Citation Nr: 21010942 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 17-17 362 DATE: February 26, 2021 REMANDED Entitlement to service connection for headaches, to include as secondary to post-traumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a gastrointestinal condition, however diagnosed, to include as secondary to PTSD, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps in 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from July 2015 and June 2017 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In September 2020, the Veteran testified at a hearing before the undersigned via videoconference. A transcript of her testimony has been associated with the claims file. As a preliminary matter, the Board notes that although the Veteran initially filed a claim for entitlement to service connection for ulcers secondary to service-connected PTSD, the record reflects a current diagnosis of gastroesophageal reflux disease. As such, the Board has widened the scope of the claim from ulcers to a gastrointestinal condition, however diagnosed, secondary to PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Knees and back Having reviewed the Veteran’s hearing testimony, the Board notes that it appears that there are outstanding private treatment records that have not yet been associated with the claims file. To that end, the Veteran testified that she had a long history of knee and back pain and that she began seeing private doctors to treat these problems after she was discharged for service. She stated that she had not yet tried to obtain these records. In the interest of assembling clear findings, the Board finds that additional remand is warranted so that the RO can make reasonable attempts to obtain any relevant, outstanding private treatment records. Additionally, with respect to the Veteran’s knees, she testified that her knees were injured during service when she was attacked by a male soldier, who punched her, knocked her to the ground, and kicked her. The record contains lay statements describing this attack, and the Board notes that service connection has been granted for PTSD stemming from this assault. As such, the record contains evidence of a current disability in both knees, as well as credible evidence of an in-service injury. To date, however, the Veteran has not been afforded a VA examination in connection with her claim. On remand, the RO should thus schedule a VA examination with respect to her claims for bilateral knee disabilities. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Headaches The Veteran also testified with respect to her history of headaches, which she says had their onset after her in-service assault and have continued since service. She also stated that she went to the infirmary to receive treatment for them. Additionally, at the time of her hearing, she was set to undergo additional tests with VA treatment providers in connection with her headaches. However, the most recent VA treatment records in the claims file are from April 5, 2017. As such, it appears that there are outstanding VA treatment records that must be obtained. Moreover, in the interest of assembling clear and reliable findings, remand is necessary to afford the Veteran a VA examination with respect to the nature and etiology of her headaches. See McLendon, 20 Vet. App. at 83-86. Furthermore, the Veteran has consistently reported that her headaches began only after her in-service assault, which suggests that they could be secondary to her service-connected PTSD. On examination, the examiner is thus asked to consider both direct and secondary theories of entitlement to service connection for headaches. 3. Gastrointestinal condition Last, the Veteran contends that she is entitled to service connection for a gastrointestinal condition secondary to her PTSD. To that end, she has testified that after she was attacked during service, she began having stomach problems that have been ongoing since that time. She reported that she has acid reflux and that she previously had ulcers, which required surgery. In addition, she testified that she would also throw up and pass blood. The Veteran was afforded a VA examination with respect to her claim for ulcers in May 2017. At that examination, the VA examiner reviewed her medical history and noted that she had symptoms such as nausea and heartburn. The examiner also noted that she had been treated in the past for stomach ulcers, and that she also had a history of acid reflux. Ultimately, the examiner opined that there was no current evidence of ulceration in her stomach and that it would have been impossible to identify the exact nature and etiology of her stomach condition immediately following service because no formal medical records from that time were available. Additionally, the examiner stated that although the Veteran had been diagnosed with gastritis in the early 2000s, this was attributable to medications to treat orthopedic conditions. However, the examiner did not offer any opinions with respect to the etiology of the Veteran’s other current stomach conditions, such as acid reflux. Moreover, the examiner failed to opine as to whether those conditions were caused or aggravated by her service-connected PTSD. Accordingly, remand is warranted to obtain an addendum VA medical opinion that contains a sufficiently detailed rationale addressing all raised theories of entitlement. The matters are thus REMANDED for the following action: 1. After obtaining appropriate authorization, obtain and associate with the claims file any outstanding VA treatment records and any outstanding, relevant private treatment records related to the Veteran’s claims. 2. After the development in the first instruction is completed, schedule the Veteran for VA examinations with an appropriate examiner(s) with respect to the nature and etiology of her claimed headache and knee disabilities. The Veteran’s claims file and a copy of this remand should be furnished to the examiner(s), who should indicate that he or she has reviewed the claims file in its entirety. With respect to the claim for bilateral knee disabilities, the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the disabilities had their onset during or otherwise are related to her active service. This includes an opinion as to whether her knee disabilities are related to an in-service physical assault. With respect to the claim for headaches, the examiner is asked to do the following: (a.) Identify any relevant conditions that have been present at any time the claim was filed or at any point during the pendency of this appeal. Any necessary tests and/or studies should be performed. (b.) For any relevant condition identified, opine as to whether it at least as likely as not (50 percent or greater probability) had its onset during or is otherwise related to her active service. In this regard, specifically consider her reports that she sought treatment for headaches during service. (c.) For any relevant condition identified, opine as to whether it is at least as likely as not (50 percent or greater probability) either (1) caused, or (2) aggravated by service-connected PTSD. “Aggravation” is defined as worsening beyond the natural progression of the disability. The examiner is reminded that causation and aggravation are distinct concepts that must be addressed separately. (d.) If the examiner determines that a relevant condition has been aggravated by the Veteran’s PTSD, provide, to the extent possible, an opinion as to the approximate baseline level of the severity of the disability before the onset of the aggravation. A complete rationale for these opinions should be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In providing these opinions and their accompanying rationales, the examiner(s) is reminded to address the Veteran’s lay statements regarding the onset of her conditions. Additionally, a lack of events recorded in service treatment records cannot be the sole basis for a negative medical opinion. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. More specifically, the examiner must explain whether the inability to provide a more definitive opinion is due to a need for additional information, the examiner’s lack of personal knowledge or training, or the limits of current medical knowledge. 3. After the development in the first instruction is completed, obtain an addendum medical opinion from an appropriate examiner with respect to the nature and etiology of the Veteran’s claimed gastrointestinal condition. If additional VA examination is necessary, a new VA examination to determine the nature and etiology of the Veteran’s condition must be obtained instead. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate that he or she has reviewed the claims file in its entirety. After reviewing the claims file, the examiner is asked to do the following: (a.) Identify any relevant gastrointestinal conditions that have been present at any time the claim was filed or at any point during the pendency of this appeal. (b.) For any relevant condition identified, opine as to whether it is at least as likely as not (50 percent or greater probability) either (1) caused, or (2) aggravated by service-connected PTSD. “Aggravation” is defined as worsening beyond the natural progression of the disability. The examiner is reminded that causation and aggravation are distinct concepts that must be addressed separately. (c.) If the examiner determines that a relevant condition has been aggravated by the Veteran’s PTSD, provide, to the extent possible, an opinion as to the approximate baseline level of the severity of the disability before the onset of the aggravation. A complete rationale for these opinions should be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In providing these opinions and their accompanying rationales, the examiner(s) is reminded to address the Veteran’s lay statements regarding the onset of her conditions. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. More specifically, the examiner must explain whether the inability to provide a more definitive opinion is due to a need for additional information, the examiner’s lack of personal knowledge or training, or the limits of current medical knowledge. (Continued on the next page)   4. Following the development set forth above, and any other development deemed necessary, readjudicate the claims on appeal. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.