Citation Nr: 21015055 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 12-12 725 DATE: March 16, 2021 ORDER Entitlement to service connection for a right leg disability, to include right knee strain, is denied. Entitlement to service connection for a left leg disability, to include left knee strain, left knee anterior cruciate ligament tear, and left knee arthritis, is denied. Entitlement to service connection for bronchitis is denied. Entitlement to service connection for a disability characterized by abdominal pain, to include a gynecological disorder, is denied. From November 29, 2017, entitlement to special monthly compensation (SMC) at the housebound rate is granted. REMANDED Entitlement to service connection for gastroesophageal reflux syndrome (GERD) is remanded. Entitlement to service connection for a bilateral foot disability, to include foot ulcers and pain, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a right leg disability, to include right knee strain, began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that a left leg disability, to include left knee strain, left knee anterior cruciate ligament tear, and left knee arthritis, began during active service, or is otherwise related to an in-service injury or disease; the Veteran’s left knee arthritis was not shown as chronic in service and did not manifest to a compensable degree within one year. 3. The preponderance of the evidence of record is against finding that the Veteran has had a bronchitis disability or similar disability, separate from her service-connected asthma, at any time during or approximate to the pendency of the claim. 4. The preponderance of the evidence is against finding that any abdominal or gynecological disability, to include uterine fibroids or ovarian cysts, began during active service, or is otherwise related to an in-service injury or disease. 5. From November 29, 2017, the Veteran has a single service-connected disability rated as 100 percent disabling and separate service-connected independently ratable at 60 percent. CONCLUSIONS OF LAW 1. The criteria for service connection for a right leg disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a left leg disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for bronchitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for an abdominal or gynecological disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. From November 29, 2017, the criteria for SMC at the housebound rate have been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from September 1997 to April 1999. These matters come before the Board of Veterans’ Appeals (Board) on appeal from November 2009, and June 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2017 and June 2018, the Board remanded the claims of entitlement to service connection for disabilities relating to the right leg, left leg, abdominal/gynecological disorders, bilateral foot, bronchitis, and GERD. In a June 2018 decision, the Board granted entitlement to a total disability rating based on individual unemployability from September 1, 2013. The Veteran timely appealed the June 2018 Board decision. In May 2019, the Court granted the Joint Motion for Partial Remand (JMPR), which vacated and remanded the Board’s June 2018 decision as to the inferred issue of entitlement to SMC at the housebound rate. In October 2019, the Board denied SMC at the housebound rate. Again, the Veteran timely appealed the Board decision. Subsequently, the Court granted a September 2020 JMPR, which vacated and remanded the Board decision as to entitlement to SMC at the housebound rate. Service Connection The Veteran asserts that her bronchitis, abdominal/gynecological condition, GERD, bilateral foot condition, and bilateral leg pain began in service and have continued to present. See December 2008 VA Form 21-4138; May 2012 VA Form 9. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). 1. Entitlement to service connection for a right leg disability is denied. 2. Entitlement to service connection for a left leg disability is denied. As noted, the Veteran reported that her right and left leg disability had onset in service and continued thereafter. Alternatively, the Veteran contends that her left leg disability is secondary to her right leg disability. See May 2012 VA Form 9. As there is considerable overlap in these claims, the Board will address them concurrently. For the reasons that follow, the Board finds that service connection is not warranted for either disability. Service treatment records note a complaints of right hip pain in November 1997. In January 1998, the Veteran also complained of right thigh pain after running and more continuous right knee pain. The Veteran was given an assessment of musculoskeletal pain. The service treatment records are silent for complaints or diagnosis related to the left leg. At separation examination in November 1998, the Veteran was given a clinical evaluation and noted to have normal lower extremities. In the November 1998 report of medical history, the Veteran checked “no” to having had swollen or painful joints, cramps in legs, arthritis, rheumatism, or bursitis, trick or locked knee, and foot trouble. The Veteran indicated that she was in average health, and that she had asthma and iron deficiency. Post service, the Veteran’s history included numerous complaints and multiple traumas related to her right and left leg. Of note, the Veteran reported that she was shot in 2000. See May 2017 VA examination. A March 2001 radiology report indicated that she a history of gunshot wound to the right buttock with a finding that a bullet remained in the soft tissue. The Veteran reported right hip pain secondary to a gunshot wound in February 2002. Separately, the Veteran was seen in December 2010 for an injury to the right knee and hip when she fell onto a concrete floor. In February 2011 treatment records, the Veteran reported severe right knee pain after falling on concrete the previous Sunday. The clinician noted negative X-rays with bilateral knee views showing no acute fracture, dislocation, soft tissue abnormality, or significant degenerative joint disease. A subsequent February 2011 MRI of the right knee showed grade II proximal MCL sprain and mild chondromalacia patella. In September 2013, the Veteran reported a left knee injury sustained from falling while playing volleyball. The MRI showed a left knee ACL tear and meniscus tear. The Veteran eventually underwent surgeries for the left knee. See May 2014 treatment records (noting an October 2013 surgery) and November 2016 treatment records. The Veteran has also reported occasional crampy pain in the bilateral lower extremities. See June 2007 and November 2013 treatment record. The Veteran was also seen for lower back pain radiating down to the right lower extremity in February 2010. The Board notes that the Veteran is already service-connected for radiculopathy of the right lower extremity. See December 2020 codesheet. The Veteran was afforded a VA examination in November 2017 with an opinion in January 2018. The examiner noted a diagnosis of bilateral knee strain, left knee anterior cruciate ligament tear, and left knee arthritis. The Veteran reported that she was told she had runner’s knees and shin splints in service, with bilateral knee and shin pain during physical training. The Veteran continued to have problems with her knees after service. The examiner provided a negative etiological opinion based on a lack of treatment in service and post-service trauma to the knees. The June 2018 Board Remand found this opinion was inadequate. Pursuant to the Board remand in August 2017, VA obtained an addendum medical opinion in April 2020 for the Veteran’s right and left leg disability. The examiner considered the Veteran’s competent report of symptoms in service and continuing after service. Nonetheless, the examiner offered a negative etiological opinion as to all diagnoses. Rather, the examiner indicated that the evidence supported an etiological link to post-service, traumatic falls of the right knee in 2011 and the left knee in 2013 with confirmed radiologic sequelae. The examiner explained that the present knee issues are best attributed to this clearly defined traumatic injury. In particular, the Veteran’s left knee injury, involving rupture of the anterior cruciate ligament, is typically from significant acute trauma. Such diagnosis is less likely to be spontaneously, or caused by remote trauma or the general wear and tear. Thus, the present knee issues are best attributed to trauma that occurred after service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has considered the statements offered by the Veteran, and opinions contained therein. The Veteran is competent to report having experienced symptoms in service and thereafter. In addition, the Veteran is not a lay person because she has some formal training and education in nursing. See May 2017 VA examination indicating that the Veteran has not completed nursing school; December 2016 reporting prior work as a nursing assistant/LPN. Nonetheless, the Board finds her opinion on the etiology of her right and left leg disability is entitled to less weight. Most importantly, she has not offered a persuasive rationale which considers the full medical history, to include multiple traumatic falls after service. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Consequently, the Board gives more probative weight to the April 2020 VA examiner’s opinion. In sum, the Board concludes that the preponderance of the evidence weighs against finding that either of the Veteran’s leg disability began during service or is otherwise related to an in-service injury, event, or disease. Accordingly, there is no reasonable doubt to be resolved in this instance. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Service connection for a left leg or right leg disability is not warranted. 3. Entitlement to service connection for bronchitis is denied. The Veteran seeks service connection bronchitis. The Board notes that the Veteran is already service-connected for asthma, another pulmonary disorder. For the following reasons, the Board concludes that the Veteran does not have a current bronchitis disability or similar disability separate from her already service-connected condition, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). VA treatment records note various respiratory symptoms, to include coughing, shortness of breath, and congestion. See e.g. VA treatment record from October 2007 and October 2015. The Veteran has also been given a diagnosis of bronchitis, as well as other conditions. Those conditions included asthma, sinusitis, and asthmatic bronchitis. See May 2016 problem list. The August 2009, and November 2017 VA examinations for respiratory conditions, as well as the January 2018 opinion, noted the only diagnosis of asthma. Pursuant to the Board’s remand, VA obtained an addendum opinion in April 2020. Based on the prior VA examinations and treatment records, the examiner found no objective evidence that the Veteran has a separate diagnosis of chronic bronchitis. The examiner explained that chronic bronchitis is an older term used to describe chronic obstructive pulmonary disease (COPD). Current objective examination was inconsistent with a finding of chronic bronchitis. Namely, the Veteran’s chest X-ray was negative for such finding and 2017 pulmonary function tests indicated a forced expiratory volume of 96 percent, which is inconsistent with such pathology. Rather, the Veteran’s respiratory symptoms are best attributed to her asthma. The examiner’s opinion is probative and based on an accurate medical history, with clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, the examiner is the only probative opinion whether the Veteran has a bronchitis disability, separate from her already service-connected asthma. In reaching this conclusion, the Board has considered the Veteran’s assertions. As noted, the Veteran is competent to testify to the presence of symptoms and competent as a medical professional. Nonetheless, her statements must be weighed against the other evidence of record. In particular, the VA examination which provided a more detailed account of her symptomatology and varying diagnosis. In addition, these VA examinations were conducted by individuals with more training and expertise, to include two nurse practitioners and a medical doctor. Consequently, the Board gives more probative weight to the VA examination reports. The Board has considered the holding in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit held that “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability” if it “reaches the level of a functional impairment of earning capacity.” Id. at 1367-69. However, there is no evidence that the Veteran has functional impairment of earning capacity due to any bronchitis symptoms, separate from her already service-connected asthma. Ultimately, the Board finds the evidence weighs against a finding of any current disability of bronchitis for which service connection may be granted. Accordingly, there is no reasonable doubt to be resolved in this instance. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Service connection for bronchitis is not warranted. 4. Entitlement to service connection for a disability characterized by abdominal pain, to include a gynecological disorder, is denied. The Veteran initially sought service connection for an abdominal disability. See December 2008 VA Form 21-4138; December 2008 VA Form 21-4142. In August 2017, the Board recharacterized the Veteran’s claim to include a possible gynecological disorder related to vaginal bleeding and menstrual cramping. The dispositive question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. For the reasons that follow, the Board finds that the preponderance of the evidence weighs against finding that the Veteran’s disorder began during service or is otherwise related to service. Service treatment records note related complaints and diagnosis. In October 1997, the Veteran reported sharp abdominal pain assessed as a strain. The Veteran also complained of abdominal pain and pressure while urinating in January 1998; an assessment of rule out UTI was given. The Veteran was treated for vaginal bleeding and abdominal pain in October 1998; an assessment of elective termination of pregnancy bleeding was given. Subsequently, the Veteran reported vaginal bleeding which ceased but symptoms of hematuria and dysuria were present. The Veteran was given an assessment of hemorrhagic cystitis and microcytic anemia. The Veteran’s separation examination in November 1998 was silent for related abnormalities. Although the Veteran identified the anemia in a November 1998 report of medical history, she did not note problems related to her gynecological or abdominal disability. Post-service, the Veteran reported gynecological symptoms and abdominal pain. Of note, the Veteran was seen for abdominal pain. See e.g. March 2006 treatment records. The Veteran also complained of heavy and continued bleeding. See e.g. August 2002 and October 2005 treatment records. The Veteran also reported a history of ovarian cysts while pregnant in September 2002 treatment records. Testing was undertaken in relation to the Veteran’s symptoms. A February 2001 CT scan of the abdomen showed no abnormality. A December 2005 pelvic ultrasound showed a uterus normal in size, small fluid within the endometrial canal, and ovaries which appear normal in size without abnormal mass or cyst. A September 2006 abdominal ultrasound showed a normal liver, gallbladder, common duct, calculi, pancreas, kidneys, and spleen. An October 2007 ultrasound showed a left ovarian cyst. In January 2009, the Veteran reported an ultrasound conducted by a friend showed a mass on the outside of her uterus and in the ovary. In a separate January 2009 treatment record, the Veteran reported a vaginal bleeding episode over one year prior with reoccurrence three months ago. The January 2009 transabdominal pelvic ultrasound was unremarkable, but the ultrasound also showed a possible uterine fibroid. Subsequent imaging showed right ovarian cysts consistent with dermoid and small fibroids. See December 2013 treatment records. A March 2015 addendum to the September 2014 CT scan of the abdomen noted that testing showed an enlarged uterus with irregular contour consistent with uterine fibroids, cyst, and hepatic hemangioma. A May 2018 gynecology consultation noted a stable dermoid cyst after pelvic ultrasound, CT scan, and MRI with intermittent pelvic pain and bloating. The Veteran was afforded a VA examination in August 2009. The Veteran reported stomach pain in service, which was treated and diagnosed as H. Pylori, GERD, and ulcer. In the diagnosis, the VA examiner note positive testing for H. Pylori, a normal upper GI series, and a normal ultrasound of the abdomen. As to etiology, the examiner noted no diagnosis identified for a nexus with current clinical examination normal. The August 2017 Board remand found this was inadequate. The Veteran was afforded a VA examination in November 2017, with an opinion in January 2018. The VA examiner opined that the Veteran’s diagnosed gynecological conditions, to include a left ovarian cyst and a uterine fibroid, were less likely than not incurred in or caused by service. However, the June 2018 Board Remand found the January 2018 VA opinion inadequate and remanded the claim for a new opinion. An addendum opinion was obtained in April 2020. After reviewing the evidence of record, the examiner indicated that it was less likely than not that any abdominal disability, to include any diagnosed gynecological disorders, was incurred in or caused by her military service. The examiner noted that although the Veteran had similar complaints in service, the clinicians who examined the Veteran also provided an in-service diagnosis. These assessments accounted for the in-service symptoms. Further, those diagnosis are not reasonably related to her current diagnosis. In addition, the examiner noted no objective findings during service associated with the present diagnoses. Ultimately, the evidence does not suggest the uterine fibroids and left ovarian cyst originated from the Veteran’s active service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The evidence of record does not contain an equally probative opinion. As noted, the Veteran has a level of competency above those of normal lay persons in this medically complex matter. The Veteran is also competent to report any symptoms she experienced, to include pain and heavy bleeding. However, her rationale is less persuasive as it is inconsistent with treatment records and objective testing that shows normal abdominal and pelvic ultrasounds for many years after service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). As a result, the Board gives more probative weight to the April 2020 VA examiner’s opinion. In sum, the preponderance of the evidence is against the Veteran’s claim and the benefit of the doubt doctrine is not applicable. Accordingly, service connection is not warranted. Increased Rating 5. From November 29, 2017, entitlement to SMC at the housebound rate is granted. In the May 2019 and September 2020 JMPR, the parties vacated and remanded this issue. Of note, the May 2019 JMPR remanded based on the Board’s failure to discuss the applicability of 38 U.S.C. § 1114(s) when awarding a TDIU effective September 1, 2013. In the September 2020 JMPR, the parties found that the Board did not address whether any of her service-connected disabilities, standing alone, were sufficient to entitle her to an award of TDIU. Under 38 U.S.C. § 1114(s), SMC is payable at the housebound rate where the Veteran has a single service-connected disability rated as 100 -percent disabling and, in addition, (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. See 38 C.F.R. § 3.350 (i). In Bradley v. Peake, 22 Vet. App. 280, 293 (2008), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.350(i) permits a TDIU rating based on a single disability to satisfy the statutory requirement of the 100 percent rating. See also Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2011). Generally, it is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” See 38 C.F.R. §§ 3.340(a)(1), 4.15. The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The United States Court of Appeals for Veterans Claims (Court), in Ray v. Wilkie, 31 Vet. App. 58 (2019), interpreted the phrase “unable to secure and follow a substantially gainful occupation” under 38 C.F.R. § 4.16(b). The Court defined the term to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component, which is pertinent in this case, includes consideration of: the veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Therefore, the question before the Board is whether any of the Veteran’s service-connected disabilities, independently, resulted in an inability to secure and follow a substantially gainful occupation for the purposes of an SMC award. In this case, the Veteran is service-connected for generalized anxiety disorder (GAD) (previously rated as insomnia), rated 30 percent disabling from October 21, 2008, to November 28, 2017, and 70 percent thereafter; chronic headaches, rated 50 percent disabling from October 21, 2008; lumbar strain, rated 10 percent disabling from October 21, 2008, and 40 percent disabling from June 2, 2010; sinusitis, rated 30 percent disabling from October 21, 2008; chronic allergic rhinitis, rated 30 percent disabling from October 21, 2008; right lower extremity radiculopathy, rated 20 percent from May 1, 2013; and asthma, rated 10 percent disabling from October 21, 2008. Looking at economic considerations, the Veteran’s DD-214 indicates that her military occupational specialty was automated logistics specialist. On the Veteran’s December 2016 VA Form 8940, she reported information about her education and prior employment. She indicated that she had completed three years of college and had work experience as a nurse assistant/LPN. In an August 2009 VA examination, the Veteran reported working as an assistant with elderly patients and previous work in medical records and filing. Thus, the Veteran had the education, training, skills, and work history to perform substantially gainful work in nursing, health care, or logistics. With regard to physical and mental disabilities, the medical evidence did show the Veteran had some difficulties due to her service-connected disabilities. As to her service-connected insomnia and GAD, the Veteran reported the disability resulted in lost time at work, inability to work full-time, and inability to successfully complete her nursing degree. See e.g. December 2010 and May 2017 VA examinations. At the December 2010 VA examination, the Veteran’s symptoms were noted to be panic attacks, generalized anxiety, excessive worry, depression, low energy, anhedonia, sleep disruption, marital discord, financial problems, tearfulness, and insomnia. The May 2017 VA examination noted fewer symptoms with the VA examiner endorsing only depressed mood, anxiety, panic attacks that occur weekly or less often, and chronic sleep impairment. The examiner noted only occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. Comparatively, the November 2017 VA examination for mental disorders noted a more severe progression of the disease since the May 2017 examination. The examiner noted that her condition had changed, with an apparent decline over time. The examiner noted multiple interwoven psychiatric diagnoses, including GAD, panic disorder with agoraphobia, and depressive disorder NOS. Among the more severe symptoms endorsed by the VA examiner were near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and impaired impulse control. The examiner concluded that the Veteran symptoms result in occupational and social impairment with deficiencies in most areas. Specifically, the examiner stated that the Veteran has endorsed rather crippling symptoms of depression /anxiety, such that it would present a barrier to her securing and maintaining employment. The evidence also indicates that the Veteran suffers from limitation due to her service-connected lumbar disability. Of note, in the May 2013 VA examination, the examiner opined that the Veteran’s service-connected low back disability mildly to moderately impacts her ability to perform physical and sedentary labor requiring prolonged sitting, standing, or walking. Similarly, the November 2017 VA examination noted mild to moderate impact on the Veteran’s ability to perform physical and sedentary labor during flare ups requiring lifting, prolonged standing, sitting, activity, and range of motion due to pain, lack of coordination, and fatigue. In addition to these limitations, the Veteran was also noted to have difficulty with concentration due to back pain in the May 2017 VA examination. In August 2016 VA examination for her service-connected headaches, the Veteran stated that she had four to five migraine headaches per month, each lasting two to three days and involving sharp pain, sensitivity to light, nausea, vomiting, sensitivity to sound, and changes in vision. The Veteran stated that she had to lie down in a dark room when having migraine headaches. The VA examiner indicated that the migraine headache disability impacted the Veteran’s ability to work. Functional impact on the Veteran’s ability to work and sleep was also noted by the May 2017 VA examiner. Although an August 2016 VA examination noted no impact of the Veteran’s sinus, nose, throat, larynx or pharynx condition on her ability to work, a November 2017 VA examination indicated otherwise. In fact, the January 2020 VA examination noted lost time at work of up to one week in a twelve month period with difficulty working and or studying due to frequent episodes of sinusitis. The November 2017 VA examination on respiratory conditions noted no functional impact from the Veteran’s service-connected asthma. The Board also noted that the Veteran submitted the January 2017 letter from Dr. Travis, her treating clinician. Dr. Travis noted that the Veteran currently suffers from left knee pain (not service-connected), back pain, anxiety, chronic sinusitis, and migraines. The clinician concluded that these conditions render the Veteran unable to work. After a review of the evidence of record and resolving any doubt in the Veteran’s favor, the Board finds that the Veteran has been unable to secure or maintain substantially gainful employment due to her service-connected GAD since November 29, 2017. At that point, the Veteran’s GAD manifested in serious decline compared with prior VA examinations. The Veteran credibly reported symptoms which impacted her ability to gain or maintain employment. Moreover, the VA examiner indicated that her symptoms presented a significant barrier to employment. As the Veteran’s remaining disabilities account for an evaluation of 60 percent or more, entitlement to SMC at the housebound rate is warranted. Prior to November 29, 2017, the evidence indicates that the Veteran did not have a single service-connected disability which was sufficient to entitle her to an award of TDIU. While the VA examinations noted some functional impact, none of the disabilities alone would preclude securing or maintaining gainful employment. Rather, the VA examinations and the January 2017 letter from Dr. Travis, all indicated that overall impact of all the service-connected disabilities in combination resulted in her being unable to obtain and maintain substantially gainful employment. It was a combination of the significant anxiety, concentration difficulties, fatigue, pain, limitation as to physical labor, and prostrating headaches that support a finding that the Veteran has been unable to obtain and maintain any form of substantially gainful employment. Based on the Board’s review, the evidentiary record fails to demonstrate that the Veteran was unemployable due to single service-connected disability prior to November 29, 2017. Thereafter, the Veteran was unemployable due to the single disability of GAD. In reaching these conclusions, the Board has resolved any doubt in the Veteran’s favor. See Gilbert v. Derwinski,1 Vet. App. 49, 55 (1990). Thus, entitlement to SMC at the housebound rate is warranted from November 29, 2017. REASONS FOR REMAND 1. Entitlement to service connection for GERD is remanded. 2. Entitlement to service connection for a bilateral foot disability, to include foot ulcers and pain is remanded. Pursuant to the Board’s remand, VA obtained an addendum opinion in April 2020 for a right and left foot condition and GERD. See also April 2020 opinion on right and left foot. In these opinions, the VA examiner indicated that obesity was a contributing factor to the Veteran’s disabilities. However, the evidence of record implicates the Veteran’s service-connected disabilities for her weight gain and any obesity, to include medication for her service-connected GAD. See VA treatment records from May 2010 (noting weight gain as a side effect of amitriptyline, but also decreased activity and smoking) and October 2010 (weight gain on Elavil); and November 2017 VA examination (reporting weight gain on psychiatric medication). As such, the Board must remand the claim for an opinion which addresses obesity as the intermediate step between a service-connected disability and the claimed disability on a secondary basis. In addition, the Board notes that the evidence shows a range in the Veteran’s body mass index (BMI) during the appeal period from normal and to obese. For example, in October 2018, the Veteran weighed 143 pounds and her BMI was 24.5, below the normal upper range cutoff of 24.9. Comparatively, she also weighed 191 pounds in April 2014 and her BMI was 32.8, in the range for obesity. If obesity is the primary contributing factor for these disabilities, another opinion which considers these discrepancies would be useful. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s bilateral foot disabilities and GERD. The examiner must review a copy of the claims file and this Remand. a) The examiner must opine as to whether the Veteran’s bilateral foot disabilities and GERD are at least as likely as not related to or caused by service. If the examiner indicates that obesity is a contributing factor, then the examiner should reconcile this with the wide variance in the Veteran’s weight during the appeal period. b) The examiner must also opine as to 1) whether the Veteran’s bilateral foot disabilities and/or GERD are at least as likely as not proximately due to any of her service-connected disabilities, AND 2) whether it is at least as likely as not that any such bilateral foot disabilities and/or GERD were aggravated beyond their natural progression by any of her service-connected disabilities. In answering this question, the examiner should consider the assertion that the Veteran’s service-connected disability, to include medication for her service-connected GAD, resulted in obesity, which in turn led to her bilateral foot disabilities and GERD. This includes considering such evidence as VA treatment records from May 2010 (noting weight gain as a side effect of amitriptyline, but also decreased activity and smoking) and October 2010 (weight gain on Elavil), and a November 2017 VA examination report (reporting weight gain on psychiatric medication). (Continued on the next page)   A fully-explained rationale for all opinions must be provided. If any of the requested opinions cannot be rendered without resorting to speculation, the examiner should clearly explain why that is so. Andrew Mack Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Vuong, 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.