Citation Nr: 21064322 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 16-53 634 DATE: October 19, 2021 REMANDED Entitlement to service connection for fibromyalgia, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1994 to June 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated April 2015 and July 2016 of the Department of Veterans Affairs (VA) Regional Office (RO). The April 2015 rating decision denied service connection for fibromyalgia. The Veteran filed a notice of disagreement (NOD) in August 2015 and a statement of the case (SOC) was issued in September 2016. She perfected a timely appeal in October 2016. The July 2016 rating decision denied service connection for disabilities of the right hip and low back. The Veteran filed a NOD in October 2016 and a SOC was issued in May 2017. She perfected a timely appeal in June 2017. In July 2021, the Veteran presented sworn testimony during a virtual hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. 1. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected PTSD, is remanded. The Veteran asserts entitlement to service connection for fibromyalgia, which she contends is secondary to service-connected PTSD. See, e.g., the Board hearing transcript dated July 2021. The Veteran's treatment records document a diagnosis of fibromyalgia. See, e.g., the private treatment records dated September 2012 and VA treatment records dated October 2014. A VA medical opinion was obtained in April 2015. The VA examiner reviewed the VA claims file and opined, "[V]eteran has muscle aches, tenderness, pain, etc., as noted above. [V]eteran has diagnosis of Hashimoto's and, as above, this disease can cause joint and muscle pain, fatigue, etc." The examiner continued, "neither Hashimoto's [n]or fibromyalgia is caused by mental disorder. [T]hus, it is less likely than not that Veteran's fibromyalgia and/or Hashimoto's is due to any type of mental disorder." In support of her contentions of secondary service connection, the Veteran submitted multiple internet articles describing an association between fibromyalgia and PTSD including an article entitled, 'Prevalence of PTSD in Fibromyalgia Patients: Overlapping Syndromes or Post-Traumatic Fibromyalgia Syndrome." Critically, the April 2015 VA examiner did not document a review of medical literature to include any of the articles subsequently submitted by the Veteran. Moreover, the April 2015 VA examiner failed to address the question of whether the Veteran's diagnosed fibromyalgia is aggravated by her service-connected PTSD. Accordingly, the Board finds that the evidence of record is inadequate to resolve the claims of entitlement to service connection for fibromyalgia. This matter must be remanded to obtain a VA medical opinion to address outstanding questions of nexus and aggravation. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made). 2. Entitlement to service connection for a right hip disability, to include as secondary to low back disability, is remanded. 3. Entitlement to service connection for a low back disability is remanded. The Veteran asserts entitlement to service connection for disabilities of the low back and right hip. She claims that she suffered from these disabilities as a result of in-service physical assaults stemming from conceded military sexual trauma. See, e.g., the Board hearing transcript dated July 2021; see also the Veteran's claim dated April 2016. Specifically, she contends that she was stomped and beaten up on multiple occasions, after reporting the military sexual assault. Id. She has alternatively argued that her right hip disability is secondary her low back disability. See the NOD dated October 2016. The Veteran's Report of Medical History at enlistment documented her endorsement of 'recurrent back pain.' However, her September 1994 enlistment examination did not document any abnormalities of the back or spine. Service treatment records (STRs) dated in October noted complaints of fatigue, congestion, and upper back pain between the shoulder blades; physical examination was normal. An October 1997 STR noted the Veteran's complaint of back pain related to urinary complaints. Notably, although the RO has conceded the Veteran's assertion of military sexual trauma (see the rating decisions dated December 2001 and September 2018), her STRs do not document any back or right hip complaints, including related to physical assaults. Magnetic resonance imaging (MRI) of the right hip performed in May 2015 revealed, "[s]mall ossicle superior relative to right greater trochanter likely the sequelae of a prior avulsion of the gluteus medius insertion." Mild gluteal tendinosis was also documented. MRI of the lumbar spine dated in March 2016 revealed, "Grade 14 anterolisthesis L4 upon L5. Probably L5 spondylosis. Facet arthropathy L4-S1. Minor degenerative changes about the discs." In support of her claim, the Veteran submitted an April 2016 letter from Dr. A.A., who stated, "I cannot exclude that this may have been caused from trauma that she endured during her time in the military." Dr. A.A. continued, "[i]n my medical opinion, her chronic low back pain started seven years ago. She endured repeated physical attacks to her low back including kicking, punched, and slammed against walls." Critically, Dr. A.A.'s medical opinion was admittedly speculative and his conclusion was based upon the Veteran's self-report without a benefit of a review of the clinical evidence. As such, this opinion is of little probative value. The Veteran has not been afforded a VA medical opinion as to her low back and right hip claims. As such, the Board finds that these matters must be remanded to obtain VA medical opinions addressing outstanding questions of nexus. The matters are REMANDED for the following action: 1. Refer the VA claims file to a medical professional with appropriate expertise to provide an opinion as to the claimed fibromyalgia. The examiner is requested to review the relevant evidence of record. The examiner should then address the following: (a). With respect to the diagnosed fibromyalgia, is it at least as likely as not that the identified disability was incurred in the Veteran's active duty service, or manifested within a year of her active duty discharge? (b). If not, is it at least as likely as not that the fibromyalgia was caused by the service-connected PTSD? (c). If not, is it at least as likely as not that the Veteran's fibromyalgia is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by service-connected PTSD? If the Veteran's fibromyalgia is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of her observable symptoms over time. Should the examiner decide that a physical examination of the Veteran is required to address these questions, such should be scheduled. 2. Refer the VA claims file to a medical professional with appropriate expertise to provide an opinion as to the claimed low back and right hip disabilities. The examiner is requested to review the claims file in its entirety including all service treatment records, VA, and private treatment records. The examiner should then address the following: (a). Whether it is at least as likely as not that the diagnosed low back and right hip disabilities began during the Veteran's active service or are related to an in-service injury, event, or disease? In rendering this opinion, the examiner must address whether the Veteran's disabilities were incurred as a result of her conceded military sexual trauma? The examiner must also consider the Veteran's description of her in-service symptoms and injuries as well as her post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injuries and symptoms in service and thereafter represented the onset of her current low back and/or hip disabilities, this should be noted. Stated another way, do the Veteran's reports about her symptoms align with how the disabilities are known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? The examiner should note that the absence of evidence of treatment for a disability in the Veteran's service treatment records should not serve as the sole basis for a negative opinion. Should the examiner decide that a physical examination of the Veteran is required to address these questions, such should be scheduled. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, 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.