Citation Nr: 21071998 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 16-30 215 DATE: December 2, 2021 REMANDED The issue of service connection for a right lower extremity disorder, to include right shin splints, is remanded. The issue of service connection for a left lower extremity disorder, to include left shin splints, is remanded. The issue of service connection for a right foot disorder is remanded. The issue of service connection for a left foot disorder is remanded. The issue of service connection for hypertension is remanded. The issue of service connection for a lumbar spine disorder is remanded. The issue of service connection for sleep apnea is remanded. The issue of service connection for migraine headaches is remanded. The issue of service connection for a thyroid disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from December 1990 to April 1991, and in the Air Force Reserve until June 2012. In July 2021, the Veteran was afforded a virtual hearing before the undersigned Veterans Law Judge. 1. The issue of service connection for a right lower extremity disorder, to include right shin splints, is remanded. 2. The issue of service connection for a left lower extremity disorder, to include left shin splints, is remanded. 3. The issue of service connection for a right foot disorder is remanded. 4. The issue of service connection for a left foot disorder is remanded. 5. The issue of service connection for hypertension is remanded. 6. The issue of service connection for a lumbar spine disorder is remanded. 7. The issue of service connection for sleep apnea is remanded. 8. The issue of service connection for migraine headaches is remanded. 9. The issue of service connection for a thyroid disorder is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: In December 2014, the RO denied service connection for the issues on appeal. Later that month, the Veteran submitted a notice of disagreement (NOD), which did not include the issues of service connection for sleep apnea, migraine headaches, or a thyroid disorder. On March 2015 Statement in Support of Claim forms, the Veteran indicated that she was appealing those issues as well. These documents were received before the date on which NODs had to be filed on a particular form. Therefore, the Board finds that they were properly appealed. A statement of the case (SOC) as to those issues has not been provided to the Veteran. Therefore, remand is necessary. See Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). At her Board hearing, the Veteran reported participating in drill activities every month and for two weeks every year from 1990 to 1998. Her complete dates of active duty have not been verified. Additionally, in July 2021, she indicated that some service treatment records (STRs) and service personnel records (SPRs) may be missing from the record. Therefore, remand is necessary to verify her complete dates of service and to obtain any missing STRs and SPRs. At her Board hearing, the Veteran also testified that she may have private treatment records from 1990 to 1998. On remand, she should provide information about any medical treatment she received during that time that is not already of record so that VA can attempt to obtain the records. Lastly, the Veteran has not been afforded VA examinations for her claimed disabilities. Therefore, remand is necessary to obtain the necessary examinations and medical opinions. 2. Issue an SOC to the Veteran and her accredited representative which addresses the issues of service connection for sleep apnea, migraine headaches, and a thyroid disorder. The Veteran should be given the appropriate opportunity to respond to the SOC. 3. Contact the National Personnel Records Center (NPRC) and/or the appropriate service entity and request that it (1) verify the Veteran's complete periods of active service, active duty, active duty for training (ACDUTRA), and inactive duty for training (INACDUTRA) and (2) forward all available STRs and SPRs not already of record for association with her file. Verification of service requires a complete list of all individual dates for which the Veteran had each type of service. A list of points for retirement or general information about the number of days in a month or year of a certain type of service is not sufficient. 4. Advise the Veteran that she may submit any additional medical and non-medical evidence relating to her claimed disorders that is not already in VA's possession. Specifically request authorization to obtain any records of private treatment for the claimed disorders that is not already of record, including those from 1990 to 1998. 5. AFTER COMPLETION OF THE ABOVE AND THE ADDITION OF ANY RECORDS TO THE FILE, schedule the Veteran for all necessary VA examinations to obtain an opinion as to the nature and etiology of her claimed disorders. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Identify each right and left foot disorder which the Veteran currently has or has had at any point during the pendency of this claim. (b.) Identify each right and left lower extremity disorder which the Veteran currently has or has had at any point during the pendency of this claim. (c.) Identify each lumbar spine disorder which the Veteran currently has or has had at any point during the pendency of this claim. (d.) Provide an opinion as to whether each of the following was caused by any active service or active duty event, injury, disorder, or disease, or in any way originated during active service or active duty: i. Each identified right foot disorder. ii. Each identified left foot disorder. iii. Each identified right lower extremity disorder. iv. Each identified left lower extremity disorder. v. Each identified lumbar spine disorder. vi. Hypertension. (e.) Provide an opinion as to whether each of the following was caused by a disease or injury incurred or aggravated during a period of ACDUTRA: i. Each identified right foot disorder. ii. Each identified left foot disorder. iii. Each identified right lower extremity disorder. iv. Each identified left lower extremity disorder. v. Each identified lumbar spine disorder. vi. Hypertension. (f.) Provide an opinion as to whether each of the following was caused by an injury incurred or aggravated during a period of INACDUTRA: i. Each identified right foot disorder. ii. Each identified left foot disorder. iii. Each identified right lower extremity disorder. iv. Each identified left lower extremity disorder. v. Each identified lumbar spine disorder. vi. Hypertension. The examiner's attention is drawn to the following: *August 1989 physical examination for service entrance. VBMS Entry 8/8/2014, p. 55-56. *August 1989 report of medical history at service entrance on which the Veteran reported a history of frequent headaches, dizziness or fainting spells, throat trouble, hay fever, cramps in her legs, broken bones, and car sickness. It was noted that she broke her right shoulder as a child. VBMS Entry 8/16/2014, p. 34-35. *March 1991 STR stating that the Veteran had shin splints and right arch pain, and that she had complaints of pain in the lower legs and in the feet that had been ongoing for 3 to 4 months. VBMS Entry 8/16/2014, p. 55. *March 1991 physical profile due to shin splints and stating that she was to do no marching, running, or jumping. The profile was set to end in April 1991. VBMS Entry 8/4/2014, p. 1. *April 1993 examination in which the Veteran's feet, lower extremities, and spine were normal, and on which her blood pressure was noted to be 100/60. VBMS Entry 8/16/2014, p. 19-20. *April 1993 report of medical history on which the Veteran reported recurrent back pain and on which it was noted that the Veteran was in a motor vehicle accident in 1992 and injured her back. VBMS Entry 8/16/2014, p. 21-22. *February 1998 examination indicating only a partial thyroidectomy. VBMS Entry 8/16/2014, p. 7. *February 1998 medical record addendum noting a 1995 partial thyroid removal and high blood pressure. VBMS Entry 8/16/2014, p. 9. *May 2002, May 2003, April 2005, May 2014, and April 2016 health risk assessments indicating only that the Veteran had a partial removal of her thyroid gland in 1995. VBMS Entries 8/16/2014, p. 2-5, 76-79, 81-88, 90-93. *April 2006 and June 2007 physical profiles indicating no physical symptoms or injuries. VBMS Entry 8/16/2014, p. 71, 75. *March 2008 STR stating that the Veteran had untreated hypertension. VBMS Entry 8/16/2014, p. 4. *March 2008 Reserve Component Periodic Health Assessment stating that the Veteran was not qualified for worldwide duty because she needed treatment for hypertension. VBMS Entry 9/11/2014, p. 1. *May 2008 dental STR stating that the Veteran had hypertension. VBMS Entry 8/16/2014, p. 51. *August 2009 private treatment record stating a diagnosis of hypertension. VBMS Entry 8/13/2014, p. 5. *December 2010 private treatment record stating that the Veteran fell out of bed and landed on a treadmill injuring her back and shoulder. VBMS Entry 3/17/2015, p. 12. *May 2011 Department of the Air Force Memorandum stating that the Veteran had a medical condition which required limitations in her workplace or other life activities. The memorandum stated that an encrypted email would be sent with further details. A handwritten note on the document states "back, leg pains." VBMS Entry 12/20/2014. *May 2011 statement from the Veteran's spine physician that she was being treated for cervical, thoracic, and lumbar spine. VBMS Entry 7/21/2014. *May 2011 STR stating a diagnosis of lumbago. VBMS Entry 8/16/2014, p. 35. *May 2011 private treatment records from the Veteran's spine physician stating that she had low back pain; pain, numbness, and weakness in the bilateral lower extremities; and stating diagnoses of lumbar pain, contusion of the back, and lumbar radiculopathy. VBMS Entry 11/7/2014, p. 1-2. *August 2011 private treatment record stating a diagnosis of lumbago. VBMS Entry 3/17/2015, p. 51. *August 2013 private treatment record stating that the Veteran had lumbar spine pain and was in physical therapy. VBMS Entry 3/17/2015, p. 84. *July 2014 statement from the Veteran that she injured both of her legs and feet in basic training because of daily marching and in which she described the history of the disorders. *September 2014 private treatment records from the Veteran's spine physician stating a diagnosis of thoracic-lumbar scoliosis. VBMS Entry 11/25/2014, p. 6. *September 2014 private treatment record which states that the Veteran reported that her back pain began in 1990 when she was in basic training. VBMS Entry 1/16/2015, p. 12. *December 2014 NOD on which the Veteran provided the history of and what she believed was the nexus to service for her disorders. *December 2014 private treatment records stating that the Veteran had chronic bilateral foot pain and decreased ankle mobility and stating a diagnosis of plantar fasciitis. VBMS Entry 1/16/2015, p. 1-2. *December 2014 private treatment record stating that the Veteran had a more-than-15-year history of bilateral foot pain which was diagnosed as plantar fasciitis, and that she was constantly in pain. VBMS Entry 7/21/2021, p. 3. *March 2015 NOD on which the Veteran reported that she began taking medication for hypertension while on active duty. *March 2015 internet article about back pain, chronology of the Veteran's back symptoms, and Statement in Support of Claim describing the history of her back symptoms. *March 2015 internet article about hypertension, chronology of the Veteran's hypertension treatment, and Statement in Support of Claim describing the history of her hypertension. The Veteran stated that she believed hypertension was caused by being overweight, and that she was overweight because of the limitations caused by her chronic foot and leg pains which began in service. *March 2015 internet article about plantar fasciitis, chronology of the Veteran's foot and lower extremities symptoms, and Statements in Support of Claim describing the history of her symptoms and stating that her symptoms began while on active duty. *August 2015 private foot clinic treatment record stating that the Veteran reported that she was diagnosed with plantar fasciitis and shin splints while in basic training. VBMS Entry 1/23/2016, p. 1. *August 2015 private treatment record stating a diagnosis of bilateral plantar fasciitis with associated heel spur syndrome and infracalcaneal bursitis and gastrocnemius equinus contracture and bilateral pronation. VBMS Entry 7/21/2021, p. 8. *July 2021 Board hearing where the Veteran stated that her right and left foot pain and right and left leg pain began in basic training, that she first reported it in March 1991, and that it had continued since that time. She stated that back pain began in 1992 or 1994 because of marching and lifting boxes of medical records at her Reserve job, and that she first reported her symptoms in 1998. She also stated that hypertension began while in the Reserve. She stated that she did not report many of her symptoms for fear of being recycled out and because the military culture was not to report symptoms. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. E. Miller, Counsel The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.