Citation Nr: 21021623 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 17-12 280 DATE: April 13, 2021 ORDER Service connection for lumbar spine strain is granted. Service connection for left knee strain is granted. Service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD), is denied. Service connection for migraines is denied. REMANDED Service connection for Wolff-Parkinson-White syndrome (WPW) is remanded. A higher (compensable) disability rating for right foot plantar warts is remanded. FINDINGS OF FACT 1. The Veteran is currently diagnosed with lumbar strain, left knee strain, GERD, and migraine headaches. 2. The currently diagnosed lumbar spine and left knee strain disabilities had their onset during service. 3. There was no migraine or gastrointestinal injury or disease during service. 4. Migraines and a gastrointestinal disorder manifested many years after service and are not causally or etiologically related to service. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for lumbar spine strain are met. 38 U.S.C. §§ 1110, 5103A, 5103(a); 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for left knee strain are met. 38 U.S.C. §§ 1110, 5103A, 5103(a); 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for service connection for a gastrointestinal disorder, to include IBS and GERD, are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a). 4. The criteria for service connection for migraines are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2000 to September 2005, and from September 2005 to May 2018 had additional periods of inactive duty for training (INACDUTRA) and active duty for training (ACDUTRA) in the Air Force Reserve and Air National Guard. In the February 2017 Substantive Appeal (on VA Form 9), the Veteran requested a hearing before a Veterans Law Judge. In a subsequent August 2017 letter, the Veteran’s representative stated that the Veteran wished to withdraw the hearing request. Thus, the hearing request is considered withdrawn. 38C.F.R. §20.704(e). In December 2020, the Board, in pertinent part, remanded the issues on appeal to the Agency of Original Jurisdiction (AOJ) for additional development. Further discussion of the AOJ compliance with the December 2020 Board remand directives as to the issue of service connection for WPW, as well as a higher rating for right foot plantar warts is included in the Remand section below. See Stegall v. West, 11 Vet. App. 268 (1998). As to the issues of service connection for lumbar spine, left knee, and gastrointestinal disorders, as well as service connection for migraines, VA examination reports and VA medical opinions have been associated with the record; therefore, an additional remand to comply with the December 2020 remand directives is not required as to these issues. Id. 1. Service Connection for Lumbar Spine 2. Service Connection for Left Knee Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. The Veteran essentially contends developing lumbar spine and left knee disabilities during service. See May 2015 VA-526EZ. Initially, the Board finds that the Veteran is currently diagnosed with lumbar spine and left knee strain disabilities. See January 2021 VA examination reports. After a review of all the lay and medical evidence of record, the Board finds that the evidence is at least in equipoise on the question of whether there was onset of symptoms of lumbar spine and left knee strain disabilities in service and since service separation, that is, to show that a lumbar spine and left knee disabilities were “incurred in” service. The evidence weighing in favor of the finding of in-service onset includes the February 2005 and July 2005 service treatment records reflecting the Veteran reported back pain. The January 2021 VA examination report and August 2016 Decision Review Officer hearing transcript each reflect the Veteran reported overuse of the left knee during service and that symptoms of a left knee and a back disability began during service. Further, the Veteran’s consistent lay statements demonstrate lumbar spine and left knee symptoms since service, to include the January 2021 VA examination report. The evidence weighing against favor of the finding of in-service onset includes VA examiners’ opinions, all of which fail to address the Veteran’s competent lay statements regarding in-service onset and continued symptomatology. For these reasons, and after resolving reasonable doubt in the Veteran’s favor, the Board finds that lumbar spine and left knee strain disabilities were incurred in active service; thus, the criteria for direct service connection for the lumbar spine and left knee strain disabilities are met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service Connection for Gastrointestinal Disorder 4. Service Connection for Migraines The Veteran essentially contends developing gastrointestinal and migraine disabilities during service. See May 2015 VA-526EZ. At the outset, the Board finds that the Veteran is currently diagnosed with GERD, IBS, and migraines. See January 2021 VA examination report, VA treatment records. Having reviewed all the relevant evidence of record, the Board finds that the weight of the evidence shows no relevant in service gastrointestinal or migraine injury or disease. The service treatment records, which are complete, do not reflect any relevant injury, complaints, diagnoses, or treatment relating to symptoms of a gastrointestinal or migraine disorder. As discussed below, the January 2021 VA examiner specifically attributed in-service headaches to a sinus infection and assessed that vomiting and diarrhea were related to an acute episode of gastroenteritis. The earliest post-service evidence of GERD-related symptoms and GERD diagnosis appears in a 2013 treatment record. Further, the earliest post-service evidence of migraine-related symptoms and a migraine diagnosis appears in a 2016 treatment record. On the question of direct nexus between the current gastrointestinal and migraine disorders, the Board finds that the weight of the evidence demonstrates no in service injury or disease to which the currently diagnosed GERD and migraine disorders may be contributed by competent evidence. As stated above, the evidence shows diagnoses of gastrointestinal and migraine disorders after separation from service. On the question of direct nexus, the January 2021 VA examiner also opined that a gastrointestinal disorder was unrelated to vomiting and diarrhea during service. The VA examiner reasoned that the October 2001 service treatment records reflecting vomiting and diarrhea were related to an acute episode of gastroenteritis. The January 2021 VA examiner also opined that the service treatment records reflect that headaches during service were related to a sinus infection, and that the Veteran first sought treatment for migraines post-service in 2016. The Board finds that the January 2021 VA examiner’s opinions are highly probative as they are based on an accurate history and objective findings as shown by the record with supporting rationales. Insomuch as the Veteran asserts that the gastrointestinal and migraine disorders are directly related to service, the Board finds that, under the specific facts of this case that include episodes of vomiting and diarrhea related to acute episode of gastroenteritis and episodes of headaches related to a sinus infection, with no in-service gastrointestinal or migraine injury or disease, and no post-service symptoms, treatment, or diagnosis for years after service, the Veteran is not competent to relate the currently diagnosed gastrointestinal disorder and/or migraines to active service. While the Veteran is competent to describe symptoms he experiences at any time, he does not have the requisite medical expertise needed to provide a competent opinion regarding causation of a complex medical condition such as a gastrointestinal disorder and/or migraines and their relationship to active service years earlier, which requires specialized medical knowledge of the digestive system and knowledge of various possible etiologies of migraines, especially in the context of this case where gastrointestinal and migraine disorders are first diagnosed after separation from service. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Clyburn v. West, 12 Vet. App. 296, 301 (1999); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997). Based on the foregoing, the Board finds that the weight of the evidence demonstrates no in-service injury or disease that may be attributed to the currently diagnosed gastrointestinal disorder and migraines. For these reasons, service connection must be denied. REASONS FOR REMAND 5. Service Connection for WPW In August 2019, the Board directed the AOJ to schedule a VA heart examination to determine whether the WPW syndrome was congenital in nature, and if so, whether it was a congenital disease or defect. Upon examination, a January 2020 VA examiner noted diagnoses of WPW syndrome and myocardial infarction in 2008 while on active duty. The VA examiner opined that the WPW syndrome was a congenital disease that clearly and unmistakably pre-existed service. The VA examiner reasoned that the heart disorder was present since birth and caused a rapid heartbeat. The VA examiner also opined that the WPW syndrome was not aggravated during service as the service treatment records did not suggest aggravation. In December 2020, in pertinent part, the Board remanded the heart issue on appeal to provide the Veteran with a VA heart examination to assess whether the myocardial infarction was related to the WPW syndrome. The January 2021 VA examination report does not reflect the VA examiner attempted to address whether the myocardial infraction was related to the WPW syndrome. See Stegall, 11 Vet. App. 268. Accordingly, upon Remand, the AOJ should schedule an addendum opinion. 6. Rating Right Foot Disability In December 2020, in pertinent part, the Board remanded the right foot rating issue on appeal to provide the Veteran with a VA examination to assess flare-ups and whether prior subjective reports of pain and flare-ups impacted the right foot, to include the report that certain types of shoes caused flare-ups. The January 2021 VA examination report does not reflect the VA examiner attempted to address flare-ups. See Stegall, 11 Vet. App. 268. Accordingly, upon Remand, the AOJ should obtain an addendum opinion. The matters are REMANDED for the following action: 1. Request that a VA medical professional, other than the VA examiner who provided the January 2021 VA opinion, review the electronic file, and provide the VA addendum opinions requested below. The relevant documents in the electronic file should be made available to, and be reviewed by, the VA examiner. The VA examiner should note such review in the addendum opinions. If the VA examiner determines that additional examination(s) of the Veteran is necessary to provide reliable opinions, such examination(s) should be scheduled; however, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The VA examiner should provide the following aggravation opinions with supporting rationale: A. Is it at least as likely as not (50 percent or higher degree of probability) that the 2008 in-service myocardial infarction is related to the WPW syndrome? B. As to the right foot rating issue, the VA medical professional should express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. The VA medical professional should consider the Veteran’s lay statements regarding right foot pain, to include the report that certain types of shoes cause flare-ups. 2. Then, readjudicate the issues on appeal. L. BARSTOW Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Tenney, 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.