a prior treatment record dated April 8, 2004, where it was noted the Veteran had a long history of migraines, with migraine syndrome at the age of seven. In November 2014 correspondence, A.R. reported that she had known the Veteran for more than 30 years. A.R. indicated the Veteran reported experiencing edema of the feet, fatigue, memory loss, muscle pain, and weakness shortly after she completed the 15-day Non-prior Service Accession Course in August 2001. In November 2014 correspondence, J.G. reported that he spent time with the Veteran during her period of ACDUTRA in May 2005. J.G. reported that during his visit with the Veteran in May 2005, the Veteran was unable to walk more than two blocks. J.G. indicated he observed significant swelling of the Veteran’s feet. J.G. indicated the Veteran reported she often experienced swelling of her feet and ankles during her periods of military service. The Board notes that on the Annual Certificate of Physical Condition completed by the Veteran in June 2005, she reported that she had no physical defects that might restrict her performance on active duty In January 2016 correspondence, the Veteran reported she began experiencing many symptoms, including edema of the lower extremities, associated with fibromyalgia after completing gas chamber training during the Non-prior Service Accession Course in August 2001. See also April 2018 correspondence from the Veteran. In the April 2016 private medical opinion, Dr. M.R.N. indicated that the Veteran’s fibromyalgia, diagnosed in April 2008, was a result of physical and emotional trauma incurred during the 15-day Non-prior Service Accession Course in August 2001, support operations while performing ACDUTRA (in a TNPQ drill status) aboard the USS Harry S. Truman in May 2002, and other military training. Dr. M.R.N. opined the Veteran’s physical trauma in service “caused, contributed to and aggravated her totally disabling condition(s)…” Dr. M.R.N.’s medical opinion is not supported with a clinical explanation or rationale, nor does it appear to consider the evidence of record suggesting the Veteran had symptoms related to the diagnoses above prior to entering service. Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds remand is necessary to obtain a medical opinion to address the nature and etiology of the Veteran’s rheumatoid arthritis, fibromyalgia, edema of the bilateral lower extremities, insomnia, and migraine headaches. Low Back & Sciatica of the Left Leg In January 2016 correspondence, the Veteran indicated that she injured her back during fire fighter training at the 15-day Non-prior Service Accession Course in August 2001, and while moving large missiles, missile casings, cargo, and equipment during her ACDUTRA (in a TNPQ drill status) aboard the USS Harry S. Truman in May 2002. In October 2016 correspondence, the Veteran reported that she strained her lower back lifting a more than 50-pound sea bag on her way to the 15-day Non-prior Service Accession Course in August 2001. The Veteran reported the continuous lifting/carrying of her sea bag and performing sit-ups on a concrete floor during the 15-day Non-prior Service Accession Course in August 2001 caused her to develop low back pain and sciatic nerve pain in her left leg. In April 2018 correspondence, the Veteran reported that the physical demands of the military, including prolonged standing, marching (particularly with a fully packed sea bag), and sitting in class for extended periods of time, put a lot of stress, pressure, and strain on her back. The Board observes that in a May 2000 private treatment record, prior to entry into service, the Veteran reported recurring back pain. However, the Veteran denied recurrent back pain on her January 2001 Report of Medical History, and clinical evaluation of her spine was normal. See also January 2001 Report of Medical Examination. In a January 2002 private treatment record, the Veteran reported low back pain as a result of three motor vehicle accidents traveling in snow to New York three weeks earlier. The Board notes that the Veteran was not assigned to a Reserve unit in New York in January 2002. The evidence does not demonstrate, nor has the Veteran asserted, that she performed ACDUTRA or INACDUTRA in New York in January 2002. Dr. G.R.C. noted that he provided the Veteran with an excusal from activity that might put undue stress on her back (standing for long periods of time, frequent twisting, or bending the back, etc.). See January 2002 private provider’s prescription (limiting Veteran from prolonged standing, and frequent back bending or twisting); see also DD Form 2766 (TNPQ status from February 9, 2002 to December 14, 2003). In a November 2003 Certificate to Return to Work, a private treatment provider noted the Veteran was “ok to return to drill duty.” Service treatment records are otherwise silent for reports related to the Veteran’s back. As discussed above, the Veteran completed an Annual Certificate of Physical Condition in May 2004 and June 2005, in which she reported that she had no physical defects that might restrict her performance on active duty. In a March 2015 medical evaluation, the Veteran reported a history of two auto accidents. Dr. M.S. noted a July 2014 deposition in which the Veteran reported neck and back injury from a motor vehicle accident in 2006 and in 2009. In the April 2016 private medical opinion, Dr. M.R.N. indicated that the Veteran’s current low back disability and associated symptoms were a result of injuries to her back during the 15-day Non-prior Service Accession Course in August 2001, while performing ACDUTRA (in a TNPQ drill status) aboard the USS Harry S. Truman in May 2002, and INACDUTRA support operations in 2008. Dr. M.R.N. opined the Veteran’s physical trauma in service “caused, contributed to and aggravated her totally disabling condition(s)…” Although Dr. M.R.N. indicated his August 2016 medical opinion was based on his treatment of the Veteran (since August 2014) and a review of her medical records and history, his positive nexus opinion does not include any discussion of the Veteran’s report of recurring back pain prior to service, or the Veteran’s report of low back pain as a result of car accident(s) in January 2002 that occurred between periods of active service when the Veteran was not in a duty status, and which resulted in the Veteran being placed in a TNPQ in a drill status (limiting the Veteran from prolonged standing, and frequent back bending or twisting while in a duty status from February 9, 2002 to December 14, 2003). Additionally, Dr. M.R.N.’s positive nexus opinion is not supported with a clinical explanation or rationale. Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds remand is necessary to obtain a medical opinion to address the nature and etiology of the Veteran’s claimed low back disability and sciatica of the left leg. Carpal Tunnel Syndrome In January 2016 and April 2018 correspondence, the Veteran reported she developed carpal tunnel syndrome during her 15-day ACDUTRA aboard the USS Harry Truman in May 2002, during INACDUTRA from August 6-8, 2004, and during her other periods of ACDUTRA and INACDUTRA. The Veteran indicated her carpal tunnel syndrome developed during active service while performing administrative duties, standing watch with her rifle, weapons handling exercises, performing push-ups in physical training, and moving heavy equipment during ACDUTRA and INACDUTRA. The Veteran reported she experienced significant weakness in her bilateral wrists, loss of grip and hand coordination, sharp, shooting and throbbing pain, numbness, and tingling sensations. Service treatment records are silent for the Veteran’s reported symptoms of carpal tunnel syndrome, which she asserts developed during active service. Social Security Administration (SSA) records associated with the claims file include a March 2015 medical evaluation that was conducted in connection with the Veteran’s claim for workers’ compensation for right carpal tunnel syndrome. See March 2015 Qualified Medical Evaluation. The Veteran reported she started having pain in the right fourth and fifth digit in April 2013, but did not report it until April 2014. Dr. M.S. reviewed the Veteran’s medical records and noted the Veteran underwent a nerve conduction study in April 2014, and was diagnosed with mild bilateral carpal tunnel syndrome. See April 2014 nerve conduction studies; see also December 2014 VA Wrist Conditions Disability Benefits Questionnaire. Although the evidence of record indicates the Veteran was not diagnosed with bilateral carpal tunnel syndrome until April 2014, Dr. M.S. reported the Veteran had “definite medical records stating previous existence of carpal tunnel syndrome on the right side for a long time,” and opined 25 percent of the impairment from her current bilateral carpal tunnel syndrome was due to a preexisting condition. The Board observes that the list of medical records reviewed by Dr. M.S. include a reference to a February 2010 medical record in which Dr. J.A. indicated the Veteran had possible carpal tunnel syndrome of the right hand. During Dr. M.S.’s medical evaluation, the Veteran reported only “occasional work” as a member of the Naval Reserve from February 2001 to February 2009. In the Veteran’s June 2014 Work History Report associated with SSA records, she indicated her previous full-time employment included: administrative assistant from January 1999 to January 2003; purchasing logistics coordinator from January 2003 to March 2004; executive assistant from March 2004 to June 2007; administrative assistant from June 2007 to June 2010; and management associate from February 2011 to April 2014. The Veteran reported her duties in those occupations included administrative support and heavy lifting of files and supplies. In the April 2016 private medical opinion, Dr. M.R.N. indicated the Veteran sustained injuries to her left and right wrist in service which led to her diagnosis of bilateral carpal tunnel syndrome. Dr. M.R.N.’s positive nexus opinion contains no discussion of the Veteran’s workers’ compensation claim for carpal tunnel syndrome in which bilateral carpal tunnel syndrome was attributed to the Veteran’s administrative occupation from February 2011 to April 2014, the first medical evidence of symptoms of carpal tunnel syndrome in February 2010, or the Veteran’s report that the first onset of her right carpal tunnel syndrome was in April 2013. Additionally, Dr. M.R.N.’s medical opinion is not supported with a clinical explanation or rationale. Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds remand is necessary to obtain a medical opinion to address the nature and etiology of her carpal tunnel syndrome. Pes Planus and Achilles Tendonitis In October 2016 correspondence, the Veteran reported she developed flat feet and achilles tendonitis during her ACDUTRA and INACDUTRA from wearing steel toe boots and dress shoes while performing standing watch duty, routine marching, and physical training. In April 2018 correspondence, the Veteran reported such activities performed during active service led to stress on her tendon causing posterior tibial tendon dysfunction, which led to her diagnosis of flat feet. While service treatment records are silent for a diagnosis of pes planus or reports of painful feet, the Veteran reported that she recalled having pain and swelling in her feet in June and July 2001. The Veteran noted that she received a prescription from Dr. G.R.C. in June 2001 for Furosemide (which appears to have been prescribed for bloating). See June 2001 prescription. Although Dr. G.R.C. noted the Veteran reported recent running in preparation for the 15-day Non-prior Service Accession Course in August 2001, she did not report pain related to her feet. See July 2001 private treatment record; see also July 2001 note from Dr. G.R.C. (indicating the Veteran may return to work with no limitations). In an October 2016 VA Foot Conditions Disability Benefits Questionnaire submitted by the Veteran, Dr. A.M. indicated the Veteran has a current diagnosis of pes planus with associated posterior tibial tendon dysfunction. See also October and December 2016 VA podiatry note. Dr. A.M. indicated, per the Veteran’s report, she experienced painful flat feet since military service. The Board finds remand is necessary to obtain a medical opinion to address the nature and etiology of her pes planus and achilles tendonitis. Obstructive Sleep Apnea, Psychiatric Disorder & residuals of a Head Injury In October 2016 correspondence, the Veteran asserted that she suffered a head injury during her period of training in August 2001 where she was kicked in the head by a steel toe boot and was knocked unconscious for what she was told was approximately 2 to 3 minutes. She claims her residuals include sleep apnea and a psychiatric disorder. She has also noted her insomnia and headaches (discussed above) may also be due to this head injury. In April 2018 correspondence, the Veteran indicated her symptoms were first treated after her August 2001 training, and she was prescribed medication for her psychiatric disability and sleeping problems at that time. While the Veteran submitted a March 2020 opinion from Dr. Y.J.K. stating that it was at least as likely as not that the Veteran’s sleep apnea was caused or made worse by her time in the military from February 2001 to 2009, the opinion did not provide further explanation as to how this conclusion was reached other than pointing out that there was no pre-existing sleep apnea or genetic pre-disposition for sleep apnea. The examiner speculated that “perhaps,” sleep apnea was also related to stressors she experienced in basic training, including mild TBI. With respect to psychiatric disabilities, a July 2020 examination noted the presence of generalized anxiety disorder, bipolar disorder, II, and alcohol use in remission. At the examination, the Veteran discussed her head injury, but the examiner provided no opinion as to whether any diagnosed disability was related to service. The examiner did appear to link the Veteran’s symptoms of anxiety to her service-connected tinnitus, but the opinion is unclear as to whether it was the opinion of the examiner that tinnitus actually caused a current psychiatric disorder. On remand, opinions should be obtained addressing the etiology of all the Veteran’s claimed head injury residuals, to include sleep apnea and a psychiatric disability. TDIU The Veteran’s claim for entitlement to a TDIU is inextricably intertwined with the issues being remanded by the decision herein, and must be deferred pending the development and adjudication of these issues. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate examiner addressing the nature and etiology of the Veteran’s right and left shoulder disabilities. The examiner must review the claims file, to include the medical history outlined in the body of the Remand above. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. Based on a review of the record, and if necessary, an examination, the examiner should address the following: (a.) Identify all current right and left shoulder disabilities. (b.) Please provide best estimates as to dates of onset for each right shoulder disability. Please discuss what in the record helps inform your estimate, and specify whether it is at least as likely as not (50 percent or greater probability) that any of these disabilities had onset during a period of training. Please consider that in correspondence submitted by the Veteran in January 2016, she indicated that she injured her right shoulder during fire fighter training at the 15-day Non-prior Service Accession Course in August 2001, and while moving large missiles, missile casings, cargo, and equipment during her ACDUTRA (in a TNPQ drill status) aboard the USS Harry S. Truman in May 2002. (c.) For each right shoulder disability that existed prior to the Veteran’s enlistment in February 2001, or otherwise during a period of nonactive status, please indicate whether it is at least as likely as not that such disability underwent an increase in disability during a period of ACDUTRA and/or INACDURA. If so, please also indicate whether it is clear and unmistakable (i.e., undebatable) that the increase in disability was due to the natural progression of the disease. Please consider a June 1999 Claim for Disability Insurance Benefits – Doctor’s Certificate indicating a diagnosis of calcific tendinitis of the right shoulder, the Veteran’s reports of in-service injury above, and her contention that the physical demands of the military, including hauling heavy boxes and equipment, and physical training, and weapons training, aggravated, weakened, and re-injured a preexisting right shoulder condition. (d.) For each right shoulder disability that had onset after the Veteran’s discharge, please indicate whether it is at least as likely as not that such disability is otherwise related to injuries sustained during her service training periods. (e.) With respect to the Veteran’s service connection claim for a left shoulder disability, is it at least as likely as not (50 percent or greater probability) that the Veteran’s left shoulder disability had onset in or is otherwise related to a period of active service, as described above? (f.) Alternatively, is it at least as likely as not (50 percent or greater probability) that such left shoulder disability was caused or aggravated by her right shoulder disability, to include based on overuse or overcompensation? A clinical rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 2. Obtain medical opinions from appropriate medical professionals regarding the nature and etiology of the Veteran’s rheumatoid arthritis, fibromyalgia, edema of the bilateral lower extremities, insomnia, and migraine headaches. The examiner(s) must review the claims file, to include the medical history outlined in the body of the Remand above. If an examiner or examiners determine that an opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. Based on a review of the record, and if necessary, an examination, the examiner(s) should address the following, as appropriate: (a.) Please provide best estimates as to dates of onset for each of the following disabilities: rheumatoid arthritis, fibromyalgia, edema of the bilateral lower extremities, insomnia, and migraine headaches. Please discuss what in the record helps inform your estimate, and specify whether it is at least as likely as not (50 percent or greater probability) that any of these disabilities had onset during the Veteran’s periods of training. If some of these claimed disabilities are actually symptoms of another disability, and are not stand-alone disorders, this should be made clear wherever applicable. For example, if edema of the lower extremities is a symptom of fibromyalgia and not a manifestation of a separate disease entity, please indicate as much and explain how you know. (b.) For each disability that existed prior to the Veteran’s enlistment in February 2001, or otherwise during a period of nonactive status, please indicate whether it is at least as likely as not that such disability underwent an increase in disability during a period of ACDUTRA and/or INACDURA. If so, please also indicate whether it is clear and unmistakable (i.e., undebatable) that the increase in disability was due to the natural progression of the disease. (c.) For each disability that had onset after the Veteran’s discharge, please indicate whether it is at least as likely as not that such disability is otherwise related to injuries sustained during her service training periods. A clinical rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 3. Obtain a medical opinion from an appropriate medical professional regarding the nature and etiology of the Veteran’s low back disability and sciatica of the left leg. The examiner must review the claims file, to include the medical history outlined in the body of the Remand above. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. Based on a review of the record, and if necessary, an examination, the examiner should address the following: (a.) Please provide a best estimate as to the date of onset for the Veteran’s low back disability and sciatica of the left leg. Please discuss what in the record helps inform your estimate, and specify whether it is at least as likely as not (50 percent or greater probability) that any disability had onset during the Veteran’s periods of training. (b.) For any disability that existed prior to the Veteran’s enlistment in February 2001, or otherwise during a period of nonactive status, please indicate whether it is at least as likely as not that such disability underwent an increase in disability during a period of ACDUTRA and/or INACDURA. If so, please also indicate whether it is clear and unmistakable (i.e., undebatable) that the increase in disability was due to the natural progression of the disease. (c.) For any disability that had onset after the Veteran’s discharge, please indicate whether it is at least as likely as not that such disability is otherwise related to injuries sustained during her service training periods. A clinical rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 4. Obtain a medical opinion from an appropriate medical professional regarding the nature and etiology of the Veteran’s carpal tunnel syndrome. The examiner must review the claims file, to include the medical history outlined in the body of the Remand above. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. Based on a review of the record, and if necessary, an examination, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s carpal tunnel syndrome had onset in or is otherwise related to the Veteran’s active service training periods, to include as due to repetitive use injury, as described in the body of the Remand above. A clinical rationale for all opinions offered is requested as the Board is precluded from making any medical findings. 5. Obtain a medical opinion from an appropriate medical professional regarding the nature and etiology of the Veteran’s pes planus and Achilles tendonitis. The examiner must review the claims file, to include the medical history outlined in the body of the Remand above. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. Based on a review of the record, and if necessary, an examination, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has pes planus and/or ankle tendonitis disabilities that had onset in or are otherwise related to the Veteran’s active service training periods, to include as due to wearing steel toe boots and dress shoes while performing standing watch duty, routine marching, and physical training, as described in the body of the Remand above. 6. Obtain medical opinions from an appropriate medical professionals regarding the nature and etiology of the Veteran’s claimed head injury residuals, to include sleep apnea and a psychiatric disability. The examiners must review the claims file, to include the medical history outlined in the body of the Remand above. If the examiner determines that opinions cannot be provided without examination, the Veteran should be scheduled for such examinations. Based on a review of the record, and if necessary, an examination, the examiners should respond to each of the following, as appropriate: a.) Is it at least as likely as not that the Veteran’s sleep apnea had onset in, or is otherwise related to injury incurred during the Veteran’s active duty training periods, to specifically include her described head injury while training in August 2001? b.) Is it at least as likely as not that the Veteran has a psychiatric disability, to include anxiety disorder and/or bipolar, II disorder, that had onset in, or is otherwise related to injury incurred during the Veteran’s active duty training periods, to specifically include her described head injury while training in August 2001? c.) Is it at least as likely as not that the Veteran has a psychiatric disability, to include anxiety disorder and/or bipolar, II disorder, that is caused or aggravated by another disability, to include service-connected tinnitus? d.) Clarify whether the Veteran suffers any other disabling residuals of her in-service head injury, to include insomnia or headaches. If there medical reason to call into question the Veteran’s report of having suffered a head injury as she has so described in August 2001, please indicate as much and explain. 7. If the benefits sought on appeal remain denied, to include entitlement to a TDIU, issue the Veteran and her attorney a supplemental statement of the case and inform the Veteran of her appeal options. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Mask, Associate Counsel 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.