Citation Nr: 21061681 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 15-27 459A DATE: October 5, 2021 ORDER Entitlement to an effective date prior to March 29, 2013, for the grant of service connection of migraine headaches is denied. Entitlement to an initial rating in excess of 50 percent for service-connected migraine headaches is denied. Entitlement to service connection of viral meningitis is denied. Entitlement to service connection of a left hand disability, claimed as a pinched nerve, is denied. Entitlement to service connection of bilateral plantar fasciitis is granted. REMANDED Entitlement to service connection of an acquired psychiatric disability, diagnosed as posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection of a left shoulder disability is remanded. Entitlement to service connection of a cervical spine disability is remanded. Entitlement to service connection of a left elbow injury, claimed as a pinched nerve is remanded. Entitlement to service connection of peripheral enthesopathy, claimed as shin pain, is remanded. Entitlement to service connection of polyuria is remanded. Entitlement to service connection of a lumbar spine disability is remanded. Entitlement to service connection of a skin disability, claimed as tinea pedis and toenail fungus is remanded. Entitlement to service connection of a skin condition, claimed as acne, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU). FINDINGS OF FACT 1. The Veteran did not submit a claim of service connection or any other written correspondence indicating an intent to file for service connection of migraine headaches prior to March 29, 2013. 2. The Veteran's migraine headache disorder is rated as 50 percent disabling, which is the maximum schedular rating available for that disorder; the symptoms of her migraine headache disorder are contemplated by the diagnostic criteria. 3. The Veteran does not have a present diagnosis of viral meningitis or any residuals thereof; she was not diagnosed with viral meningitis during any period of active duty service. 4. The Veteran does not have a left hand pinched nerve or other left hand disability which is separate and distinct from her claimed ulnar neuropathy, affecting the elbow; the ulnar neuropathy claim is remanded, below. 5. The Veteran's bilateral plantar fasciitis was diagnosed in service with continuity to the present. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to March 29, 2013, for the grant of service connection of migraine headaches have not been met. 38 U.S.C. §§ 5101, 5107, 5110; 38 C.F.R. §§ 3.155, 3.400. 2. The criteria for a disability rating in excess of 50 percent for migraines have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8100. 3. The criteria for service connection for viral meningitis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a left hand disability, claimed as a pinched nerve, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for bilateral plantar fasciitis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January to August 2008, with additional periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2014 and September 2016 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, and July 2019, the Veteran testified at hearings before the undersigned Veterans Law Judge. Transcripts of those hearings are of record. The Board notes that the Veteran has not explicitly claimed TDIU at this time. However, a claim of TDIU is part and parcel of an increased rating when reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). Although the increased rating claim for headaches has been granted in full, the evidence of record suggests that the Veteran's service-connected disabilities may interfere with her ability to obtain and maintain employment. As such, the Board has included entitlement to TDIU as part of the appeal. Earlier Effective Dates Generally, except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date which the entitlement arose, whichever is later. See 38 U.S.C. § 5110 ; 38 C.F.R. § 3.400. The effective date of an original award of direct service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, it is the date of receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110 ; 38 C.F.R. § 3.400(b)(2)(i). 1. Entitlement to an effective date prior to March 29, 2013, for the grant of service connection of migraine headaches The Veteran has appealed the effective date of the grant of service connection of migraine headaches. The Board finds that the claim should be denied. The evidence of record indicates that claims of service connection for a headache condition, as well as multiple other disabilities, were submitted to VA on March 29, 2013. While the Board does recognize that several days prior to that, the Veteran submitted several documents from a treating physician, as well as evidence of vocational rehabilitation applications through the State of Rhode Island, that correspondence did not include any actual indication of a desire to claim service connection of any specific condition. In this case, the earliest evidence of a claim for service connection for any disability is March 29, 2013. The evidence does not indicate that the Veteran intended to submit a claim of service connection in the year prior to the date of formal claim. Indeed, with the exception of the vocational rehabilitation documents submitted on March 22, 2013, there are no communications from the Veteran during this period, or at any time prior to the March 29, 2013, claim. In light of this, the Board finds that the earliest possible date of service connection of migraine headaches is March 29, 2013, the date the claim for that disability was received by VA. As such, the earlier effective date claim is denied. Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's bilateral hearing loss, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. 2. Entitlement to an initial rating in excess of 50 percent for the Veteran's service-connected migraine headaches The Veteran was granted service connection of a migraine headache disorder and assigned a 30 percent disability rating. In a February 2018 rating decision, the RO granted an increased rating of 50 percent from the date of service connection. She seeks a higher rating. The Veteran's disability is rated under Diagnostic Code (DC) 8100, which specifically compensates for migraine headache disorders. Under the applicable rating criteria, a maximum 50 percent rating is assigned for migraine headaches with frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. No higher rating is provided. 38 C.F.R. § 4.124a, DC 8100. In this matter, the Veteran has been afforded the maximum schedular rating for all periods on appeal, and therefore, there is no basis upon which to assign a higher schedular rating. Therefore, an increased schedular rating beyond 50 percent for migraine headaches is denied. To accord justice in the exceptional case where the criteria in VA's Rating Schedule are found to be inadequate, an extraschedular rating that is commensurate with the average earning capacity impairment caused by the service connected disability is warranted. 38 C.F.R. § 3.321 (b)(1). Such a rating is warranted when the case presents such an unusual disability picture with related factors such as marked interference with employment as to render impractical the application of the regular schedular standards. Id. When the Board finds that an extraschedular rating may be warranted based on the above factors, it cannot grant an extraschedular rating in the first instance. Anderson v. Shinseki, 23 Vet. App. 423, 428-429 (2009). Rather, it must remand the claim to the Agency of Original Jurisdiction (AOJ) for referral to the Director of Compensation Service (Director). See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The United States Court of Appeals for Veterans Claims (Court) has set out a three-part test, based on the language of 38 C.F.R. § 3.321 (b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. All three criteria must be met for referral for an extraschedular rating. Id. If the Board finds that the Veteran has not met the criteria set forth in Thun, then it is not required to remand for initial extraschedular consideration, and the increased rating claim is denied. In this case, the Board does not find referral is warranted. The Veteran's migraine headaches have been manifested by episodes of migraine pain. For her part, in the hearing before the undersigned, the Veteran did not assert any symptoms beyond those already addressed by the rating criteria, but merely asserted that her migraines continued to plague her, and that she required treatment with injections every few months, as well as oral medication to control them. When questioned whether she had any new symptoms associated with migraines, the Veteran asserted just that her symptoms continue to exist. In this case, the Board finds that such symptoms do not take the Veteran's case outside the norm as to require consideration of a higher evaluation on an extraschedular basis. The Veteran's symptoms are exactly the type anticipated by the schedular criteria, and the schedular criteria already anticipates significant interference with economic adaptability. Therefore, referral for extraschedular consideration is not warranted.\ Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may 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). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including arthritis and other organic diseases of the nervous system, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Regardless of whether a disability is considered "chronic" for presumptive purposes, a continuity of symptoms from the time of service is a factor to consider in assessing the claim. The presumptive regulations, 38 C.F.R. §§ 3.307 and 3.309, as well as the presumptions of soundness and aggravation, attach independently to each period of service. However, presumptive regulations do not apply to periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA), even where the claimant had a prior period of active duty. See Smith v. Shinseki, 24 Vet. App. 40 (2010). Generally speaking, service connection may be granted for a disease or injury incurred in or aggravated during a period of ACDUTRA. For periods of INACDUTRA, service connection may be granted for a disease or injury incurred in or aggravated in the line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 C.F.R. § 3.6(a). Only service department records can establish if and when a person was serving on active duty, ACDUTRA, or INACDUTRA. Venturella v. Gober, 10 Vet. App. 340 (1997). 3. Entitlement to service connection of viral meningitis The Veteran seeks service connection of viral meningitis. The Board finds that the claim should be denied. The Veteran asserts she contracted viral meningitis due to a spinal puncture, during a period of ACDUTRA in 2011. Initially, the Board does not find any evidence of a present disability manifested by vital meningitis or residuals thereof. With the exception of a 2011 record where the Veteran self-reported viral meningitis, and a subsequent notation of that history, there is no evidence in the record that the Veteran was ever actually diagnosed with that disability, or that she has any present symptoms or residuals of meningitis. As such, the claim fails the primary criterion of service connection, namely, a presently diagnosed disability. Additionally, there is no evidence in the record that she was ever actually diagnosed with meningitis during a period of active service. The evidence suggests that she served a period of ACDUTRA in August 2011. Of record is a medical billing statement indicating she underwent a spinal puncture on August 19, 2011, as well as other radiology services. Also of record is an August 19, 2011, statement of medical examination and duty status, for which the Veteran complained of a worsening headache since physical training with the National Guard. That record also indicated a history of cervical disc disease, headache for four days, worsened by physical training. A sword statement dated September 30, 2011 by the Veteran states that she was required to undergo a spinal puncture for her headaches and she was diagnosed with viral meningitis at that time. Notably, although a cervical spine and headache disorder were documented at that time, and a spinal puncture is confirmed via billing statements, there is no evidence of any actual diagnosis of meningitis during a period of active duty service. Here, although ancillary diagnoses and treatments are noted, these do not actually confirm a diagnosis of meningitis. A viral meningitis is a complex disease requiring specialized testing and treatment by a qualified medical specialist to confirm. The only evidence of such a diagnosis in the record is the Veteran's own lay statements that she was diagnosed with that condition. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, when addressing complex diagnoses such as meningitis, the diagnosis and etiology of that disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran, as a lay person, is not competent to provide such a diagnosis. Absent some actual medical evidence that she was diagnosed with meningitis during a period of active service, the Board must conclude that she did not suffer such an in-service illness. Finally, there is no evidence of record linking any present meningitis or residuals thereof (as noted above, there is no such evidence of any such present diagnosis or residuals), to any incident of active service. The Board recognizes in this matter that the Veteran has not been afforded a VA examination in connection with this claim. However, absent evidence of a present disability, as well as evidence of a confirmed in-service illness, the duty to assist does not require VA to obtain such an examination in this matter. 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In sum, the Board finds that there is no evidence of a present meningitis or residuals thereof, nor any evidence of an in-service diagnosis of meningitis. As such, the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 4. Entitlement to service connection of a left hand disability, claimed as a pinched nerve The Veteran seeks service connection of a left hand disability, claimed as a pinched nerve. The Board finds that the claim should be denied. Initially, the Board does not find any evidence of a presently diagnosed hand disability. Although ulnar neuropathy was noted upon examination in 2013, that diagnosis generally applies to the elbow, although there is some indication that the symptoms in this case extend to the wrist. There is no evidence of any actual functional disability or diagnosis affecting the left hand itself in the record. To the extent that the Veteran has testified before the undersigned that the symptoms affect both the elbow and hand, the ulnar neuropathy diagnosis is remanded for further development, below. However, the Board does not find evidence of any actual hand disability at this time, which is separate and distinct from the ulnar neuropathy, and the claim fails the primary criteria of service connection. Additionally, the Board has reviewed the Veteran's service treatment records and finds no evidence of any specific injury to her hand during active duty service. The Board recognizes the Veteran's assertion that her condition is related to use of an M16 weapon during service, and that she first experienced symptoms in service. While she is competent to report observable symptoms such as nerve pain, once basic competency is met, the Board must assess the general credibility of the lay evidence. In this case, despite seeking treatment for multiple other complaints such as headaches, shin pain, foot pain, back pain, and neck pain, she never complained of any issues affecting her left hand. Rather, her assertions were made years after she separated from her period of active duty in 2008. There is no indication of any actual nerve or hand injuries during any period of ACDUTRA. As such, the Board also finds that the record does not support any type of in-service nerve pain in the hand or other hand injury. See Caluza v. Brown, 7 Vet. App. 498 (1995) (giving factors to consider when assessing the credibility of lay evidence, to include facial plausibility, internal consistency, consistency with other evidence, and self-interest or bias). In sum, the Board does not find that the Veteran has a present pinched nerve or any other left hand disability which is separate and distinct from the ulnar neuropathy remanded below. As such, the claim fails the general criteria for a grant of service connection and must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 5. Entitlement to service connection of bilateral plantar fasciitis The Veteran seeks service connection of bilateral plantar fasciitis. The Board finds the claim should be granted. The Veteran was afforded a VA examination in August 2016. At that time the examiner diagnosed with bilateral plantar fasciitis, with a date of diagnosis given as 2008 for both feet. The Veteran's service treatment records from 2008 indicate complaints of foot pain, with a diagnosis of right plantar fasciitis. The examiner stated that it would be speculative to state that the current plantar fasciitis is due to her military service. However, the examiner then states that she was diagnosed in 2008 while 40 years old, which would give the date of onset as during her period of active duty service. It was also noted that the Veteran continued to show mild plantar fasciitis and sought treatment with physical therapy in 2013, confirming her reports of symptoms from the time of service. The Veteran was not found to have any foot diagnoses upon entrance to active service in December 2007, and therefore her feet are considered sound upon entry. Regardless of whether a condition was specifically caused by an incident of active service, if the disability is first diagnosed during active service, and there is evidence that the same condition persists to the present, service connection should be granted. Given the physical nature of a plantar fasciitis, it is unlikely that it would resolve entirely, only to reappear at a later date. In this case, the evidence suggests the Veteran was first diagnosed with the condition in 2008, as confirmed by the 2016 examiner, during a period of active duty service. She continued to seek treatment in 2013 and 2016 for the same symptoms and her diagnosis was confirmed on both occasions. As such, the Board will afford the Veteran the benefit of the doubt and grant service connection of bilateral plantar fasciitis as being incurred in service. REASONS FOR REMAND Inasmuch as the Board regrets further delay in the adjudication of this appeal, a remand is necessary to ensure proper development of the following issues. 1. Entitlement to service connection of an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD) is remanded. The Veteran seeks service connection of PTSD, which she asserts is the result of an in-service assault. Initially, the Board recognizes that an assault is documented in the record, and VA has conceded that it took place during her period of active duty service in 2008. The Court of Appeals for Veterans Claims (Court) has held that a claim of service connection for PTSD encompasses any possible other psychiatric diagnoses which may account for the Veteran's reported symptoms. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this case, the record indicates various diagnoses to include bipolar disorder, depression, anxiety, and various substance abuse disorders. The Veteran was afforded a PTSD examination in 2016, which diagnosed that disability, and found it likely related to the in-service stressor. However, the examiner stated that opinion was based solely on the self-report of subjective symptoms, as there was no objective evidence in the record to support the frequency and severity of the Veteran's claimed symptoms. The Board finds this problematic for several reasons. Initially, the Board recognizes that the record includes several years of psychiatric treatment records, which the examiner does not appear to have considered in assessing the claim. Additionally, the examiner appears to rely upon an incorrect medical history as reported by the Veteran. Specifically, although the Veteran reported in her examination that her cocaine and alcohol use began after her in-service assault, she has reported to VA treatment providers on other occasions that such substance use began many years prior to her entering active duty service. Additionally, that examination report did not address her various other diagnoses in the medical record. Although other diagnoses are noted, she has not been evaluated for those conditions as related to active service. Because a psychiatric claim includes any possible related diagnoses, and because the PTSD examination is not based on a complete review of the medical record, but only the Veteran's subjective reports of symptoms and history, the Board would request that a complete psychiatric profile be completed which fully assesses the Veteran's psychiatric claim. 2. Entitlement to service connection of a left shoulder disability is remanded. The Veteran was afforded a VA examination in August 2016. At that time the Veteran was diagnosed with arthritis of the left shoulder. The examiner then concluded that the Veteran's present shoulder arthritis was not aggravated by service. The Board finds this opinion to be inadequate to fully adjudicate the claim. The examiner bases the conclusion that the present arthritis was not aggravated by service on the premise that the Veteran fractured her shoulder as a child. However, her enlistment examination from 2007 did not list a shoulder disability upon entrance to service, so even if a shoulder fracture occurred prior to service, there was no diagnosis of arthritis at that time, and her shoulder was presumed sound upon entry absent some clear and convincing evidence that the present arthritis preexisted her period of active service. The examiner failed to address whether or not the present arthritis clearly and unmistakably preexisted service, and therefore any opinion based on aggravation is inadequate. Additionally, after the Veteran's shoulder was found sound at entrance, there is evidence of a left shoulder injury in service. Presuming there is no evidence that the present arthritis preexisted service, the examiner has not opined whether the present arthritis of the left shoulder is at least as likely as not related to that in-service injury. As such, on remand, an addendum opinion should be obtained which fully assesses the Veteran's claimed shoulder condition. 3. Entitlement to service connection of a cervical spine disability is remanded. The Veteran seeks service connection of a cervical spine disability. The evidence does not document any cervical spine issues during her initial period of active duty service in 2008. However, during a period of ACDUTRA in 2011, she was noted to have a pre-existing cervical spine disability. She also complained of increased neck pain during that period of time. The Veteran was afforded a VA examination in November 2013, which confirmed a diagnosis of degenerative disc disease. The examiner then concluded that the current condition was less likely than not caused by any incident of active service. In support of this, the examiner stated "[t]here is no documentation in her record to indicate that she sought treatment or had any complaints of neck condition or headaches related to her training with the [G]uard in August 2011." However, since the time of that examination the Veteran has submitted records indicating that she made such complaints and did seek treatment for increased neck pain at that time. As such, on remand, an addendum opinion should be obtained which addresses any possible causation or aggravation of her present cervical spine condition by the period of service in 2011. 4. Entitlement to service connection of a left elbow injury, claimed as a pinched nerve is remanded. The Veteran seeks service connection of a left elbow injury, which she has claimed as a pinched nerve. Notably, the Veteran has not asserted that her elbow disability is related to any other disability, but rather it was the result of shooting heavy guns during her various periods of training. While the Board has found that there was no hand injury related to any gun use in service, above, the Board does note that the 2013 cervical spine examination indicated ulnar neuropathy as the cause of the Veteran's elbow and associated wrist symptoms. Unfortunately, that examination report was unclear as to whether this neuropathy is secondary to the degenerative disc disease of the cervical spine. As such, the Board will also remand this claim as potentially intertwined with the cervical spine claim. On remand, an addendum opinion should be obtained which clarifies the cause of the Veteran's ulnar neuropathy. 5. Entitlement to service connection of peripheral enthesopathy, claimed as shin pain is remanded. The Veteran seek service connection of shin pain. To date, the Veteran has not been afforded a VA examination in connection with her claim. The claim has been denied based on a lack of present diagnosis. In her hearing before the undersigned, the Veteran has testified to ongoing lower leg pain, also potentially associated with her feet (it is noted that the Veteran has granted service connection of plantar fasciitis, above). The Veteran is competent to report observable symptoms such as pain. Based on the Veteran's competent reports of present shin pain, and in-service diagnosis of peripheral enthesopathy, and recent service connection of plantar fasciitis, the Board finds that the duty to assist in providing an examination has been triggered. 6. Entitlement to service connection of polyuria is remanded. The Veteran seeks service connection of polyuria. The Board recognizes that the Veteran's service treatment records from 2008 document at least one diagnosis of polyuria. To date, she has not been afforded a VA examination, and the claim has been denied based on a lack of a present diagnosis of any chronic urinary condition. However, the Veteran has testified before the undersigned that she experiences urinary frequency. She has also attributed this to her various psychiatric diagnoses. The Veteran is competent to report observable symptoms of a disability, such as urinary frequency. In light of this, the Board finds that the duty to assist in providing an examination has been triggered. 7. Entitlement to service connection of a lumbar spine disability is remanded. The Veteran seeks service connection of a lumbar spine disability. She was scheduled for an examination in February 2018, however, the RO was unable to reach the Veteran and the requested examination was cancelled. Although her VA Vocational Rehabilitation program took additional steps to update the contact information for the Veteran, it is unclear whether the Veteran was ever adequately notified of her low back examination, or what additional steps were taken to notify her that such an examination had been scheduled. Despite being unavailable while the RO attempted to schedule this examination, the Veteran has continued to pursue her claims to the Board and engage activity in her appeals, to include multiple other examinations. Thus, with adequate notice via her present contact information, there is no indication that she might not appear for her examination. The evidence suggests she has a present low back disability or symptoms. There are complaints of low back pain during her initial period of active service in March 2008, and also sought treatment for back pain during a period of ACDUTRA in September 2010. As such, an examination should be scheduled which fully assesses the Veteran's low back claim. In remanding this appeal for an examination, the Veteran is notified that the duty to assist is not a one-way street, and any further failure to appear for her low back examination may result in the denial of her appeal. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) . 8. Entitlement to service connection of a skin disability, claimed as tinea pedis and toenail fungus is remanded. The Veteran seeks service connection of a skin disability, claimed as tinea pedis and toenail fungus. The record indicates that in July 2008, during her period of active duty, the Veteran sought treatment for athlete's foot. In her hearing before the undersigned, the Veteran attested to ongoing symptoms of foot fungus or athletes foot, and a review of her VA treatment records indicate ongoing treatment for dry skin and other possible toenail pathology as recently as March 2017. Despite this, the RO has denied the claim based on a lack of diagnosis of a present foot disability. To date, she has not been afforded a VA examination in connection with her claim. Because the evidence suggests an initial diagnosis of athletes foot in service, and at least some evidence of present toenail symptoms, the Board finds that the duty to assist has been triggered in this matter, and a VA examination should be scheduled which assesses the Veteran's claim. 9. Entitlement to service connection of a skin condition, claimed as acne is remanded. The Veteran seeks service connection of acne, which she has attributed to her psychiatric stress. Because the claim for a psychiatric disorder is remanded for further development, the Board will also remand this appeal as intertwined. 10. Entitlement to TDIU is remanded. The Board has found a claim of TDIU to be part of the increased rating claim for headaches which was previously part of this appeal prior to being granted in full. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, some additional development is necessary, to include requesting employment history from the Veteran, and to assign ratings for the claims granted above. The matters are REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of her appeal. Request that the Veteran submit a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). 2. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any posttraumatic stress disorder (PTSD), as well as any other psychiatric diagnoses. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. In this matter, it is conceded that the Veteran was assaulted during service in 2008. If any other acquired psychiatric disorders are diagnosed other than PTSD, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the in-service assault. A rationale should accompany any opinion given. 3. Obtain an addendum opinion from a qualified examiner to assess the Veteran's left shoulder arthritis. The examiner should review the complete claims file and determine whether the Veteran's left shoulder arthritis, as diagnosed at this time, clearly and unmistakably preexisted service. If so, the examiner should state whether that condition was aggravated by active service. If the examiner finds that the present arthritis did not preexist active service, they should state when the present arthritis had onset, and whether that occurred during her period of active service in 2008, or within one year of separation thereafter. The examiner should also state whether the present arthritis is at least as likely as not related to any incident of active service, to include the 2008 shoulder injury. A rationale should accompany any opinion given. 4. Obtain an addendum opinion from a qualified examiner to assess the Veteran's cervical spine degenerative disc disease. The examiner should review the complete claims file and state whether it is at least as likely as not that the Veteran's degenerative disc disease was aggravated by her period of ACDUTRA in 2011. In providing the opinion, the examiner is requested to discuss the medical records indicating the Veteran sought treatment for increased neck pain at that time. The examiner is also requested to state whether the Veteran's ulnar neuropathy is either cause or aggravated by the cervical spine disability. A rationale should accompany any opinion given. 5. Schedule the Veteran for an examination to assess her complaints of shin pain. The examiner should review the complete claims file and take a history from the Veteran. The examiner should then state whether the Veteran has a presently diagnosed condition associated with her shin pain complaints. For each diagnosed shin condition, the examiner is requested to state whether it is at least as likely as not related to her in-service diagnosis of peripheral enthesopathy. The examiner should also state whether the present condition is either caused or aggravated by the service-connected plantar fasciitis. A rationale should accompany any opinion given. 6. Schedule the Veteran for an examination to assess her complaints of polyuria and urinary frequency. The examiner should review the complete claims file and take a history from the Veteran. The examiner should then state whether the Veteran has a presently diagnosed condition associated with her urinary frequency complaints. For each diagnosed genitourinary condition (if found), the examiner is requested to state whether it is at least as likely as not related to her in-service diagnosis of polyuria in 2008. A rationale should accompany any opinion given. 7. Schedule the Veteran for an examination to assess her low back disability. The examiner should review the complete claims file and take a history from the Veteran. The examiner should then state whether the Veteran has a presently diagnosed condition associated with her low back pain. If the diagnosed disability falls under the diagnostic umbrella of "arthritis," the examiner should state whether the condition had onset during, or within one year of separation from active service. For each diagnosed disability, the examiner is requested to state whether it is at least as likely as not related to her in-service complaints of low back pain in 2008 or 2010. A rationale should accompany any opinion given. 8. Schedule the Veteran for an examination to assess her tinea pedis and foot fungus claim. The examiner should review the complete claims file and take a detailed history from the Veteran of her symptoms. The examiner should then state whether the Veteran has a present skin condition affecting her feet. For each diagnosed skin condition of the feet, the examiner is requested to state whether it is at least as likely as not related to her July 2008 diagnosis of athlete's foot. A rationale should accompany any opinion given. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel