Citation Nr: 22010348 Decision Date: 02/23/22 Archive Date: 02/23/22 DOCKET NO. 19-04 913 DATE: February 23, 2022 ORDER Service connection for hemorrhoids is granted. Service connection for tinnitus is granted. REMANDED Entitlement to service connection for left knee disability is remanded. Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for a left ankle disability is remanded. FINDINGS OF FACT 1. The evidence shows the Veteran has had hemorrhoids since active duty service. 2. The evidence shows the Veteran has had tinnitus since noise exposure during active and inactive duty training. CONCLUSIONS OF LAW 1. The criteria for service connection for hemorrhoids have been met. 38 U.S.C. § 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for tinnitus have been met. 38 U.S.C. § 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from September 1985 to April 1986. She then served in the Army and Air Force Reserves from April 1986 to May 2007. These issues were previously denied by the Agency of Original Jurisdiction in an unappealed, July 2016 rating decision. After that decision, VA received a new record in April 2017 listing additional periods of reserve service. As such, readjudication of these claims is appropriate. See 38 C.F.R. § 3.156(c). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" also known as the "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Active service is defined as active duty, as well as, any period of active duty for training (ADT) during which disability or death is incurred or aggravated by disease or injury in the line of duty, and any period of inactive duty training (IDT), during which disability or death is incurred or aggravated by injury in the line of duty. Acute myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during a period of IDT is also subject to service connection. 38 U.S.C. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303, 3.304; Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt is resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Service connection for hemorrhoids Based on the evidence, the Board finds the criteria for service connection for hemorrhoids have been met. 38 C.F.R. § 3.303. The evidence shows current hemorrhoids began during active duty service. Service treatment records from November 1985 and August 1987 show the Veteran was first treated for internal hemorrhoids during active duty and treated again during Reserve service. At the Board hearing, the Veteran reported having hemorrhoids currently and ongoing problems and treatment for them since service. The Veteran is a nurse and is competent to provide evidence of current hemorrhoids and ongoing hemorrhoids since service. The April 2017 examiner found no current external hemorrhoids. As such, there is an approximate balance of evidence supporting and against a finding of current hemorrhoids. The Board resolves doubt in the Veteran's favor and finds she has current hemorrhoids. Accordingly, there is competent evidence of a current disability, in-service incurrence, and continuous disability in between, and service connection for hemorrhoids is warranted. 2. Service connection for tinnitus After reviewing the evidence, the Board finds the criteria for service connection for tinnitus have been met. 38 C.F.R. § 3.303. First, the evidence shows a current disability. During the Board hearing and at the May 2017 examination, the Veteran reported tinnitus, or ringing in the ears. The Veteran is competent to provide evidence of tinnitus as it is readily observable by the senses. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Therefore, the first element of service connection is established. Next, after resolving doubt in the Veteran's favor, the evidence shows she had noise exposure during active and inactive duty training. During the Board hearing, the Veteran reported exposure to loud noise from generators and other equipment while stationed in a combat support hospital in the early 1990s. Her service personnel records show the Veteran was transferred to the 350th combat support hospital in 1993 and that she served 14 days of ADT and 27 days of IDT during that time. The evidence shows the Veteran worked as a school nurse as a civilian. The Board sees no reason to doubt that the Veteran's most substantial exposure to noise came from her military service. The Board finds her reports of in-service noise exposure credible. Finally, the evidence shows the Veteran continued to experience tinnitus since the time of in-service noise exposure. During the Board hearing, the Veteran reported that her tinnitus began and continued since her time in the combat support hospital. Again, the Veteran is competent to provide evidence of tinnitus and continuous tinnitus. See Charles, 16 Vet. App. at 374. The May 2017 VA examiner first provided a positive opinion that tinnitus was related to service based on the Veteran's report of onset and continued symptoms; however, the examiner then provided an addendum opinion against service connection citing the lack of record of tinnitus or noise exposure. The addendum opinion appears to ignore the Veteran's reports of in-service noise exposure and continuous symptoms and rely solely on the lack of contemporaneous treatment records, which renders the opinion inadequate, particularly given an extremely sparse record, discussed below. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). The Board relies on the competent and credible evidence provided by the Veteran that she has current tinnitus that has continued since the time of noise exposure in service. Service connection for tinnitus is granted. REASONS FOR REMAND 1. Entitlement to service connection for left knee disability is remanded. 2. Entitlement to service connection for right knee disability is remanded. 3. Entitlement to service connection for a left ankle disability is remanded. Additional development is needed for the remaining claims. Service personnel records show the Veteran had reserve service through 2007, but the record does not include service medical records after 1994, except for a report of medical history from November 1999. The AOJ should make additional requests for service treatment records from the Veteran's periods of reserve service in the Army and Air Force to ensure the record is complete. Similarly, the Veteran reported receiving medical treatment from private providers, but there are very few medical records in the claims file. The AOJ should request the Veteran identify and provide releases for any private providers who treated her knees and left ankle. Next, the May 2013 VA examination revealed less than normal range of motion of the left ankle, and service treatment records show a left ankle sprain in February 1986. The VA examiner opined that the left ankle disability was less likely than not related to service for lack of record of treatment or complaints. During the Board hearing, the Veteran reported continued ankle problems; therefore, the examiner's reliance on the lack of contemporaneous treatment records is inadequate to support the negative opinion, particularly considering the extremely sparse record. See Dalton, 21 Vet. App. at 39. A new opinion is needed. Regarding the left knee, the Veteran submitted a few private treatment records that show left knee patellofemoral syndrome diagnosed in 2008 and current treatment for the left knee. The Veteran testified to wear and tear on the knee from physical training during her 22 years of service and experiencing problems with the knee shortly before separation. A medical opinion should be obtained to determine if the Veteran's current left knee disability is related to her active service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Request copies of the Veteran's service medical records from her periods of reserve service in the Army and Air Force from the 1990s through 2007. Requests for federal records should continue until the records are obtained or deemed unavailable. 2. Request the Veteran identify and provide releases for any private providers who treated her knees and left ankle. 3. Then, obtain an addendum opinion for the Veteran's left ankle. The medical expert should review the claims file and address whether the Veteran's current left ankle disability, evidence by pain and limited range of motion, is at least as likely as not related to her service. The expert should consider all relevant lay and medical evidence, including February 1986 treatment for sprained ankle and the Veteran's reports of the ankle continuing to be weak and give out since the in-service injury. All opinions must be supported by detailed rationale. If the opinion cannot be provided without resort to speculation, the expert should explain why, and state whether the inability is due to the absence of evidence or limits of scientific/medical knowledge. 4. Schedule the Veteran for an examination and medical opinion for the left knee. The examiner should review the claims file and address whether the Veteran's current left knee disability is at least as likely as not related to wear and tear injuries she reported from physical training during active duty, active duty training, and inactive duty training. The expert should consider all relevant lay and medical evidence. All opinions must be supported by detailed rationale. If the opinion cannot be provided without resort to speculation, the examiner should explain why, and state whether the inability is due to the absence of evidence or limits of scientific/medical knowledge. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.P. Armstrong 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.