Citation Nr: 1711787 Decision Date: 04/12/17 Archive Date: 04/19/17 DOCKET NO. 06-37 317A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a left knee disability. 2. Whether new and material evidence has been received to reopen a claim of service connection for a back disability. 3. Whether new and material evidence has been received to reopen a claim of service connection for a disability manifested by hair loss. 4. Whether new and material evidence has been received to reopen a claim of service connection for a skin disease. 5. Whether new and material evidence has been received to reopen a claim of service connection for a bilateral eye disability. 6. Whether new and material evidence has been received to reopen a claim of service connection for a headache disability. 7. Whether new and material evidence has been received to reopen a claim of service connection for a respiratory disease. 8. Entitlement to service connection for a gynecological disability, to include irregular menses and total hysterectomy. 9. Entitlement to service connection for bilateral degenerative arthritis of the knees. 10. Entitlement to service connection for a right elbow strain. 11. Entitlement to service connection for a left elbow disability. 12. Entitlement to service connection for hemorrhoids. 13. Entitlement to service connection for a left shoulder disability. 14. Entitlement to service connection for a right shoulder disability other than rotator cuff tendonitis. 15. Entitlement to service connection for a bilateral hand/finger disability. 16. Entitlement to service connection for bilateral peripheral venous insufficiency of the lower extremities (claimed as swollen calves). 17. Entitlement to service connection for bilateral hearing loss. 18. Entitlement to service connection for chronic constipation. 19. Entitlement to service connection for hematomas. 20. Entitlement to service connection for anemia. 21. Entitlement to service connection for intervertebral disc syndrome (IVDS) with degenerative arthritis of the thoracolumbar spine. 22. Entitlement to service connection for bilateral sciatic nerve impairment of the lower extremities (claimed as a bilateral burning sensation of the buttocks). 23. Entitlement to service connection for seborrheic dermatitis with hair loss. 24. Entitlement to service connection for a skin disease other than seborrheic dermatitis. 25. Entitlement to service connection for a bilateral eye disability. 26. Entitlement to service connection for migraine headaches. 27. Entitlement to service connection for a respiratory disease, to include asthma and sarcoidosis. 28. Entitlement to service connection for a right ear disability other than hearing loss and tinnitus. 29. Entitlement to service connection for allergic rhinitis (claimed as sinusitis). 30. Entitlement to service connection for hypertension. 31. Entitlement to an initial rating higher than 10 percent for a cervical strain. 32. Entitlement to an initial compensable rating for dysphagia. 33. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from September 1990 to May 1991 and from March 2003 to May 2004, which includes service in Southwest Asia. She had additional service with the Army Reserve. These matters come before the Board of Veterans' Appeals (Board) from August 2005, March and July 2009, and March 2014 rating decisions of the Department of Veterans Affairs (VA), Regional Offices (RO) in San Juan, Puerto Rico and Seattle, Washington. The RO in San Juan, Puerto Rico currently has jurisdiction over the Veteran's claims. In February 2009, November 2010, March 2012, and December 2013, the Board remanded the issues of entitlement to service connection for a right ear disability, a sinus disorder, and hypertension for further development. In September 2014, the Board remanded the issues of entitlement to service connection for a right ear disability, a sinus disorder, hypertension, bilateral hearing loss, a bilateral elbow disability, degenerative arthritis of the right knee, hysterectomy due to irregular menstruation, and bilateral peripheral neuropathy of the lower extremities, whether new and material evidence had been received to reopen a claim of service connection for left knee bursitis, and entitlement to higher ratings for PTSD and a cervical strain for further development. In July 2015, the RO granted a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, from October 4, 2014. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a November 2016 videoconference hearing at the RO. A transcript of the hearing has been associated with the file. In light of the Veteran's reported symptoms and contentions, the fact that her claimed hair loss and sinus symptoms have been attributed to seborrheic dermatitis and allergic rhinitis, and as the Board is granting service connection for seborrheic dermatitis with hair loss, the Board has recharacterized the claims of service connection for hair loss, sinusitis, and a skin disease as claims of service connection for seborrheic dermatitis with hair loss, allergic rhinitis, and a skin disease other than seborrheic dermatitis as set forth on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant's description of the claim, the symptoms described, and the information submitted or developed in support of the claim). Moreover, the Veteran had also perfected an appeal with regard to the issue of entitlement to service connection for a psychiatric disability. The Appeals Management Center (AMC) granted service connection for chronic PTSD by way of an April 2010 rating decision, and thereby resolved the appeal as to this issue. As a final preliminary matter, the Board notes that the issues of entitlement to service connection for a head scar, chronic fatigue syndrome, carpal tunnel syndrome, and benign neoplasms are included on an August 2016 "Certification of Appeal" form (VA Form 8). It does not appear, however, that these issues have ever been adjudicated by the AOJ, much less appealed to the Board. Hence, the Board does not currently have jurisdiction over these matters, and they will not be addressed at this time. These matters are referred to the AOJ for appropriate action, to include, if warranted, providing the appropriate forms to the Veteran. See 38 C.F.R. § 3.150(a) (2016) (providing for furnishing of appropriate application form upon request for VA benefits); 38 C.F.R. § 19.9(b) (2016) (continuing to provide for Board referral of unadjudicated claims). The issues of entitlement to service connection for a left elbow disability, a left shoulder disability, a right shoulder disability other than rotator cuff tendonitis, a bilateral hand/finger disability, bilateral hearing loss, hematomas, a skin disease other than seborrheic dermatitis, a bilateral eye disability, a right ear disability other than hearing loss and tinnitus, and hypertension, entitlement to higher initial ratings for a cervical strain and dysphagia, and entitlement to an increased rating for PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's claims of service connection for a left knee disability and a headache disability were originally denied in a June 1999 rating decision on the basis that there was no medical evidence that these disabilities were incurred in or caused by service; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 2. The Veteran's claims of service connection for a back disability and a skin disease were originally denied in the June 1999 rating decision on the basis that the disabilities pre-existed service and were not permanently aggravated therein; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 3. The Veteran's claims of service connection for a disability manifested by hair loss and a respiratory disease were originally denied in the June 1999 rating decision on the basis that there was no medical evidence of any such disabilities which were incurred in or caused by service; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 4. The Veteran's claim of service connection for a bilateral eye disability was originally denied in the June 1999 rating decision on the basis that her eye condition was a congenital or developmental defect and that there was no medical evidence of any eye condition recognized as a disability for VA compensation purposes which was incurred in or caused by service; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 5. Evidence received since the June 1999 RO decision includes information that was not previously considered and which relates to unestablished facts necessary to substantiate the claims of service connection for a left knee disability, a back disability, a disability manifested by hair loss, a skin disease, a bilateral eye disability, a headache disability, and a respiratory disease, the absence of which was the basis of the previous denial. 6. The Veteran has a current gynecological disability (to include irregular menses and total hysterectomy) which had its onset in service. 7. A left knee disability existed prior to the Veteran's second period of active duty from March 2003 to May 2004. 8. The evidence is at least evenly balanced as to whether the Veteran's pre-existing left knee disability was aggravated during service. 9. The Veteran has current degenerative arthritis of the right knee which had its onset in service. 10. The Veteran has a current right elbow strain which had its onset in service. 11. The Veteran has current hemorrhoids which had their onset in service. 12. The Veteran has current bilateral peripheral venous insufficiency of the lower extremities which had its onset in service. 13. Gastrointestinal symptoms existed prior to the Veteran's periods of active duty service. 14. The evidence is at least evenly balanced as to whether the Veteran's pre-existing gastrointestinal problems were aggravated during service. 15. The Veteran has current anemia related to her irregular menses. 16. A back disability existed prior to the Veteran's periods of active duty service. 17. The evidence is at least evenly balanced as to whether the Veteran's pre-existing back disability was aggravated during service. 18. The Veteran has current bilateral sciatic nerve impairment of the lower extremities related to her IVDS with degenerative arthritis of the thoracolumbar spine. 19. The Veteran has current seborrheic dermatitis with hair loss which had its onset in service. 20. The Veteran has current migraine headaches which had their onset in service. 21. The Veteran has a current respiratory disease (to include asthma and sarcoidosis) which had its onset in service. 22. The Veteran has current allergic rhinitis which had its onset in service. CONCLUSIONS OF LAW 1. The RO's June 1999 rating decision that denied the claims of service connection for a left knee disability, a back disability, a disability manifested by hair loss, a skin disease, a bilateral eye disability, a headache disability, and a respiratory disease is final. 38 U.S.C.A. § 7105(d)(3) (West 2014); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103 (2016). 2. The evidence received since the June 1999 RO decision is new and material and sufficient to reopen the claims of service connection for a left knee disability, a back disability, a disability manifested by hair loss, a skin disease, a bilateral eye disability, a headache disability, and a respiratory disease. 38 U.S.C.A. §§ 5107(b), 5108 (West 2014); 38 C.F.R. § 3.156(a). 3. The criteria for service connection for a gynecological disability (to include irregular menses and total hysterectomy) are met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2016). 4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for bilateral degenerative arthritis of the knees are met. 38 U.S.C.A. §§ 1110, 1137, 1153, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2016). 5. The criteria for service connection for a right elbow strain are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for hemorrhoids are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for bilateral peripheral venous insufficiency of the lower extremities are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 8. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for chronic constipation are met. 38 U.S.C.A. §§ 1110, 1137, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 9. The criteria for service connection for anemia are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2016). 10. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for IVDS with degenerative arthritis of the thoracolumbar spine are met. 38 U.S.C.A. §§ 1110, 1137, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 11. The criteria for service connection for bilateral sciatic nerve impairment of the lower extremities are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 12. The criteria for service connection for seborrheic dermatitis with hair loss are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for service connection for migraine headaches are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 14. The criteria for service connection for a respiratory disease (to include asthma and sarcoidosis) are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 15. The criteria for service connection for allergic rhinitis are met. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). In light of the Board's favorable decision in reopening the claims of service connection for a left knee disability, a back disability, a disability manifested by hair loss, a skin disease, a bilateral eye disability, a headache disability, and a respiratory disease and as the Board is granting the claims of service connection for a gynecological disability, bilateral degenerative arthritis of the knees, a right elbow strain, hemorrhoids, bilateral peripheral venous insufficiency of the lower extremities, chronic constipation, anemia, IVDS with degenerative arthritis of the thoracolumbar spine, bilateral sciatic nerve impairment of the lower extremities, seborrheic dermatitis with hair loss, migraine headaches, a respiratory disease, and allergic rhinitis, the claims are substantiated and there are no further VCAA duties at this time. Wensch v. Principi, 15 Vet App 362, 367-68 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). Analysis I. Applications to Reopen Generally, an RO decision denying a claim which has become final may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(d)(3). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The newly presented evidence is presumed to be credible for purposes of determining whether it is new and material. Savage v. Gober, 10 Vet. App. 488 (1997). For the purpose of determining whether new and material evidence has been presented to reopen a claim, the evidence for consideration is that which has been presented or secured since the last time the claim was finally disallowed on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). In this case, the RO initially denied the Veteran's claims of service connection for a left knee disability, a back disability, a disability manifested by hair loss, a skin disease, a bilateral eye disability, a headache disability, and a respiratory disease by way of a June 1999 rating decision. The claims of service connection for a left knee disability and a headache disability were denied on the basis that there was no medical evidence that these disabilities were incurred in or caused by service. Specifically, the RO explained that the Veteran was treated for left knee pain in June and November 1991 following her initial period of service and was diagnosed as having left knee infrapatellar bursitis during a May 1995 VA examination. Also, she was diagnosed as having cluster type headaches/migraine headaches in September 1993. Regardless, there was no evidence of any left knee problems or diagnosed headache disability during the period of service from September 1990 to May 1991. The Veteran's claims of service connection for a back disability and a skin disease were denied on the basis that the disabilities pre-existed service and were not permanently aggravated therein. The RO explained that the Veteran was treated for a lumbosacral strain prior to active service in June 1986, but that there was no evidence of any treatment for back problems during the period of service from September 1990 to May 1991. Also, the Veteran was treated for skin problems (including acne) prior to service in 1988. The claims of service connection for a disability manifested by hair loss and a respiratory disease were denied on the basis that there was no medical evidence of any such disabilities which were incurred in or caused by service. Specifically, the Veteran reported hair loss and shortness of breath, but examinations conducted in August 1994, June 1995, and January 1999 did not reveal any such disabilities. Lastly, the claim of service connection for a bilateral eye disability was denied on the basis that the Veteran's eye condition was a congenital or developmental defect and that there was no medical evidence of any eye condition recognized as a disability for VA compensation purposes which was incurred in or caused by service. The RO explained that other than a single record of treatment for right eye irritation in May 1991, there was no evidence of any treatment for an eye condition other than refractive error, which is considered a congenital or developmental defect. The Veteran was notified of the RO's June 1999 decision, she did not appeal the decision within one year of its issuance, and new and material evidence was not received within that year. Therefore, the June 1999 decision became final. See 38 U.S.C.A. § 7105(d)(3); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. Pertinent new evidence received since the June 1999 denial includes the Veteran's service treatment records for her second period of service from March 2003 to May 2004, the reports of VA Gulf War, eye, and neurological examinations dated in May 2009, a February 2013 VA examination report, and the Veteran's testimony during the November 2016 hearing. This additional evidence reflects that the Veteran's hair loss has been attributed to seborrheic dermatitis and that she has also been diagnosed as having bilateral eye floaters, bilateral cataracts, asthma, and sarcoidosis. The additional evidence also reflects that the Veteran experienced left knee, back, hair loss, skin, eye, headache, and respiratory problems during her second period of service and that such symptoms have continued in the years since service. Moreover, the evidence includes a medical opinion that the seborrheic dermatitis is likely related to service. Hence, the additional evidence pertains to elements of the claims that were previously found to be lacking and raises a reasonable possibility of substantiating the claims by indicating that the Veteran has a current skin disease manifested by hair loss, a current bilateral eye disability, and current respiratory diseases and suggesting that the claimed left knee disability, back disability, skin disease manifested by hair loss, eye disability, headache disability, and respiratory disease may have been incurred or aggravated in service. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (evidence raises a reasonable possibility of substantiating a claim if it would trigger VA's duty to provide an examination). The evidence is, therefore, new and material, and the claims of service connection for a left knee disability, a back disability, a disability manifested by hair loss, a skin disease, a bilateral eye disability, a headache disability, and a respiratory disease are reopened. II. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. VA has amended 38 C.F.R. § 3.310 to reflect that it will not concede aggravation unless certain additional conditions are met. 38 C.F.R. § 3.310 (b). As service connection for a claimed disability is not being granted on the basis of aggravation by a service-connected disability, it is not necessary to determine which version of 38 C.F.R. § 3.310 is applicable in this case. Under 38 C.F.R. § 3.303(b), an alternative method of establishing service connection for certain chronic disabilities listed in 38 C.F.R. § 3.309 (a), including arthritis and organic diseases of the nervous system, is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a). In relevant part, 38 U.S.C.A. § 1154(a) (West 2014) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. §§ 1153, 1137; 38 C.F.R. § 3.306 (a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. §§ 3.304, 3.306(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Gynecological Disability, Degenerative Arthritis of the Right Knee, Right Elbow Strain, Hemorrhoids, Peripheral Venous Insufficiency, Anemia, Seborrheic Dermatitis with Hair Loss, Migraines, Respiratory Disease, Allergic Rhinitis The reports of VA Gulf War, gynecological, and neurological examinations dated in May 2009, a July 2009 VA primary care treatment note, a November 2009 VA internal medicine pre-operative evaluation note, a December 2009 VA inpatient interdisciplinary surgical note, an April 2012 VA examination report, and a February 2013 VA examination report reflect that the Veteran has been diagnosed as having irregular menses, degenerative arthritis of the right knee, a right elbow strain, hemorrhoids, bilateral peripheral venous insufficiency of the lower extremities, anemia, seborrheic dermatitis with hair loss, migraine headaches, asthma, sarcoidosis, and allergic rhinitis. She underwent a total hysterectomy in December 2009 due to menorrhagia (i.e., irregular menstruation). Thus, current disabilities have been demonstrated. There is also evidence of gynecological, right knee, right elbow, hemorrhoid, lower extremity venous, skin/hair, headache, respiratory, and rhinitis symptoms in service and evidence of continuous symptoms in the years since service which indicates that the current disabilities were incurred in service. Service treatment records include October, June, and December 2003 and February and March 2004 records of treatment for a cough, sneezing, nasal congestion, chest pressure with inhalation, headaches, a skin rash, hair loss, menstrual irregularity, and a facial lesion. The Veteran was treated with albuterol for her respiratory symptoms. She reported on an April 1991 report of medical history form that she had a history of headaches, leg cramps, and chest pressure on deep inhalation. She reported on a March 2004 "Post Deployment Health Assessment" form (DD Form 276) that during her deployment to Kuwait and Iraq she experienced a chronic cough, runny nose, and difficulty breathing. Also, a July 2011 "Statement of Medical Examination and Duty Status" form (DA Form 2173) and undated DA Forms 2173 indicate that she developed erythema, a skin rash, a dry cough, sneezing, congestion, headaches, hair loss, and irregular menstruation during active service in 2003 and 2004 while serving in Kuwait and Iraq. The Veteran's post-service medical records and lay statements (including her testimony during the November 2016 hearing and her reports during the May 2009, April 2012, and February 2013 VA examinations) indicate that she began to experience irregular menstruation, right knee symptoms, right elbow symptoms, hemorrhoids, leg swelling, hair loss/skin symptoms, headaches, lung problems, and upper respiratory symptoms during service and that such symptoms have continued in the years since that time. The physician who conducted the May 2009 VA Gulf War examination opined that the Veteran's bilateral peripheral venous insufficiency of the lower extremities, hemorrhoids, and seborrheic dermatitis with hair loss were most likely caused by or a result of service. He essentially reasoned that these disabilities began just after the Veteran returned from Iraq. The physician who conducted an April 2012 VA examination opined that the Veteran's allergic rhinitis was not incurred in or caused by service. The examiner reasoned that there was no evidence of any treatment for or diagnosis of allergic rhinitis in the Veteran's service treatment records, that there was no evidence of allergic rhinitis in her VA treatment records until March 2010, and that there was no evidence of any treatment for allergic rhinitis in her VA treatment records until February 2011. The April 2012 opinion is of little, if any, probative value because it is entirely based on a lack of evidence of continuous treatment for allergic rhinitis since service. The examiner did not acknowledge or discuss the clinical evidence of upper respiratory symptoms in service and discounted, without explanation, the Veteran's reports of continuous upper respiratory symptoms in the years since service. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran's reports of symptoms and history. Buchanan v. Nicholson, 451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006) (noting that VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran's] disability such that his claim for service connection could be proven without contemporaneous medical evidence"). The Veteran is competent to report a continuity of gynecological, right knee, right elbow, hemorrhoid, bilateral leg, skin/hair, headache, lung, and upper respiratory symptomatology in the years since service and her reports are consistent with the evidence of record. Thus, the Board finds that the reports of a continuity of symptomatology in the years since service are credible. In sum, the evidence reflects that the Veteran experienced gynecological, right knee, right elbow, hemorrhoid, bilateral leg, skin/hair, headache, lung, and upper respiratory symptoms in service and that there have been continuous symptoms in the years since service. She has also been diagnosed as having current irregular menses and total hysterectomy, degenerative arthritis of the right knee, a right elbow strain, hemorrhoids, bilateral peripheral venous insufficiency of the lower extremities, seborrheic dermatitis with hair loss, migraine headaches, asthma, sarcoidosis, and allergic rhinitis. In light of this evidence and the June 2009 opinions, the evidence is at least evenly balanced as to whether the evidence indicates that the current disabilities had their onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for the currently diagnosed gynecological disability, degenerative arthritis of the right knee, right elbow strain, hemorrhoids, bilateral peripheral venous insufficiency of the lower extremities, seborrheic dermatitis with hair loss, migraine headaches, asthma, sarcoidosis, and allergic rhinitis is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. With respect to anemia, the physician who conducted the May 2009 VA Gulf War examination opined that the disability was most likely caused by or a result of service because it was "secondary to irregular menstruations." Also, a July 2009 VA primary care treatment note includes a diagnosis of anemia secondary to metrorrhagia. Hence, the evidence supports a conclusion that the Veteran's current anemia is caused by her now service-connected irregular menstruation. There are no medical opinions contrary to this conclusion with respect to the diagnosed anemia. Thus, resolving reasonable doubt in favor of the Veteran, the Board concludes that her current anemia was caused by her now service-connected irregular menstruation. Accordingly, service connection for anemia is also granted. 38 U.S.C.A. §§ 1110 , 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. B. Degenerative Arthritis of the Left Knee, Chronic Constipation, IVDS with Degenerative Arthritis of the Thoracolumbar Spine, and Sciatic Nerve Impairment The May 2009 VA Gulf War examination report and the February 2013 VA examination report indicate that the Veteran has been diagnosed as having degenerative arthritis of the left knee, chronic constipation, IVDS with degenerative arthritis of the thoracolumbar spine, and bilateral sciatic nerve impairment of the lower extremities. Thus, current disabilities have been demonstrated. As explained below, the Board finds that the Veteran had left knee problems which began following her first period of service and which pre-existed her second period of service. Also, she had back and gastrointestinal problems which pre-existed both her periods of active duty. The pre-existing left knee, gastrointestinal, and back disabilities were aggravated during service. Service treatment records indicate that the Veteran was treated for abdominal cramps, vomiting, and back pain in June 1986 and was diagnosed as having a mild lumbosacral strain. A June 1991 "Individual Sick Slip" form ("DD Form 689) and a June 1991 VA medical certificate reflect that she reported a one month history of left knee pain and swelling with limited movement. An examination of the knee revealed swelling and pain to movement. A diagnosis of "left knee bursitis vs. tendonitis" was provided. A November 1991 VA medical certificate and a May 1995 VA examination report reflect that she continued to experience left knee pain with prolonged walking and running. Examinations revealed left knee crepitus and tenderness. The Veteran was diagnosed as having left knee infrapatellar bursitis. In addition, she reported during the May 2009 VA examination that she had experienced chronic constipation prior to her active service in Iraq. A review of the claims file reflects that there is a February 1986 report of an enlistment examination at the time of the Veteran's entry into the Army Reserve, but that there are no enlistment examinations of record for the Veteran's periods of active duty from September 1990 to May 1991 and from March 2003 to May 2004. Also, a review of the record does not suggest that such examinations were conducted. In Smith v. Shinseki, 24 Vet. App. 40, 45 (2010), it was clarified that the presumption of soundness applies when a veteran has been "examined, accepted, and enrolled for service," and where that examination revealed no "defects, infirmities, or disorders." 38 U.S.C. § 1111 (West 2014). Plainly, the statute requires that there be an examination prior to entry into the period of service on which the claim is based. See Crowe v. Brown, 7 Vet. App. 238, 245 (1994) (holding that the presumption of sound condition "attaches only where there has been an induction examination in which the later-complained-of disability was not detected" (citing Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991)). Accordingly, because enlistment examinations are not of record for the Veteran's periods of active service, the presumption of soundness does not apply to these periods. See Crowe, supra. Thus, as there is medical evidence of left knee problems which began following her first period of active service and which pre-existed her second period of active service, and as there is medical evidence of back and gastrointestinal problems which pre-existed both her periods of active service, the only means by which direct service connection may be established for these disabilities is by showing that they were permanently worsened beyond their natural progression during service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. As for whether the Veteran's pre-existing left knee, back, and gastrointestinal disabilities were aggravated by service, the evidence indicates that they became symptomatic in service. Service treatment records include an October 1990 record of treatment for abdominal pain. An examination revealed mild tenderness to the lower abdomen bilaterally. The Veteran was evaluated for back and lower abdominal pain in April 1991 and was diagnosed as having possible chronic constipation. The report of an April 1991 demobilization examination includes a notation referencing a pulsating abdominal mass and the Veteran reported on an April 1991 report of medical history form that she had experienced recurrent back pain since her arrival in Saudi Arabia. She was evaluated for a one month history of back pain in March 2004 and a July 2011 DA Form 2173 and other undated DA Forms 2173 indicate that she injured her back in March 2004 while moving and lifting heavy equipment. An examination in March 2004 revealed lumbosacral muscular tenderness and discomfort with motion and a diagnosis of mechanical back pain was provided. In addition, the Veteran reported on the March 2004 "Post-Deployment Health Assessment" form that during her deployment to Southwest Asia from March 2003 to April 2004 she experienced back pain. Moreover, the Veteran reported during the May 2009 and February 2013 VA examinations and during the November 2016 hearing that she experienced left knee problems with prolonged marching in service, that she injured her left knee when she fell while carrying equipment in Saudi Arabia, that her constipation worsened during her service in Iraq because she often had to hold in her bowel movements due to unsanitary facilities and frequent lack of facilities, and that she experienced back pain in service. The post-service treatment records and lay evidence reflect that left knee, constipation, and back symptomatology have continued in the years since service. Furthermore, the physician who conducted the May 2009 VA Gulf War examination opined that the Veteran's chronic constipation was most likely permanently aggravated by service. This opinion was based on the fact that the chronic constipation began before her active service, but that it worsened during her service in Iraq and continued to be an active problem. This opinion was based upon an examination of the Veteran and a review of her medical records and reported history, and it is accompanied by a specific rationale which is consistent with the evidence of record. Hence, the May 2009 opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). In light of the documented and reported symptoms during active service, as described above, the Board finds that there was an increase in disability during service and aggravation of the underlying left knee, gastrointestinal, and back disabilities is presumed. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306 (a). Additionally, the Veteran is competent to report left knee, gastrointestinal, and back symptoms as well as the continuance of such symptoms in the years since service. See Jandreau, 492 F.3d at 1377; Buchanan, 451 lisa82@example.com. Also, her reports are generally consistent with the evidence of record and treatment records document a history of left knee, gastrointestinal, and back symptomatology in the years since service. Thus, the Board concludes that the Veteran's reports of continuing left knee, gastrointestinal, and back symptoms in the years since service are credible. There have been no findings that the increase in the Veteran's left knee, gastrointestinal, and back disabilities was due to the natural progression of the diseases. Therefore, the Board must conclude that the pre-existing left knee, gastrointestinal, and back disabilities were aggravated in service. The record shows current findings of left knee, gastrointestinal, and back disabilities and a continuity of symptomatology in the years since service. In light of this evidence and resolving all reasonable doubt in the Veteran's favor, service connection is granted for the currently diagnosed degenerative arthritis of the left knee, chronic constipation, and IVDS with degenerative arthritis of the thoracolumbar spine. 38 U.S.C.A. §§ 1110, 1153, 5107(b); 38 C.F.R. §§ 3.303, 3.306. Lastly, the physician who conducted the February 2013 VA examination concluded that the Veteran's claimed burning sensation on both sides of the buttocks was associated with his lumbar IVDS. The most likely peripheral nerve involved was the sciatic nerve and "[t]he etiology of the peripheral nerve disease is lumbar IVDS." Therefore, the evidence indicates that the Veteran's current bilateral sciatic nerve impairment of the lower extremities (claimed as a bilateral burning sensation of the buttocks) is caused by her now service-connected IVDS with degenerative arthritis of the thoracolumbar spine. There are no medical opinions contrary to this conclusion. Resolving reasonable doubt in favor of the Veteran, service connection for bilateral sciatic nerve impairment of the lower extremities is also granted. 38 U.S.C.A. §§ 1110 , 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. ORDER The application to reopen the claim of service connection for a left knee disability is granted. The application to reopen the claim of service connection for a back disability is granted. The application to reopen the claim of service connection for a disability manifested by hair loss is granted. The application to reopen the claim of service connection for a skin disease is granted. The application to reopen the claim of service connection for a bilateral eye disability is granted. The application to reopen the claim of service connection for a headache disability is granted. The application to reopen the claim of service connection for a respiratory disease is granted. Entitlement to service connection for a gynecological disability (to include irregular menses and total hysterectomy) is granted. Entitlement to service connection for bilateral degenerative arthritis of the knees is granted. Entitlement to service connection for a right elbow strain is granted. Entitlement to service connection for hemorrhoids is granted. Entitlement to service connection for bilateral peripheral venous insufficiency of the lower extremities is granted. Entitlement to service connection for chronic constipation is granted. Entitlement to service connection for anemia is granted. Entitlement to service connection for intervertebral disc syndrome with degenerative arthritis of the thoracolumbar spine is granted. Entitlement to service connection for bilateral sciatic nerve impairment of the lower extremities is granted. Entitlement to service connection for seborrheic dermatitis with hair loss is granted. Entitlement to service connection for migraine headaches is granted. Entitlement to service connection for a respiratory disease (to include asthma and sarcoidosis) is granted. Entitlement to service connection for allergic rhinitis is granted. REMAND In its September 2014 remand, the Board instructed the AOJ to schedule the Veteran for a VA examination to assess the nature of any right ear disability and to provide a medical opinion as to the etiology of any such disability. The AOJ was also instructed to obtain a medical opinion from the examiner who conducted the February 2013 VA examination as to when the Veteran's hypertension had its onset and, if it pre-existed service, whether it was permanently aggravated in service. Lastly, the AOJ was instructed to issue a statement of the case as to the matter of entitlement to an increased rating for PTSD. A review of the claims file reflects that the Veteran was never afforded the requested VA examination, that the requested medical opinion has not been obtained, and that no statement of the case addressing the matter of entitlement to an increased rating for PTSD was ever issued. A remand by the Board confers on an appellant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms. Stegall v. West, 11 Vet. App. 268, 271 (1998). Where a remand order of the Board is not complied with, the Board itself errs in failing to ensure compliance. Id. at 270-71. As the Veteran has not been afforded a VA examination for her claimed right ear disability, an opinion has not been obtained as to the etiology of her hypertension, and a statement of the case pertaining to the matter of entitlement to an increased rating for PTSD has not been issued, the Board is unfortunately compelled to remand the claims of service connection for hypertension and a right ear disability other than hearing loss and tinnitus and entitlement to an increased rating for PTSD for compliance with the instructions in its September 2014 remand. Furthermore, although it appears that the issues of entitlement to service connection for a right ear disability and hypertension have been returned to the Board for further consideration, it is unclear as to whether they were actually re-certified to the Board. Hence, in addition to completing the development as set forth above, the AOJ should determine the overall status of these claims. As for the claim of service connection for a left elbow disability, the February 2013 VA examination report documents the Veteran's reports of bilateral elbow symptoms. The only diagnosis attributed to the Veteran's claimed bilateral elbow disability, however, was a right elbow strain. It is unclear as to whether the diagnosed elbow strain was intended to pertain to both elbows or whether the examiner concluded that the Veteran did not have any left elbow disability. There is otherwise no specific left elbow disability identified in the claims file. Additionally, the February 2013 examination report includes a diagnosis of a left shoulder strain, but the examiner did not provide any opinion as to the etiology of this disability. Therefore, the Board finds that a remand is necessary to afford the Veteran new VA examinations to determine whether she has a current left elbow disability and to obtain medical opinions as to the etiology of any such disability and as to the etiology of any current shoulder disability other than right rotator cuff tendonitis. With respect to the claim of service connection for hematomas, the examiner who conducted the May 2009 VA examination concluded that the Veteran's hematomas had resolved and that there was no evidence of any bruises during the examination. The examiner opined that the claimed hematomas were not caused by or a result of service because they had resolved and were, therefore, not a chronic condition. The May 2009 hematoma opinion is insufficient because although no hematomas were present at the time of the examination, the examiner did not acknowledge an August 2008 VA primary care treatment note which reflects that the Veteran had lower extremity hematomas. Also, bruising was visible on her arms during the November 2016 Board hearing (see pages 59-61 of the hearing transcript). In this regard, the requirement for a current disability is satisfied if there is evidence of the disability at any time since approximately October 2008 when the Veteran's claim of service connection for hematomas was received, even if the disability is currently in remission or has completely resolved. McClain v. Nicholson, 21 Vet. App. 319 (2008). Thus, a remand is necessary to afford the Veteran a new VA examination to assess the nature and etiology of the claimed hematomas. With respect to the claim of service connection for a bilateral eye disability, the Veteran contends that she began to experience eye problems in service due to exposure to environmental contaminants in Southwest Asia and that eye problems have continued in the years since that time. She was afforded VA examinations in May 2009 and February 2013 and was diagnosed as having, among other things, bilateral floaters and bilateral cataracts. The examiner who conducted the May 2009 examination opined that the floaters were not related to service. There was no specific explanation or rationale provided for this opinion. The February 2013 examiner did not provide any opinion as to the etiology of the cataracts. The May 2009 opinion is insufficient because it is not accompanied by any explanation or rationale. See Nieves-Rodriguez, 22 Vet. App. at 304. In light of the fact that the May 2009 opinion is inadequate and that no opinion was provided as to the etiology of the current cataracts, a new examination is necessary to assess the nature and etiology of any current eye disability. As for the appeal for a higher initial rating for the service-connected cervical spine disability, disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2016), pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011). Moreover, the Court recently held that the joints involved should be tested for pain on both active and passive motion, in weight bearing and non weight bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). In this case, the Veteran was afforded a VA examination in February 2015 to determine the severity of her service-connected cervical spine disability. The ranges of active motion of the cervical spine were reported and it was noted that there was objective evidence of pain with all ranges of motion and that the pain caused functional loss. It is unclear from the February 2015 examination report the points at which pain began during the ranges
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