Citation Nr: 21066029 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 18-45 366 DATE: October 28, 2021 ORDER As new and material evidence has been received, the petition to reopen the claim for service connection for left hip disability is granted. Entitlement to service connection for left hip disability is denied. Entitlement to a rating in excess of 10 percent for Graves' disease is denied. FINDINGS OF FACT 1. In an unappealed May 2015 rating decision, the RO denied service connection for left hip disability. 2. Evidence received since the May 2015 denial relates to unestablished facts necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. 3. A left hip injury or disability was not shown to have been incurred during military service and the Veteran's current left hip disability is not shown to be related to service. 4. The Veteran's Graves' disease/hypothyroidism has required continuous medication but has not been manifested by fatigability, constipation, and mental sluggishness during the appeal period. CONCLUSIONS OF LAW 1. The May 2015 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 2. The criteria for reopening of the claim for service connection for left hip disability have been met. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156(a), 20.1103. 3. The criteria for entitlement to service connection for left hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 3.309. 4. The criteria for a rating in excess of 10 percent for Graves' disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.13, 4.14, 4.119, Diagnostic Code (DC) 7903. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training from July 1991 to December 1991 and on active duty from January 2005 to November 2005, including service in Southwest Asia with additional service in the Reserve. This matter is on appeal before the Board of Veterans Appeals (Board) from December 2016 and May 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, a Board hearing was held before the undersigned; a transcript of the hearing is of record. 1. Whether new and material evidence has been received to reopen the claim of service connection for left hip disability. In a May 2015 rating decision, the RO, in pertinent part, denied service connection for left hip disability. The basis for the denial was that the disability was determined to result from a known clinical diagnosis of degenerative arthritis, which was neither incurred in nor was caused or aggravated by service The Veteran did not submit a valid notice of disagreement with this decision within one year of its issuance. Moreover, no new and material evidence was received by VA within one year of the decision. As such, the rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362, 13676 (Fed. Cir. 2011). In August 2016, the Veteran filed a petition to reopen the service connection claim. Since the May 2015 rating decision, evidence added to the record includes the Veteran's September 2020 Board hearing testimony, where he indicated that he had actually developed an injury to his hip from doing physical training prior to deployment in Iraq along with his actual duty in Iraq and that the hip continued to bother him since that time, initially on an intermittent basis but ultimately progressing to regular and severe symptomatology. This evidence is new as it was not of record at the time of the final May 2015 rating decision. It also tends to indicate that the Veteran suffered left hip injury during service and that there might be a relationship between that injury and his current left hip disability. Thus, this new evidence is also material as it relates to unestablished facts necessary to substantiate the claim for service connection (i.e. injury in service and a nexus between current disability and service) and under the low applicable evidentiary standard, raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156; Shade v. Shinseki, 24 Vet. App. 110. Accordingly, new and material evidence has been received since the May 2015 rating decision and the claim for service connection for left hip disability may be reopened. 2. Entitlement to service connection for left hip disability. The Veteran alleges that his current left hip disability is related to all the PT exercise he had to perform during service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the currently claimed disability - which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain listed, chronic disabilities, including arthritis, are presumed to have been incurred in service if they become manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Veteran's service treatment records do not show any findings or complaints of hip problems. In a March 2005 Reservist Medical History Processing Form, the Veteran reported that he had no history of bone, back or joint disorders and no chronic pain problems. He also indicated that he had no medical condition that might interfere with recall to active duty. On an August 31, 2005 post-deployment health assessment, the Veteran reported that he was in excellent health and his health had stayed the same or gotten better during deployment. He indicated that he did not currently have any swollen, stiff, or painful joints and he did not develop any such problem during deployment. On a subsequent September 2005 report of medical assessment, the Veteran reported that he did not have any ongoing medical issues and that his overall health was the same as compared to his last medical assessment/physical examination. He noted that since his last medical assessment/physical examination, he had not been seen or treated by a health care provider. He also noted that he had not suffered from an injury while on active duty for which he did not seek medical care. At a September 2007 private endocrinology visit, the Veteran received a general physical examination, which included a musculoskeletal evaluation. It was noted that this evaluation specifically included the head, neck, spine, ribs, and pelvis, along with the upper and lower extremities. The clinician found that the Veteran's station and gait, joint inspection/palpation, range of motion and manual muscle testing were all within normal limits. The clinician also noted that the Veteran was suffering from hand tremors. In a November 2008 military personnel memorandum, it was noted that based on medical information and recommendation, the Veteran had been found temporarily not physically qualified in ready reserve. The Veteran had been assigned physical risk classification 4 pending final determination of fitness for retention and was not currently authorized to perform inactive duty training, annual training, or active duty training. The supporting Naval Occupational and Support Center medical department was to resubmit a current physical evaluation and address current suitability for military service. A December 2008 VA medical problem list includes hip pain as a current medical problem. In a July 2009 letter, the Veteran's private treating physician indicated that he received radioactive iodine treatment (RAI) for Graves' disease, a form of hyperthyroidism, in September 2007. It was noted that the RAI treatment destroyed the thyroid gland, leading to the Veteran switching from a hyperthyroidism state to a hypothyroidism state. The Veteran's condition had then been completely stabilized since the beginning of his treatment with Synthroid (i.e. a thyroid hormone replacement therapy). Thus, he did not have any physical limitations, his weight had returned to baseline and he was currently suitable for military service. Private medical records show that at a January 2014 family medicine visit, the Veteran reported that for exercise he ran and walked three times per week. The Veteran reported musculoskeletal complaints, including left hip pain. He noted that he had received physical therapy and that this had not been helpful, and he wanted to see an orthopedist. The pertinent diagnosis was pelvic arthralgia. The treatment plan was for him to follow up with an orthopedist. At a January 2015 follow-up visit, the Veteran again presented with musculoskeletal complaints, including joint pain, joint stiffness and left hip pain. He noted that it hurt for him to walk but he could run without pain. Physical examination showed mild tenderness in the left hip. At a March 2015 VA history and physical examination, the Veteran reported that he had had left hip pain present for many years that had gotten worse in the previous two years. He reported that the pain was almost daily and was aggravated by prolonged walking and standing. He indicated that at times, the hip seemed to lock up and he was unable to bear weight on it. He noted that he was employed by the fire department. The diagnostic assessment was chronic left hip pain. A subsequent March 2015 VA left hip X-ray produced a diagnostic impression of mild to moderate degenerative changes of the left hip joint. At a May 2015 VA examination, the diagnosis was degenerative arthritis of the left hip. The Veteran reported that the condition was diagnosed in 2005. He noted increasing pain in his left hip while he was stationed in Gulfport, Mississippi for combat training. He denied that he received any treatment for his hip while on active duty. He reported that X-rays were ultimately performed through his primary care provider and that he was prescribed physical therapy. He also noted that he had had recent X-rays through VA. The Veteran reported intermittent pain several times per month and denied flare-ups. He noted that he had pain with fast movements and that he could no longer run. Physical examination showed some decreased abduction and adduction, external rotation, and internal rotation of the hip. The examiner noted that traumatic arthritis of the left hip had been shown on X-ray. The examiner indicated that the functional impact of the hip disability was that the Veteran was no longer able to run and had pain with extended walking and standing. In a May 2015 VA medical opinion, the clinician found that the Veteran had diagnoses with clear and specific etiologies. Therefore, it was less likely than not that the Veteran's currently assessed disabilities, to include his left hip disability, were related to any exposure event experienced by the Veteran during service in Southwest Asia. In an August 2016 claim, the Veteran appeared to report that his left hip degenerative arthritis was related to exposure to environmental hazards during the Gulf War. At an August 2016 VA orthopedic visit, the Veteran reported that he had had hip pain dating back 10 years with increased pain for the past two years. He indicated that he currently had difficulty walking and even putting shoes on and that his hip pain was severe. The orthopedist found that X-rays had shown probable avascular necrosis of the left femoral head. However, an MRI was to be performed for further assessment. At a subsequent October 2016 VA orthopedic visit, it was noted that MRI had been done three weeks previously, which revealed no avascular necrosis, just degenerative joint disease with questionable impingement. The Veteran was noted to have limited flexion and rotation of the hip and pain with extremes of motion. The treatment plan was use of NSAIDs for pain and the Veteran was noted not to be a current candidate for a total hip arthroplasty. In a February 2017 statement, the Veteran reported that during his appointment with the orthopedic physician at the VA medical center, the physician evaluated the Veteran's hip x-rays from 2014 and 2016, and after comparing the two, he diagnosed his condition as being avascular necrosis of the femoral head due to the limited range of motion during abduction and flexion along with severe pain and the presence of an abnormal femoral head. The Veteran indicated that the doctor stated that the x-rays indicated that his hip condition resembled that of a sports injury and could have been the result of years of exercising, running, and jumping during military training. The Veteran noted that his condition had gotten worse since retiring from the Reserve, with an increased limitation on range of motion, including his inability to lace his left shoe. He reported that he was currently walking with a limp. In a September 2017 statement, the Veteran reported that he had been treated by several physical therapists for his left hip problems and they had all concluded that his condition had gotten worse as he continued to perform physical fitness in conjunction with his military duties. In a November 2017 statement, the Veteran reported that after 23 years of service in a combat unit, his condition had been classified as equivalent to a sports injury likely caused by physical and tactical training endured throughout his career. He indicated that his orthopedist from VA initially diagnosed his condition as avascular necrosis (AVN) of the femoral head and stated that the condition was worsened by the running and jumping during his military training exercises. In a July 2018 statement, the Veteran reported that he served with the Navy Seabees for 23 years until his retirement in August 2014. He noted that his role as a Seabee was physically demanding and required routine exercise and running capability. At the September 2020 Board hearing, the Veteran reported that as a construction mechanic during service, he worked on heavy equipment and also went through tactical training, weapons qualifications and annually went on field exercises. Additionally, he noted that he was a certified fitness leader for the Navy. Thus, during the first part of his Navy career, he was always physically able. The Veteran testified that he had to bend and squat to reach difficult places to repair things during service and during field exercises, he carried backpacks and 50 to 60-pound sea packs on his back. He noted that he got activated in January 2005 and was deployed to Iraq sometime around March 2005. Then he returned from deployment in November 2005. The Veteran reported that during deployment in Iraq in 2005, he saw a physician for several different conditions, including his hip. He noted that about 5 years previously, he had been given a copy of service treatment records on a disk, which included X-rays of the hip, which he turned over to VA, but nobody could ever read the disk. However, the Veteran emphasized that he had two X-rays during deployment, one for his index finger, which he broke while in Ramadi and one for his hip. The Veteran also indicated that military medical personnel were aware of his hip even at the time that he demobilized in West Virginia. However, there had been problems finding documentation of this. The Veteran testified that he began having problems with his hip while engaging in pre-deployment training in Gulfport, Mississippi. He indicated that he was there for about 30 days doing 5-mile marches and other PT every day. Thus, by the time he reached Iraq, he noticed during PT that his hip pain was actually starting to get bad. He noted that at that time he would have about a day or so of severe pain but then it would stop after a while. He also noted that the pain at the time was nowhere as severe as it was currently, and he received something like Motrin from medical personnel to help ameliorate it. The Veteran indicated that he went to his personal physician for the problem about a month after he returned home from deployment and that over time his symptoms had progressed. The Veteran also reported that he had found in his records the November 2008 notation that indicated he was assigned a risk classification of 4, 'pending final determination of fitness for retention" and appeared to report that this assessment had been done because of his left hip problem. He also noted that because of this, he was not authorized to perform inactive duty training, annual training, or active duty training. The Veteran testified that his VA orthopedist informed him that his hip condition reminded him of a sports injury. The Veteran noted that he had never played sports in his life but that his duty in the Seabees involved similar physical exertion. He also noted that after his period of active duty ending in November 2005, he was activated again in November 2009, but his orders were cancelled due to his physical limitations. The Veteran indicated that he served in the Seabees from 1991 to 2014, for 23 years. The Veteran indicated that during this time, he did tactical training similar to Marine training, along with specific job training. He noted that for his entire career he was a mechanic and that he served every year, in most cases two to six weeks a year going on different training exercises with his home port in Gulfport. He also noted that he drilled once a month as a reservist. Additionally, he reported that during his time in the Reserve, he worked for the city. A July 2021 private operative report shows that the Veteran underwent total left hip replacement surgery. The above summarized medical evidence does not show that the Veteran experienced a left hip injury during service. In this regard, the service treatment records are negative for any left hip problems. As noted above, on his March 2005 Reservist Medical History Processing Form, he reported that he no history of bone back or joint disorders and no chronic pain problems, and indicated that he had no medical condition that might interfere with recall to active duty. Also, on the September 2005 report of medical assessment, the Veteran reported that he did not have any ongoing medical issues. There is also no medical evidence suggesting a nexus between current left hip disability and the Veteran's military service. In this regard, the only medical opinion of record to address the likely etiology of the Veteran's current left hip disability, the May 2015 VA opinion, found it was less likely than not that the Veteran's current left hip disability was related to any exposure event experienced during service in Southwest Asia. The Veteran has testified that he began having problems with his hip during pre-deployment training in Gulfport in early 2005; that by the time he reached deployment in Iraq, the pain had gotten severe; and that the left hip problem continued ever since that time, progressing and worsening. He also reported that during deployment in Iraq in 2005, he saw a physician for his hip and that X-rays were taken. Additionally, he referred to a service personnel record from November 2008, indicating he had been assigned a physical risk classification of 4, pending final determination of fitness and retention and appeared to report that this assessment had been done for his hip problem. The Board notes, however, that on the September 2005 report of medical assessment, the Veteran reported that he did not have any ongoing medical issues, noted that since his last medical assessment/physical examination, he had not been seen by or treated by a health care provider, and noted that he had not suffered from any injury while on active duty for which he did not seek medical care. Also, on the earlier August 31, 2005 post deployment health assessment, the Veteran specifically classified that his health as excellent, indicated that his health had stayed the same or gotten better rather than worse, indicated that he did not currently have any swollen stiff or painful joints, and had not developed any such problems during deployment. Additionally, at the September 2007 private medical visit, the Veteran received a physical examination, including a musculoskeletal assessment, which included the hips, which showed normal station and gait, joint inspection and palpation, range of motion and manual muscle testing. Moreover, the Board notes that the November 2008 personnel record noted by the Veteran does not identify the physical condition resulting in the final determination of fitness and retention being pending; that the private treatment records show that during this time frame, the Veteran was recovering from September 2007 radioactive iodine therapy (RAI) therapy for Graves' disease with subsequent ongoing thyroid hormone replacement therapy (i.e. thyroxine); and that in the subsequent July 2009 letter, the Veteran's treating physician indicated that his current condition had stabilized, he did not have any physical limitations and he was currently suitable for military service. Thus, given that the November 2008 personnel record is essentially contemporaneous to the Veteran receiving and recovering from the RAI therapy and being stabilized on thyroid replacement therapy, it is reasonable to conclude that the November 2008 personnel record pertains to the need to assess the Veteran's fitness vis a vis his thyroid condition and does not pertain to any left hip problem. Given the specific lack of report of any hip problems or treatment for such problems on the August 2005 post deployment assessment and September 2005 report of medical assessment; given the specific finding of normal hip function found at the post-service private medical musculoskeletal assessment in September 2007; and given that the November 2008 pending determination of physical fitness for military duty is reasonably shown to have been related to the Veteran's Graves' disease/thyroid condition, the Board is not able to credit the Veteran's reporting that he began having problems with his left hip during pre-deployment training in Gulfport in early 2005; that the condition progressed to severe pain during deployment that was accompanied by a medical visit and X-ray findings; and that the left hip problem continued ever since that time, progressing and worsening. Instead, the Board must credit the history of the left hip condition indicated by the medical evidence, which shows a first indication of pelvic pain in 2008 with specific finding of mild to moderate degenerative changes in March 2015, a subsequent MRI finding of degenerative joint disease of the left hip in approximately September 2016, and a total hip arthroplasty performed in July 2021. The Veteran has also reported that he has been to several physical therapists and that all had concluded that his left hip condition had gotten worse as he continued to perform military physical fitness training over the years. He also reported that his treating physician concluded that his hip condition was worsened by the running and jumping during his military training exercises. The Board notes, however, that there are no medical opinions of record from this doctor or any physical therapists, which even suggest that the Veteran's current left hip disability was caused or aggravated by his military service, including his periods of active duty or reserve service. The Board presumes that had a doctor or a physical therapist rendered such an opinion, it either would be documented in the treatment records or the clinician rendering the opinion would have provided the Veteran with a statement to that effect. In the absence of such documentation, the Board is not able to credit his report of these clinicians finding possible causation and/or aggravation of the Veteran's left hip disability by military service. Instead, the Board must credit the medical evidence, which once again, does not suggest that the Veteran's current left hip disability was caused or aggravated by military service. The Board also notes that the Veteran testified that he was originally ordered to active duty in November 2009 but that his orders were cancelled due to him not being physically fit to serve due to his left hip disability. The Board notes that there is no documentation of record of any such physical unfitness secondary to any hip problem. Also, given the lack of credibility of reporting noted above, the Board is also unable to credit this report. Additionally, the report itself does not indicate that any hip problem had resulted from military activity as opposed to the Veteran's civilian life. In sum, because a left hip injury was not shown during military service, and because the Veteran's current left hip disability is not otherwise shown to have been caused by military service or to have been aggravated by military service, the preponderance of the evidence is against this claim and it must be denied. 3. Entitlement to a rating in excess of 10 percent for Graves' disease. Service connection for hypothyroidism was granted by an April 2015 Board decision and implemented by an August 2015 rating decision. A 10 percent rating has assigned effective December 2, 2008. In a June 2016 rating decision and subsequent December 2016 rating decision, the RO continued the 10 percent rating. In a May 2018 rating decision, the RO again continued the 10 percent rating, noting that the underlying disability had been recharacterized as Graves' disease. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran's Graves' disease is rated under Diagnostic Code 7903 for hypothyroidism. Under this Code, a 10 percent rating is warranted for hypothyroidism involving fatigability, or continuous medication required for control. A 30 percent rating is warranted for hypothyroidism involving fatigability, constipation, and mental sluggishness. A 60 percent rating is warranted for hypothyroidism involving muscular weakness, mental disturbance, and weight gain. A 100 percent rating is warranted for hypothyroidism involving cold intolerance, muscle weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119. In a September 2007 letter, a private endocrinologist indicated that he had evaluated the Veteran for Graves' disease. The Veteran reported that the problem had started when he was in Iraq. He noted that he had had unexplained weight loss and was still consistently losing weight. He also noted that he had experienced increased frequency of bowel movements, along with palpitations, tachycardia, and hand tremors. The assessment was hyperthyroidism, likely secondary to Graves' disease and the Veteran opted for radioactive iodine (RAI) treatment. A November 2007 private progress note shows that the Veteran was seen for follow up status post RAI therapy. It was noted that he had started taking Synthroid and had resolution of symptoms, including palpitations and diarrhea. He did report tiredness with easy fatigability. In a December 2007 physician's recommendations/limitations for civilian employment and/or military duty, it was noted that a current physical examination was normal and that the Veteran was feeling better. It was also noted that the Veteran would be taking Synthroid for the rest of his life. Additionally, it noted that no limitations had been placed on the Veteran and that he was able to perform the duties of his civilian position. A February 2008 private progress note shows that the Veteran was seen for follow-up status post RAI treatment. It was noted that he was continuing to take Synthroid and that he did not have any chest pain or shortness of breath, palpitations, diarrhea, constipation, dysphoria, or dysphagia. In the July 2009 letter, the Veteran's private treating physician indicated that the Veteran received RAI for Graves' disease, a form of hyperthyroidism, in September 2007. It was noted that the RAI treatment destroyed the thyroid gland, leading to the Veteran switching from a hyperthyroidism state to a hypothyroidism state. The Veteran's condition had been completely stabilized since the beginning of his treatment with Synthroid. Thus, he did not have any physical limitations, his weight had returned to baseline and he was currently suitable for military service. VA treatment records from October 2015 to January 2016 show some treatment and evaluation for Graves' disease/hypothyroidism. At an October 2015 visit, the Veteran was noted to have Graves' disease and current hypothyroidism and that he had come in for a refill of Synthroid. It was also noted that he was not currently experiencing any problems. At a subsequent January 2016 visit, it was noted that his thyroid levels had remained quite fluid; that he had recently been taking 175 Mcg of Synthroid with a marginally low TSH level and a normal free T4 level. No associated symptoms were noted, and the Veteran was to be seen for follow-up in 180 days. At an August 2015 private medical visit, it was noted that the Veteran had presented for hypothyroidism follow-up. It was also noted that he had no history of cold intolerance, fatigue, muscle weakness or muscle cramps and no other symptoms associated with the hypothyroidism were noted. The Veteran also specifically denied the presence of any gastrointestinal symptoms, to include constipation. Similar findings were presented at January 2017 and September 2017 medical visits. At the September 2017 visit, the Veteran did report fatigue, but this was associated with diabetes not with hypothyroidism. In a September 2015 statement in support of claim, the Veteran indicated that he was seeking a higher, 60 percent rating for his hypothyroidism due to the fluctuation in his TSH levels, which caused him to be hyperthyroid as often as he was hypothyroid. He noted that this condition caused a constant increase in his heart rate, a fluctuation in his mood and emotions and had affected his ability to function regularly on a daily basis due to extreme fatigue. The Veteran noted that his medication for his thyroid changed periodically causing the hyperthyroid and hypothyroid condition to interchange repeatedly. He indicated that this was an unstable fluctuation that would require constant management. The Veteran noted that he had received B12 injections for constant fatigue and weakness but that these injections had only created high levels of B12 in his system without improving his symptoms. He also noted that he had been prescribed Metoprolol to control his increased heart rate and periodic heart palpitations. He indicated that his condition had caused him to have irregular bowel movements so that he would either be constipated or have diarrhea. He noted that additional symptoms included rapid weight loss, fatigue, and hypertension. The Veteran also reported that the fluctuation in TSH levels had affected his ability to regulate his body temperature, causing rapid fluctuation from extremely hot to extremely cold. He noted that the condition also caused unstable emotions and that he had been prescribed medications for depression over the previous 8 years but had been unable to take these medications consistently due to an increased feeling of paranoia and sluggishness. He indicated that other periodic symptoms associated with his condition included nervousness, tremors, weight fluctuation and inability to focus or concentrate. At a March 2016 VA examination, the diagnoses were Graves' disease and hypothyroidism. The Veteran reported that he was having a fluctuation of his TSH and T4, that he was taking prescription Synthroid and that his prescribed amount changed at least once a year. He indicated that he was alternating doses of the medication on even and odd days but was currently taking the same dose every day. The examiner noted that this continuous medication was required for control of the Veteran's condition. The examiner also noted that the Veteran reported that tachycardia was his major symptom associated with his condition but that it was not as bad as it had been after the initial diagnosis. He indicated that he was taking Metoprolol for this problem. The examiner noted that he was not able to locate a prescription for Metoprolol in the record. The Veteran described the functional impact of his condition as he was tired throughout the day during his work for the city and he also had sluggishness. He indicated that when he was lifting things, he was tired more of the time. He noted that sometimes he felt that he was missing the drive or energy ("get up") that he used to have. He also noted that sometimes he went from his body feeling cold to breaking a big sweat and that this was a very uncomfortable feeling, especially during work. Additionally, he reported that his tachycardia would sometimes make him feel like his heart was racing away. He indicated that on these occasions, he had to slow himself down some. Moreover, he reported that he suffered from irregular bowel movements and he felt that this would always be a problem associated with his condition. During a March 2016 VA mental disorders examination, the examiner noted that symptoms attributable to the Veteran's mental disorder included sleep impairment. The Veteran reported that he had not had a good night's sleep in 10 years. He noted that he had had sleep studies and had been given medications to help him sleep in the past, including Doxepin, an antidepressant. In an August 2016 statement, the Veteran indicated that he was seeking a 100 percent rating for his hypothyroidism/Graves' disease. He indicated that he suffered from cold intolerance, inability to regulate his body temperature, muscular weakness, fatigue. mental disturbance, high cholesterol, weight gain and constipation. Regarding muscular weakness and fatigue, the Veteran indicated that he was unable to perform any strenuous activities such as running, lifting, and carrying. He also reported that he had arm and leg trembles when attempting to perform such physical activities. He noted that since he had been diagnosed with hypothyroidism, his cholesterol levels had undergone an extreme increase for which he needed to take medication. He also noted that he had been under observation for his fluctuating heart rate, which had caused him to have occasional chest pains. Regarding weight gain, he indicated that since he had been diagnosed, he had gained 51 pounds, his weight increasing from 142 to 193. Regarding constipation, he noted that this condition had also been directly linked to his hypothyroidism and that he was currently taking Docusate to treat it. At an August 2016 VA examination, the diagnoses were hypothyroidism and Graves' disease. The Veteran reported that his TSH level fluctuated and that as a result, the dosage of his medication changed throughout the year. The examiner noted that the Veteran reported that the signs and symptoms attributable to his thyroid condition included constipation, depression, the need to take continuous medication, sleepiness, and cold intolerance. The examiner commented that regarding the sleepiness, the Veteran reported somnolence during the day; however, he also reported that he did not sleep at night due to PTSD. Regarding the cold intolerance, the Veteran reported that he felt cold throughout the week. Regarding functional impairment, the Veteran reported somnolence and fatigue during the day with the examiner noting that a sleep study had been ordered and that the Veteran had the history of PTSD. The Veteran also reported hot flashes after taking his levothyroxine in the morning. At an August 2016 VA primary care behavioral health initial evaluation, the Veteran reported that he was seeing his private provider for his thyroid disease. He noted that the provider had him taking Synthroid doses that alternated with him taking 0.75 mg one day and then 0.15 mg the next day. The Veteran indicated that this had worked well to help him with his thyroid symptoms. The Veteran reported poor sleep, indicating that he fell asleep well but woke up startled around 3 to 4 AM daily. He was prescribed hydroxyzine for the sleep impairment. At September 2017 and November 2017 VA medical visits, the Veteran denied any gastrointestinal symptoms, to include constipation or diarrhea. At a June 2017 VA PTSD examination, the Veteran reported persisting hypothyroidism that had resulted in several medication changes, persisting constipation, and persisting diarrhea. The Veteran's PTSD symptoms were noted to include anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances. At a November 2017 VA contract examination, the Veteran was diagnosed with Graves' disease with hypothyroidism. The examiner noted that the Veteran did not have any current symptoms and was continuing to take Synthroid. Physical examination did not produce any abnormal findings. The examiner found that the Veteran's condition did not impact his ability to work. On his September 2018 Form 9, the Veteran indicated that at his most recent compensation and pension examination, the physician noted that he had developed a puffy face and baggy eyes. The Veteran reported that these conditions had been linked to his hypothyroidism. Additionally, he again reported that he had suffered from the discomforts of constipation and abnormal bowel movements, which had also been directly linked to his hypothyroidism and that he was currently taking Docusate and Sennosides for this problem. At the September 2020 Board hearing, the Veteran testified that he had been taking medication for constipation since approximately 2007 and that the constipation was related to his Graves' disease/thyroid condition. The Veteran also reported that he had suffered from fatigue since 2008 or 2009 and treating clinicians had tried to manage this by continuously changing the level of his Synthroid medication but this had not really helped. Additionally, he noted that he felt his Graves' disease was not being managed effectively through treatment with Synthroid because his treating clinicians were constantly having to adjust the medication, which they informed him was pretty much to be expected. He indicated that he was currently having labs done every 4 to 6 months to check his thyroid levels and they tended to always fluctuate. The Veteran also testified that the Graves' disease/thyroid condition caused mental sluggishness. In this regard, he indicated that treating physician had told him that his thyroid problem was possibly causing this symptomatology while also indicating that the level of mental sluggishness he was experiencing was consistent with the severity of his PTSD. The Veteran noted that the thyroid condition did impact his occupational functioning as he would get up two hours earlier to take his Synthroid medication in order to manage his body temperature before going to work. Also, there were times when he had missed work or had to do a shortened work-day due to the Graves' disease. In this regard, he indicated that around midday, he would feel very sluggish and there were several days when he had to leave early from work or miss work entirely because he simply felt too tired/fatigued. The Veteran's representative pointed out at the hearing that the August 2016 VA examination included notations that the Veteran's thyroid condition was manifested by constipation, fatigability, and mental tiredness and that this symptomatology should entitle him to a higher, 30 percent rating. The above summarized medical evidence generally indicates that during the appeal period, the Veteran's Graves' Disease/hypothyroidism, while requiring ongoing Synthroid therapy, has been largely asymptomatic. In this regard, neither the private treatment records or VA treatment records show any significant symptomatology associated with the disability and generally do not include findings of fatigability, constipation or mental sluggishness resulting from the hypothyroidism. Similarly, at the November 2017 VA contract examination, the examiner specifically found that the Veteran did not have any symptoms attributable to his hypothyroidism and that the condition did not impact his ability to work. Notably, at the March 2016 VA examination, the Veteran reported that tachycardia was the major symptom associated with his hypothyroidism and that he was taking Metoprolol for this problem. However, the examiner pointed out that a review of the record did not show the Veteran having been prescribed Metoprolol. Similarly, on review of the record, the Board finds that tachycardia was shown to be occurring before the Veteran underwent the RAI therapy in September 2007 but is not shown in the medical documentation during the appeal period. The March 2016 VA examiner also noted that the Veteran reported tiredness and sluggishness, his body changing quickly from feeling cold to feeling hot and experiencing irregular bowel movements. Additionally, at the August 2016 VA examination, the Veteran reported that his thyroid condition resulted in constipation, depression, sleepiness, and cold intolerance. Further, at the June 2017 VA PTSD examination, the Veteran reported that persisting hypothyroidism that had resulted in several medication changes, persisting constipation, and persisting diarrhea. However, once again, the VA and private treatment records do not document any such symptomatology associated with the hypothyroidism during the appeal period. In this regard, cold intolerance is not documented in these treatment records as a hypothyroid symptom during the appeal period. Also, tiredness and fatigue have been attributed to the Veteran's psychiatric disability, his diabetes and/or to potential sleep apnea. Similarly, to the extent the Veteran has suffered from depression, it has not been attributed to Graves' disease/hypothyroidism in these treatment records. The Veteran also reported various symptoms associated with his hypothyroidism in his September 2015 and August 2016 statements, his September 2018 Form 9 and in his September 2020 Board hearing testimony, including increase in heart rate, periodic palpitations, fluctuation in mood and emotions, fatigue, irregular bowel movements with either constipation or diarrhea, rapid weight loss, hypertension, rapid fluctuation in his body from hot to cold, with inability to regulate his body temperature, nervousness, tremors, weight fluctuation, inability to focus or concentrate, muscular weakness, high cholesterol, inability to perform any strenuous activities and puffy and baggy eyes. Once again the Board notes that VA and private treatment records pertaining to the Veteran's hypothyroidism, while indicating that the Veteran has required some adjustment in his medication, do not show any significant symptomatology associated with the condition. The Board presumes that had the Veteran been experiencing the above reported symptoms during the appeal period and believed that they were caused by his hypothyroidism, he would have reported them to his treatment providers when being seen for his hypothyroidism. In the absence of such reporting in the context of this treatment, the Board is not able to credit the Veteran's reporting as an accurate account of symptoms associated with the hypothyroidism. Instead, the Board must credit the findings shown in VA and private treatment records, which generally indicate that while requiring continuous medication and adjustments thereof, the Veteran's hypothyroidism has been predominantly asymptomatic during the appeal period. The Board notes that while there are VA examination notations summarized above indicating symptoms associated with the Graves' disease/hypothyroidism, including constipation, fatigability, and mental sluggishness, these are based on the Veteran's self-reporting, which as explained, is not deemed credible. In sum, the most probative evidence of record indicates that during the appeal period, the Veteran's Graves' disease/hypothyroidism has required continuous medication but has not been shown to result in constipation, fatigability, and mental sluggishness. Accordingly, a higher 30 percent rating for the disability is not warranted and the claim for increase must be denied. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dan Brook, 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.