Citation Nr: 22017786 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 19-12 127 DATE: March 26, 2022 REMANDED Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for migraines is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1990 to January 1998. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2018 decision by a Department of Veterans Affairs (VA) regional office (RO). In October 2021 the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. The transcript of the hearing is of record. Unfortunately, the Board finds that additional development is needed prior to appellate adjudication. 1. Entitlement to service connection for sinusitis is remanded. The Veteran seeks service connection for sinusitis, which he contends is due to his service. The Veteran testified at his October 2021 Board hearing that he developed sinus issues during service and has experienced them ever since. The Veteran's service treatment records (STRs) indicate that in November 1995 he complained of congestion, facial pain, and a productive cough. His sinuses were tender upon palpation. The Veteran was diagnosed with mild sinusitis. Additional November 1995 STRs indicated the Veteran complained of fever and pressure in his nose and eyes. February 1997 STRs indicated that the Veteran was experiencing sinus issues such as nasal discharge, facial tenderness, a headache, and ear discomfort. They noted that the Veteran was taking over the counter medication. The Veteran was diagnosed with a sinus infection. September 1997 STRs stated that the Veteran complained of sinus congestion, nasal congestion, pain, and a non-productive cough. The Veteran was diagnosed with sinusitis. October 1997 STRs indicated that the Veteran took sinus medication. A November 2018 VA examination stated that the Veteran was diagnosed with sinusitis in service, but the condition had since resolved and there was no evidence of a chronic sinus condition since service. October 2020 VA treatment records diagnosed the Veteran with sinusitis. The November 2018 VA examiner's opinion was based on an incomplete medical history, as she stated that the Veteran's sinus condition had resolved, and the Board therefore finds that this opinion has little probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Furthermore, the November 2018 VA examiner did not take the Veteran's contention regarding continuity of symptomology into account. The examiner must consider the Veteran's lay statements regarding the onset and continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007). As such, on remand an addendum medical opinion must be obtained by the RO. 2. Entitlement to service connection for a left ankle disability is remanded. The Veteran seeks service connection for a left ankle disability, which he contends is due to his service. The Veteran testified at his October 2021 Board hearing that he hurt his left ankle during service, and it has caused him pain, on and off, ever since. He related that it was probably jumping out of helicopters or physical training that caused his left ankle pain. A July 1997 STR indicates that the Veteran complained of left ankle pain for two days and states that he did some garden work over the weekend. The Veteran was diagnosed with Achillis tendonitis. A November 2018 VA examiner indicated that the Veteran was diagnosed with left ankle tendinitis in July 1997 during service. She related that the Veteran stated that he experiences medial left ankle pain occasionally. The November 2018 VA examiner opined that there was no evidence of a chronic left ankle condition, however she did not consider the Veteran's testimony that he has experienced his ankle pain ever since service. The examiner must consider the Veteran's lay statements regarding the onset and continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007). As such, the Board finds that a remand for additional development is necessary. 3. Entitlement to service connection for migraines is remanded. The Veteran seeks service connection for migraines, which he contends are due to his service. The Veteran testified at his October 2021 Board hearing that he was in a motor vehicle accident (MVA) in September 1991 in Panama, and around February 1992 he started to experience sharp pain in the left side of his head. He related that he has experienced headaches ever since. An October 1991 STR titled statement of medical examination and duty status indicated that in September 1991 the Veteran was involved in an MVA where he hit a pole. It further related that the Veteran experienced head trauma. February 1992 STRs indicated that the Veteran complained of sharp pain on the left side of his head and had been experiencing this for two weeks. The Veteran was diagnosed with a headache. March 1992 STRs indicated that the Veteran complained of sharp pain on the side of his head. It related that there was a family history of migraines, and it indicated that the Veteran possibly had early onset migraines. February 1997 STRs indicated the Veteran had a headache. The Veteran provided photographs of his September 1991 car accident. An October 2018 VA examination indicated that the Veteran related that he experiences occasional headaches that started while he was in the military. He also reported occasional sharp pain on the left side of his head. The October 2018 VA examiner noted that during service the Veteran's STRs indicated that he complained of headaches. She stated that he was diagnosed with possible early onset migraines during service but there was no evidence that this became chronic during service or since. The October 2018 VA examiner opined that the Veteran did not have a diagnosis of migraine or chronic headache condition in service or since. She additionally stated that the Veteran has never been diagnosed with a headache condition. August 2019 VA treatment records indicated that the Veteran had a history of frequent and recurring headaches. While the October 2018 VA examiner's report indicated that the Veteran had never been diagnosed with a headache condition, February 1992 STRs diagnosed the Veteran with a headache and August 2019 VA medical records indicated that the Veteran had a history of frequent and recurring headaches. As the October 2018 VA examiner's opinion was based on an incomplete medical history, the Board finds that this opinion has little probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Furthermore, the October 2018 examiner did not address the Veteran's contention that his in-service MVA caused his migraines. The examiner must consider the Veteran's lay statements regarding the onset and continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007). As such, on remand an addendum medical opinion must be obtained by the RO. The matters are REMANDED for the following actions: 1. Scheduled the Veteran for a new examination with an appropriately qualified examiner, who has not previously provided an opinion on this matter, to address the nature and etiology of the Veteran's sinus disability. The examiner must review the claims file in its entirety, to include this REMAND, and the review should be noted in the examination report. Thereafter, the examiner is asked to provide a fully-articulated medical opinion with respect to the following: (a.) Whether the Veteran's sinusitis is related to his active-duty service? The examiner should address (1) the Veteran's STRs from November 1995 where he was diagnosed with sinusitis, February 1997 STRs where he was diagnosed with a sinus infection, September 1997 STRs where he was diagnosed with sinusitis, and October 1997 STRs where he took sinus medication; and (2) the Veteran's contention that his sinus issues started during service and continued ever since. 2. Forward the Veteran's claims file, including a copy of this REMAND, to an appropriately qualified examiner, who has not previously provided an opinion on this matter, to conduct a physical examination and address the nature and etiology of the Veteran's left ankle disability. The examiner must review the claims file in its entirety, to include a copy of this REMAND, and the review should be noted in the examination report. Thereafter, the examiner is asked to provide a fully-articulated medical opinion with respect to the following: (a.) Does the Veteran have a current left ankle diagnosis? (b.) Whether the Veteran's left ankle diagnosis is related to his active-duty service? The examiner should address (1) the Veteran's July 1997 STR where he was diagnosed with Achillis tendonitis and (2) the Veteran's testimony that his ankle pain probably started due to jumping from helicopters or from physical training and his testimony that he has experienced ankle pain ever since service. 3. Forward the Veteran's claims file, including a copy of this REMAND, to an appropriately qualified examiner, who has not previously provided an opinion on this matter, to conduct a physical examination and address the nature and etiology of the Veteran's headaches. The examiner must review the claims file in its entirety, to include a copy of this REMAND, and the review should be noted in the examination report. Thereafter, the examiner is asked to provide a fully-articulated medical opinion with respect to the following: (a.) Whether the Veteran's headaches had their onset during active service, within one year of separation, or are otherwise related to an in-service disease, event, or injury, to include the in-service September 1991 MVA? The examiner should address (1) the October 1991 STR indicating that in September 1991 the Veteran was involved in an MVA where he hit a pole and experienced head trauma, the February 1992 STR that states the Veteran complained of sharp pain on the left side of his head and was diagnosed with a headache, the March 1992 STR that indicated that the Veteran complained of sharp pain on the side of his head and stated that the Veteran possibly had early onset migraines, and the February 1997 STRs indicating he had a headache; (2) the Veteran's submitted photographs of the September 1991 MVA; and (3) the Veteran's testimony that his MVA was in September 1991, his headaches began in February 1992, and he continued experiencing them ever since. The examiner is advised that the Veteran is competent to report his medical history and must be considered and weighed in making the determination requested above. The examiner must provide a complete rationale for any opinion expressed. If the examiner is unable to provide an opinion without resorting to speculation, he or she should fully explain why that is so. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ahuva D. Sunshine 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.