series: legacy

judge_norm: ERIC S LEBOFF

disposition: granted

condition: hypertension

disposition: denied

condition: tinnitus

disposition: remanded

text:
Citation Nr: 1029000
Decision Date: 08/03/10    Archive Date: 08/16/10

DOCKET NO.  09-30 758	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Cleveland, Ohio

THE ISSUES

1.  Entitlement to an initial compensable evaluation for
residuals of left ring finger fracture.

2.  Entitlement to a compensable evaluation for residuals of left
wrist fracture, chronic sprain.

3.  Entitlement to service connection for hypertension.

4.  Entitlement to service connection for right arm injury.

5.  Entitlment to service connection for a low back disability.

6.  Entitlement to service connection for migraine headaches.

7.  Entitlement to service connection for tinnitus, claimed as
right ear injury.

8.  Entitlement to service connection for carpal tunnel syndrome.

9.  Entitlement to service connection for bilateral leg syndrome.

10.  Entitlement to service connection for a left ankle
disability.

11.  Entitlement to service connection for left bottom tooth.

REPRESENTATION

Appellant represented by:	Disabled American Veterans

WITNESSES AT HEARING ON APPEAL

Appellant and her spouse

ATTORNEY FOR THE BOARD

M. Carsten, Counsel

INTRODUCTION

The Veteran served on active duty from October 1981 to April
1982, October 1997 to February 1998, July 2003 to March 2004, and
October 2004 to February 2006.  She served in Kuwait from January
2005 to January 2006 and is a Persian Gulf veteran.  See
38 C.F.R. � 3.317(d) (2009).  She also had additional Reserve
service.

This matter comes before the Board of Veterans' Appeals (Board)
on appeal from a November 2007 decision by the Department of
Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio.

In March 2010, a hearing was held before the undersigned sitting
at the RO.  At that time, the Veteran submitted additional
evidence with a waiver of RO jurisdiction.  See 38 C.F.R.
� 20.1304 (2009).

The issues of entitlement to an initial compensable evaluation
for residuals of a left ring finger fracture; entitlement to a
compensable evaluation for residuals of left wrist fracture;
entitlement to service connection for migraine headaches;
entitlement to service connection for left ankle disability; and
entitlement to service connection for left bottom tooth are
addressed in the REMAND portion of the decision below and are
REMANDED to the RO via the Appeals Management Center (AMC), in
Washington, DC.

FINDINGS OF FACT

1.  Hypertension clearly and unmistakably existed prior to the
Veteran's periods of active duty beginning in July 2003 and
October 2004; however, there is no clear and unmistakable
evidence that it was not aggravated during active service.

2.  The preponderance of the evidence is against finding that the
Veteran has a current right arm disability that is related to
active military service or events therein; there is no evidence
of right arm arthritis manifested to a compensable degree within
one year following discharge from service.

3.  The preponderance of the evidence is against finding a
currently diagnosed low back disability; there is affirmative
evidence that an undiagnosed illness manifested by low back pain
was not incurred during service in Kuwait.

4.  Service records document complaints of ringing in the ears
during deployment and the Veteran has provided competent lay
testimony regarding continuing symptoms.

5.  The preponderance of the evidence is against finding a
confirmed diagnosis of carpal tunnel syndrome; there is
affirmative evidence that an undiagnosed illness manifested by
pain or neurologic signs and symptoms related to the wrists was
not incurred during service in Kuwait.

6.  The preponderance of the evidence is against finding that the
Veteran has a currently diagnosed disability of the bilateral
legs that is related to active military service or events
therein; there is affirmative evidence that an undiagnosed
illness manifested by pain or neurologic signs and symptoms
related to the bilateral legs was not incurred during service in
Kuwait.

CONCLUSIONS OF LAW

1.  Service connection for hypertension is warranted.
38 U.S.C.A. �� 1110, 1111, 1131, 5103, 5103A (West 2002 & Supp.
2009); 38 C.F.R. �� 3.159, 3.303, 3.304, 3.306, 3.307, 3.309
(2009).

2.  Service connection for a right arm disability is not
warranted.  38 U.S.C.A. �� 1110, 1131, 5103, 5103A; 38 C.F.R.
�� 3.159, 3.303, 3.307, 3.309.

3.  Service connection for a low back disability is not
warranted.  38 U.S.C.A. �� 1110, 1117, 1131, 5103, 5103A;
38 C.F.R. �� 3.159, 3.303, 3.307, 3.309, 3.317.

4.  Service connection for tinnitus is warranted.  38 U.S.C.A.
�� 1110, 1131, 5103, 5103A; 38 C.F.R. �� 3.159, 3.303.

5.  Service connection for carpal tunnel syndrome is not
warranted.  38 U.S.C.A. �� 1110, 1117, 1131, 5103, 5103A;
38 C.F.R. �� 3.159, 3.303, 3.317.

6.  Service connection for bilateral leg syndrome is not
warranted.  38 U.S.C.A. �� 1110, 1117, 1131, 5103, 5103A;
38 C.F.R. �� 3.159, 3.303, 3.317.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I. Veterans Claims Assistance Act of 2000 (VCAA)

Under the VCAA, when VA receives a complete or substantially
complete application for benefits, it is required to notify the
claimant and his or her representative, if any, of any
information and medical or lay evidence that is necessary to
substantiate the claim.  38 U.S.C.A. � 5103(a); 38 C.F.R. �
3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002).

VCAA notice consistent with 38 U.S.C.A. � 5103(a) and 38 C.F.R.
� 3.159(b) must inform the claimant of any information and
evidence not of record: (1) that is necessary to substantiate the
claim; (2) that VA will seek to provide; and, (3) that the
claimant is expected to provide.

The VCAA notice requirements apply to all five elements of a
service connection claim.  These are: (1) veteran status; (2)
existence of a disability; (3) a connection between a veteran's
service and the disability; (4) degree of disability; and (5)
effective date of the disability.  Dingess v. Nicholson, 19 Vet.
App. 473 (2006).

Notice must be provided prior to an initial unfavorable decision
by the agency of original jurisdiction (AOJ).  Pelegrini v.
Principi, 18 Vet. App. 112 (2004).  However, if VCAA notice is
provided after the initial decision, such a timing error can be
cured by subsequent readjudication of the claim, as in a
statement of the case (SOC) or supplemental statement of the case
(SSOC).  Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006).

In May 2007, prior to the decision on appeal, the RO sent the
Veteran a letter advising her of the evidence needed to
substantiate claims of service connection for right arm injury,
low back pain, carpal tunnel syndrome, and bilateral leg
condition, to include notice of what part of that evidence is to
be provided by the claimant and what part VA will attempt to
obtain.  This letter also provided notice as to how disability
ratings and effective dates are determined.

Under the VCAA, VA also has a duty to assist the Veteran in the
development of a claim.  This includes assisting with procuring
relevant records and providing a VA examination when necessary.
38 U.S.C.A. � 5103A; 38 C.F.R. � 3.159.

The claims file contains service treatment records, VA medical
center records, and private records.  The Veteran was provided a
VA examination in October 2007.  On review, the Board finds the
examination adequate and has determined no basis for further
examination or medical opinion with regard to the claims decided
herein.  See 38 C.F.R. � 3.159(c)(4); McLendon v. Nicholson, 20
Vet. App. 79 (2006).

As explained below, this decision grants entitlement to service
connection for hypertension and for tinnitus, claimed as a right
ear injury.  Therefore, a detailed explanation of how VA complied
with the VCAA is not necessary regarding these issues.

II. Analysis

In general, service connection will be granted for disability
resulting from injury or disease incurred in or aggravated by
active military service.  38 U.S.C.A. �� 1110, 1131; 38 C.F.R. �
3.303.  A preexisting injury or disease will be considered to
have been aggravated by active military 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 C.F.R. � 3.306(a).

The term "active military, naval, or air service" includes
active duty, any period of active duty for training during which
the individual concerned was disabled or died from a disease or
injury incurred or aggravated in line of duty; and any period of
inactive duty for training during which the individual concerned
was disabled or died (i) from an injury incurred or aggravated in
line of duty; or (ii) from an acute myocardial infarction, a
cardiac arrest, or a cerebrovascular accident occurring during
such training.  38 U.S.C.A. � 101(24) (West 2002); 38 C.F.R. �
3.6(a) (2009).

The term "active duty for training" is, inter alia, full-time
duty in the Armed Forces performed by Reserves for training
purposes or by members of the National Guard of any State.  38
U.S.C.A. � 101(22); 38 C.F.R. � 3.6(c).  The term "inactive duty
for training" means, inter alia, duty other than full-time duty
prescribed for Reserves or the National Guard of any State.  38
U.S.C.A. � 101(23); 38 C.F.R. � 3.6(d).

Service connection may be granted for any disease diagnosed after
discharge, when all the evidence, including that pertinent to
service, establishes that the disability was incurred in service.
38 C.F.R. � 3.303(d).

In order to establish service connection or service-connected
aggravation for a present disability the 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.  Shedden v.
Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).  Without a
currently diagnosed disability, service connection may not be
granted.  See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

Service connection will also be presumed for certain chronic
diseases, including hypertension and arthritis, if manifest to a
compensable degree within one year after discharge from service.
38 U.S.C.A. �� 1101, 1112 (West 2002 & Supp. 2009); 38 C.F.R. ��
3.307, 3.309.

Additionally, service connection can be established for a Persian
Gulf veteran who exhibits objective indications of a qualifying
chronic disability which became manifest either during active
service in the Southwest Asia theater of operations during the
Persian Gulf War, or to a degree of 10 percent or more not later
than December 31, 2011; and by history, physical examination, and
laboratory tests cannot be attributed to any known clinical
diagnosis.  38 U.S.C.A. � 1117; 38 C.F.R. � 3.317(a)(1).

Compensation shall not be paid under these provisions if there is
(1) affirmative evidence that an undiagnosed illness was not
incurred during active military service in the Southwest Asia
theater of operations during the Persian Gulf War; or (2) if
there is affirmative evidence that an undiagnosed illness was
caused by a supervening condition or event that occurred between
a veteran's most recent departure from active duty in the
Southwest Asia theater of operations during the Persian Gulf War
and the onset of the illness; or (3) if there is affirmative
evidence that the illness is the result of a veteran's own
willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. �
3.317(c).

A veteran is presumed to have been in sound condition when
examined, accepted, and enrolled for service except as to
defects, infirmities, or disorders noted at the time of
examination, acceptance, enrollment, or where clear and
unmistakable evidence demonstrates that the injury or disease
existed before acceptance and enrollment and was not aggravated
by such service.  38 U.S.C.A. � 1111; 38 C.F.R. � 3.304.

In cases where the disease or injury at issue is not noted on an
entrance examination, a two-pronged test is for consideration in
determining whether the presumption of soundness has been
rebutted.  First, VA must show by clear and unmistakable evidence
that the disease or injury existed prior to service.  Second, VA
must show by clear and unmistakable evidence that the preexisting
disease or injury was not aggravated by service.  See Wagner v.
Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July
16, 2003).

In determining whether a condition preexisted service, the
Veteran's medical history, accepted medical principles, evidence
regarding the basic character, origin and development of the
condition, and lay and medical evidence concerning the inception,
development and manifestations of the condition must be
considered.  38 C.F.R. � 3.304(b); see Quirin v. Shinseki, 22
Vet. App. 390, 396 (2009).

When there is an approximate balance of positive and negative
evidence regarding the merits of an issue material to the
determination of the matter, the benefit of the doubt in
resolving each such issue shall be given to the claimant. 38
U.S.C.A. � 5107(b) (West 2002); 38 C.F.R. � 3.102 (2009).

Hypertension

In March 2007, the Veteran submitted a claim of entitlement to
service connection for hypertension.  She reported that her
disability began in July 2003.  In November 2007, the RO denied
the claim, finding that hypertension existed prior to service and
that there was no evidence that the condition permanently
worsened as a result of service.  The Veteran disagreed with this
decision and subsequently perfected this appeal.

In her January 2008 notice of disagreement, the Veteran denied a
history of hypertension prior to service.  She asserted that her
hypertension was aggravated by being deployed on two occasions.
At the March 2010 hearing, the Veteran testified that she has had
hypertension for about five or six years.  She reported that in
2003 her blood pressure was very high and she needed medication
to bring it down.  It was her understanding that she would be
getting out on a medical discharge but when she tried to retire,
they sent her to the next war.

On VA examination in October 2007, the Veteran gave a history of
hypertension since 2002.  The examiner indicated that she had
severe hypertension that was uncontrolled under her current
medications.  Subsequent VA records show continued treatment for
hypertension and difficulties controlling the same.  A note dated
in June 2009 includes an assessment of uncontrolled hypertension.
Another note dated in February 2010 includes an assessment of
refractory hypertension.

Records associated with the Veteran's first and second periods of
service do not show any treatment for or diagnosis of
hypertension, and there is no evidence of hypertension manifested
to a compensable degree within one year following discharge from
either of these periods of service.

On review, it does not appear that the Veteran was afforded a
physical examination prior to entering service in July 2003 or
October 2004.  As hypertension was not noted, the Veteran is
entitled to the presumption of soundness.  The Board observes
that a pre-deployment health assessment was conducted in August
2003, after entry onto active duty.  At that time, the Veteran
denied any medical problems and she was considered deployable.

As to whether the presumption of soundness has been rebutted, the
Board finds that there is clear and unmistakable evidence that
the Veteran had hypertension prior to both her third and fourth
periods of service.  Indeed, a July 2002 private emergency room
record indicates that the Veteran was seen with complaints of a
headache.  At that time, she reported a history of being on blood
pressure medicines, which was stopped after about two weeks by
her primary care physician.  The diagnosis was migraine headache
with history of hypertension.  A private emergency room record
dated in November 2002 reflects complaints of abdominal pain, and
the examiner noted that the Veteran was known to have
hypertension.  Additionally, reserve records show that the
Veteran was seen in the emergency room in March 2003 with
complaints of a headache.  A history of hypertension was
documented and it was noted that she was on Norvasc.  A July 2003
record from the Veteran's private physician indicates that the
Veteran was going on active military duty and needed a 90 day
prescription for blood pressure medications faxed.

The foregoing constitutes clear and unmistakable evidence that
hypertension preexisted the Veteran's period of active service
that began in 2003.  As noted above, however, the Board can
conclude that the presumption has been rebutted only if there is
also clear and unmistakable evidence that the condition was not
aggravated by service.  Here, the Board finds no such evidence.

In making this determination, the Board observes that service
treatment records show frequently elevated blood pressure
readings and difficulties controlling hypertension.  For example,
on November 1, 2004, the Veteran's blood pressure was 165/104.
Medication was changed to Lisinopril.  A note dated November 11,
2004, indicates that blood pressure was still too high and
Lisinopril was increased.  Note dated December 8, 2004 indicates
that Inderal was discontinued and Norvasc was prescribed.  In
February 2005, it was noted that blood pressure control was
acceptable as gauged by home readings.  However, in October 2005,
it was noted that hypertension was minimally controlled with
Norvasc.  HCTZ was added and the physician was considering
increasing Norvasc at the next visit.  In November 2005, Norvasc
was increased to 10 mg a day in an attempt to control blood
pressure.  At that time, the Veteran was placed on a temporary
profile for high blood pressure.  A clinical record dated in
January 2006 indicates that the Veteran's medications were
altered at her last visit.  Norvasc was lowered to 5 mg a day and
Altace was added.

Additionally, various lay statements from individuals serving
with the Veteran during deployment indicate that she went to sick
call on multiple occasions for her blood pressure and that she
was forced to rest or be excused from work and others had to
fulfill her duties.

In light of the evidence of increased symptomatology during
service, such as the need for frequent treatment and medication
adjustments, the Board cannot conclude that the evidence
"clearly and unmistakably" (i.e., undebatably) refutes a
finding of aggravation.  Thus, the presumption of soundness is
not rebutted.

Accordingly, and because the Veteran was treated for hypertension
during active service and continues to have hypertension, the
claim of service connection is granted, based on in-service
treatment.

Right arm injury

In March 2007, the Veteran submitted a claim of entitlement to
service connection for a right arm injury.  She reported that the
injury had its onset in July 2003.  In November 2007, the RO
denied the claim, finding that there was no evidence that this
condition began in or was caused by her service.  It was noted
that service records were silent for any complaints, treatment or
diagnosis of any right arm condition in service.  The Veteran
disagreed with this decision and subsequently perfected this
appeal.

In her January 2008 notice of disagreement, the Veteran reported
that her right arm injury occurred on active duty due to her M16
butting against her shoulder.  He reported sharp pain in the
right shoulder to the tips of her fingers.  At the March 2010
hearing, she testified that her right arm injury was due to
weapons qualifications, physical fitness training, and lifting
100 pound bags of mail.  She reported that she was diagnosed with
a rotator cuff tear in 2004.  In a corresponding statement, she
reported that her shoulder injury was described as a right arm
injury and that her military service caused this injury and
aggravated and worsened the injury, ultimately causing a torn
rotator cuff.

Service records do not show treatment for a right arm injury or
right upper extremity disability.

VA primary care note dated in January 2007 indicates the Veteran
was seen with a chief complaint of right arm pain.  She reported
a two-month history of right arm pain located in the right
shoulder with radiation down the arm to the fingertips.  She
denied any trauma.  Assessment was right arm pain, bony vs.
ligamentous injury.  X-rays of the right shoulder showed no bony
abnormality.

The Veteran underwent a VA examination in October 2007.  The
examiner noted that the Veteran was there for evaluation of
bilateral shoulder condition, most likely secondary to rotator
cuff injury.  An MRI showed pan labral tear and AC joint
degeneration in the right shoulder.

VA records show the Veteran presented in December 2007 with
complaints of pain in the right upper extremity.  At that time,
she reported spontaneous onset of pain about one year ago.
Impression was right upper extremity pain, non-focal; consider
reflex sympathetic dystrophy.

The Veteran underwent a private neurological evaluation for right
arm pain in January 2008.  At that time, she reported pain in her
right arm for about two years.  Impression included right
shoulder and arm pain.

In March 2008, the Veteran underwent a right shoulder MRI for
chronic severe upper extremity pain.  The impression was atrophy
of the supraspinatus and infraspinatus muscles with early
degenerative arthritis of the glenohumeral joint.  There was
degeneration of the cartilaginous labrum with fragmentation and
small perilabral cysts, as well as atrophy with probable
tendinosis of the subscapularis muscle.

The Veteran underwent a pain clinic consult in June 2008.  It was
noted that she had chronic right shoulder pain from rotator cuff
tear complicated with reflex sympathetic dystrophy of the right
upper extremity, now worse because of right wrist fracture in
February 2008.  The assessment included chronic intractable pain
of right upper extremity and reflex sympathetic dystrophy right
upper extremity.

An orthopedic consult dated in July 2008 notes the Veteran's
complaints of right shoulder pain since December 2007 that
radiates down the arm into the hand.  She denied any trauma to
the shoulder except for firing her weapon in the military.
Assessment was right shoulder pain.

On review, evidence of record shows a current right arm/upper
extremity disability.  Service connection, however, requires that
such disability be related to active military service or events
therein.  As discussed, there is no evidence of right arm injury
or chronic upper extremity disability during any period of active
service.

The Board acknowledges the Veteran's contentions that she injured
her arm during military service.  The Veteran is competent to
report an in-service right arm injury and continuing symptoms of
right arm pain.  See Charles v. Principi, 16 Vet. App. 370, 374-
75 (2002) (appellant competent to testify regarding symptoms
capable of lay observation).  Notwithstanding, the Board does not
find the Veteran's reports supported by the overall evidence of
record.  In making this determination, it is observed that the
Veteran was not seen for right arm pain until approximately
January 2007, and at that time, reported a two-month history of
right arm pain without trauma.  This weighs against a finding of
in-service onset.  Moreover, in numerous in-service reports of
medical history, the Veteran failed to raise any complaints of
right arm pain, further weighing against his current contentions
of continuous symptoms.

In summary, evidence of record does not show that the Veteran has
a current right arm disability that is related to active military
service or events therein.  Furthermore, there is no evidence of
right arm/upper extremity arthritis manifested to a compensable
degree within one year following discharge from service.
Therefore, the preponderance of the evidence is against the claim
and the doctrine of reasonable doubt is not for application.  See
38 C.F.R. � 3.102.

Low back disability

In March 2007, the Veteran submitted a claim of entitlement to
service connection for lower back pain.  She reported that such
pain began in July 2003.  In November 2007, the RO denied the
claim, finding no currently diagnosed back condition.  The
Veteran disagreed with this decision and subsequently perfected
this appeal.

At his hearing, the Veteran testified that, to her recollection,
she first experienced back pain in 2003 while performing physical
fitness exercises.  She reported that after discharge she went to
VA.  She further testified that she had worse problems and wore a
back brace during her last tour of duty.

An active duty service record dated in October 2003 indicates
complaints of low back pain radiating down the right leg for 11/2
days.  The assessment was low back pain and right foot pain.  The
Veteran reported back pain on post-deployment questionnaires
completed in September 2005, October 2005, and June 2006.

On VA examination in October 2007, the Veteran reported a history
of low back pain since 2000.  Objectively, findings were normal,
as was an MRI.

VA x-rays of the lumbosacral spine taken in June 2008 showed no
significant degenerative change or acute abnormality.  An MRI of
the lumbar spine taken in December 2008 was normal.

In January 2009, the Veteran was seen for a VA physical therapy
consult.  She reported the insidious onset of low back pain in
2003 without relief since that time.  On examination, range of
motion was reduced.  Subsequent note indicates a diagnosis of
lumbago, which is low back pain.  The Veteran was issued a firm
density lumbar roll.

As detailed above, the evidence of record shows complaints of low
back pain during active duty in 2003 and the Veteran has reported
symptoms continuing to date.  The Board acknowledges that the
Veteran is competent to report symptoms of low back pain.  See
Charles.  However, the evidence of record does not show a
currently diagnosed low back disability.  As discussed above,
both MRI and x-ray testing of the lumbar spine was normal.  The
Board acknowledges the assessment of lumbago, but notes that pain
alone, without a diagnosed or identifiable underlying malady or
condition, does not in and of itself constitute a disability for
which service connection may be granted.  Sanchez-Benitez v.
West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and
vacated and remanded in part sub nom. Sanchez-Benitez v.
Principi, 259 F.3d 1356 (Fed. Cir. 2001).  Accordingly, service
connection is not warranted.

Having determined that there is no evidence of currently
diagnosed lumbar spine disability and observing that joint pain
may be a manifestation of undiagnosed illness, the Board has
considered whether 38 C.F.R. � 3.317 is for application.  The
Veteran has not claimed disability related to undiagnosed illness
and has clearly dated the onset of her low back pain to her
period of active duty beginning in 2003, which is prior to her
service in Kuwait.  Thus, there is affirmative evidence that an
undiagnosed illness manifested by back pain was not incurred
during active military service in the Southwest Asia theater of
operations during the Persian Gulf War.  See 38 C.F.R.
� 3.317(c).

For the above reasons, the preponderance of the evidence is
against the claim and the doctrine of reasonable doubt is not for
application.  See 38 C.F.R. � 3.102.

Tinnitus (claimed as right ear injury)

In March 2007, the Veteran submitted a claim of entitlement to
service connection for a right "ears" injury.  In November
2007, the RO denied the claim, finding that there was no evidence
that a right ear injury began in or was caused by service.  The
Veteran disagreed with this decision and subsequently perfected
this appeal.

In her January 2008 notice of disagreement, the Veteran reported
that she has constant ringing in her ear and lots of pain.  She
noted that there are times when she has to wear cotton in her
ears or put pressure on her ears to stop the constant ringing.
At the March 2010 hearing, the Veteran testified that she was
exposed to various loud noises during service.  The Veteran
agreed that "ringing in the ears" was an accurate description
of what her symptoms were.  She indicated that it was in both
ears and denied any drainage.  She testified that she had ringing
in her ears when she was in Kuwait.

The Board observes that the claim was certified on appeal as
entitlement to service connection for a right ear injury.  On
review and considering the Veteran's statements and testimony, it
appears that she is seeking entitlement to service connection for
tinnitus (ringing in the ears), bilaterally.  As such, the Board
has recharacterized the issue as stated above.  In light of the
favorable decision to grant service connection and the absence of
any additional right ear injury claimed, the Veteran is not
prejudiced by this action.  See Bernard v. Brown, 4 Vet. App. 384
(1993).

Post-deployment questionnaires dated in September 2005, October
2005, and June 2006 document complaints of ringing in the ears
during deployment and at that time.

VA records show that the Veteran called primary care in February
2009 and reported that she had ringing in her ears for many
years, and she thought it might be worsening.  The Veteran
underwent an audiology consult in March 2009.  She reported
bilateral tinnitus in both ears for years, but that it was
periodic.  She stated that in the last month, the tinnitus had
become constant.  She reported a history of military noise
exposure during service from 1981 to 2006, and denied
occupational or recreational noise exposure.

In sum, the Veteran reported ringing in her ears during active
military service and continuing to date.  The Board acknowledges
that the record does not show a confirmed diagnosis of tinnitus
related to active military service.  Tinnitus, however, is a
disability that lends itself to lay observation.  See Charles.
Additionally, lay testimony is competent when it regards the
readily observable features or symptoms of injury or illness and
"may provide sufficient support for a claim of service
connection."  Layno v. Brown, 6 Vet. App. 465, 469 (1994); see
also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

Considering the evidence of record and resolving any reasonable
doubt in the Veteran's favor, service connection for tinnitus is
warranted.  38 C.F.R. �� 3.102, 3.303.

Carpal tunnel syndrome

In March 2007, the Veteran submitted a claim of entitlement to
service connection for carpal tunnel syndrome.  In November 2007,
the RO denied the claim, noting an absence of a currently
diagnosed condition.  The Veteran disagreed with this decision
and subsequently perfected this appeal.

In her January 2008 notice of disagreement, the Veteran reported
that her carpal tunnel started in the military when her finger
was broken and she subsequently did administrative clerical work.
At the hearing, she testified that she was the acting first
sergeant in a postal unit and did considerable lifting and
typing.  She testified that she had not been diagnosed with
carpal tunnel syndrome, but the treatment providers did not know
exactly what it was.  She noticed pain in 2003 or 2004.

Service treatment records do not show treatment for,
manifestations of, or a diagnosis of carpal tunnel syndrome.

On VA examination in October 2007, the Veteran reported a history
of pain getting worse since 2003.  She described pain in her
wrist radiating down her arm.  The examiner noted that there were
no physical findings suggestive of carpal tunnel syndrome.  The
EMG was normal and physical examination was within normal limits.

VA records show that the Veteran underwent additional nerve
conduction studies in September 2009 to rule out carpal tunnel
syndrome.  At that time, she reported pain and stiffness in the
fingers and thumb of her left hand and noted that the pain
radiates up her forearm.  The impressions were normal nerve
conduction study of the left upper limb, and no evidence of
carpal tunnel syndrome. Although not clinically suspected, the
study did not rule out cervical radiculopathy.

On review, the record does not show a confirmed diagnosis of
carpal tunnel syndrome.  Thus, service connection for carpal
tunnel syndrome is not warranted.  See Brammer.

The Board acknowledges Jandreau v. Nicholson, 492 F. 3d 1372
(Fed. Cir. 2007), in which the Federal Circuit determined that
lay evidence can be competent and sufficient to establish a
diagnosis of a condition when (1) a layperson is competent to
identify the medical condition (noting that sometimes the
layperson will be competent to identify the condition where the
condition is simple, for example a broken leg, and sometimes not,
for example, a form of cancer), (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.  The relevance of lay evidence is not
limited to the third situation, but extends to the first two as
well. Whether lay evidence is competent and sufficient in a
particular case is a fact issue.

Here, however, none of the criteria set forth in Jandreau are for
application. Accordingly, the lay statements do not here serve to
establish any diagnosis and, as stated above, the claim must be
denied.

As noted, the Appellant is a Persian Gulf veteran.  Having
determined that there is no evidence of currently diagnosed
carpal tunnel syndrome and observing that neurologic signs and
symptoms and joint pain may be manifestations of undiagnosed
illness, the Board has considered whether 38 C.F.R. � 3.317 is
for application.  The Veteran has not claimed disability related
to undiagnosed illness and has clearly dated the onset of claimed
carpal tunnel syndrome prior to her service in Kuwait.  Thus,
there is affirmative evidence that an undiagnosed illness
manifested by neurologic signs or symptoms in the wrists was not
incurred during active military service in the Southwest Asia
theater of operations during the Persian Gulf War.  See 38 C.F.R.
� 3.317(c).

Regarding joint pain, the Board observes that the Veteran is
already service-connected for residuals of a left wrist fracture.
She suffered a right wrist fracture in 2008, after discharge from
active duty, with a subsequent diagnosis of reflex sympathetic
dystrophy.

Bilateral leg syndrome

In March 2007, the Veteran submitted a claim of entitlement to
service connection for bilateral leg syndrome.  She reported on
onset of disability in July 2003.  In November 2007, the RO
denied the claim, finding that she was treated only once during
service and that post-service VA examination findings were
normal.  The Veteran disagreed with this decision and
subsequently perfected this appeal.

In her January 2008 notice of disagreement, the Veteran stated
that the bilateral leg injury occurred in the military.  She
indicated that lying out in the field daily, weapons exercises,
and the cold damp weather all contributed to the problem.  At her
hearing, she testified that she first experienced problems around
2003 and was lying in bed with constant sharp burning pains in
her legs.  She added that she continued to experience problems
during her next tour.  She indicated that the doctors were still
not sure of the diagnosis.

A review of service treatment records for the Veteran's initial
two periods of active duty does not show any chronic disability
of the lower extremities.

Private medical records dated in October and December 2001
indicate diagnoses of reflex sympathetic dystrophy lower
extremity and complex regional pain syndrome, left lower
extremity, respectively.  These diagnoses appear related to a
September 2001 left ankle fracture.

In November 2003, the Veteran was seen with complaints of
shooting pain from the right hip to the right foot, of 2 days'
duration.  She had been seen in October for the same pain.   The
assessment was right leg pain of unclear etiology.  Sciatic pain
and possible piriformis inflammation was noted.  Physical therapy
record dated the same day indicates the Veteran was seen with
complaints of right lower extremity pain.  The assessment was
piriformis syndrome right lower extremity.  A treatment report
dated approximately one week later indicates that the Veteran was
taking ibuprofen for leg pain.

On VA examination in October 2007, the Veteran reported soreness
in her thigh.  She also had difficulty laying on it for a long
period.  This problem had been ongoing since 2003.  She described
the pain as severe.  Physical examination was within normal
limits.  There was no swelling and no distended veins.  Motor
strength was 5/5.  The examiner indicated that the examination
was within normal limits and that there were no abnormal
findings.

The Board acknowledges the Veteran's in-service complaints and
treatment related to reported leg pain.  The evidence of record,
however, does not show a currently diagnosed disability of the
bilateral legs that is related to her in-service complaints.
Moreover, the criteria for the Veteran's statements to satisfy
the requirement of a diagnosis per Jandreau have not here been
met.

The Board acknowledges the Veteran's testimony that the doctors
are not sure what the diagnosis is and has considered whether the
undiagnosed illness provisions are for application.  Again, the
Veteran has not claimed disability related to undiagnosed illness
and has clearly dated the onset of her bilateral leg pain to her
service beginning in July 2003, which is prior to her service in
Kuwait.  Thus, there is affirmative evidence that an undiagnosed
illness manifested by pain or neurologic signs and symptoms
related to the bilateral legs was not incurred during active
military service in the Southwest Asia theater of operations
during the Persian Gulf War.  See 38 C.F.R. � 3.317(c).

The preponderance of the evidence is against the claim and the
doctrine of reasonable doubt is not for application.  38 C.F.R.
� 3.102.

ORDER

Entitlement to service connection for hypertension is granted,
subject to governing criteria applicable to the payment of
monetary benefits.

Entitlement to service connection for right arm injury is denied.

Entitlement to service connection for a low back disability is
denied.

Entitlement to service connection for tinnitus, claimed as a
right ear injury, is granted, subject to governing criteria
applicable to the payment of monetary benefits.

Entitlement to service connection for carpal tunnel syndrome is
denied.

Entitlement to service connection for bilateral leg syndrome is
denied.

REMAND

With respect to the remaining issues on appeal, the Board has
determined that additional development is required.

Regarding the claims of entitlement to increased rating for
residuals of a left ring finger fracture and residuals of a left
wrist fracture, the Veteran most recently underwent a VA
examination in October 2007.  At the March 2010 hearing, she
reported constant sharp pain in her left wrist and described
various limitations, such as difficulty turning a knob, opening
doors, washing dishes, and washing and combing her hair.
Regarding her left ring finger, she testified that the pain is a
10/10 and that she is unable to use her finger at all.  She
indicated that it was basically in a fixed position.

Considering the Veteran's testimony regarding increased
symptomatology and functional impairment, as well as the length
of time since VA examination, the Board finds that additional
examination is necessary.  See 38 C.F.R. � 3.327 (2009); Green v.
Derwinski, 1 Vet. App. 121 (1991) (the duty to assist includes,
when appropriate, the duty to conduct a thorough and
contemporaneous examination of the Veteran); Schafrath v.
Derwinski, 1 Vet. App. 589 (1991) (where the evidence of record
does not reflect the current state of the Veteran's disability, a
VA examination must be conducted).

With respect to the claim of service connection for migraine
headaches, the Veteran has reported that migraines began on
active duty and still persist.  At the March 2010 hearing, the
Veteran testified that she had constant migraines beginning in
approximately 2003.

On review, there is no evidence of chronic migraines during the
Veteran's first two periods of active duty.  An examination
noting migraines at the time of entry onto active duty in July
2003 and October 2004 is not of record and therefore, the
presumption of soundness applies.  38 C.F.R. � 3.304.

In reviewing the claims file, private medical records clearly and
unmistakably show that migraine headaches existed prior to the
Veteran's third and fourth periods of active duty.  Specifically,
a record dated in October 2001 indicates that she was on
Propanolol every day and Midrin as needed for migraine headaches.
Another record dated in April 2003 indicates the Veteran had
frequent migraines and had already tried Maxalt and Imitrex.
Therefore, the relevant inquiry is
whether there is clear and unmistakable evidence that migraine
headaches were not aggravated during active military service.  In
this regard, a lack of aggravation may be shown by establishing
that there was no increase in disability during service or that
any increase in disability was due to the natural progress of the
preexisting condition.  Wagner, 370 F.3d at 1096; 38 U.S.C.A. �
1153 (West 2002).

Active duty records beginning in July 2003 show continued
treatment for migraine headaches.  On post-deployment
questionnaire dated in September 2005, the Veteran reported
increased migraines.  However, the medical opinions of record do
not adequately address the aggravation question.  Indeed, a
January 2008 statement from a VA neurologist clearly contains
misstatements of fact with respect to the Veteran's history of
medication use.  Therefore, an additional medical opinion is
needed to determine whether the presumption of soundness has been
rebutted.  38 C.F.R. � 3.159(c)(4).

Turning to the left ankle claim, there is no evidence of chronic
left ankle disability during the Veteran's first two periods of
active duty.  Examinations noting a chronic left ankle disability
at the time of entry on to active duty in July 2003 and October
2004 are not of record and therefore, the presumption of
soundness applies.  38 C.F.R. � 3.304.

A March 2002 private medical statement indicates that the Veteran
injured her left ankle in September 2001.  She had an ankle
sprain with avulsion fractures off the fibula.  She subsequently
developed reflex sympathetic dystrophy or more appropriately
called a complex regional pain syndrome.  She was treated and
responded quite nicely.  She was, however, left with decreased
strength and lack of flexibility in her foot and ankle.  The
physician did not believe that she would be able to perform the
running part of her physical training.

In July 2002, the Veteran was given a permanent profile (no
running or prolonged walking) due to left ankle pain.

On February 15, 2005, the Veteran was seen for pain in the left
ankle.  She reported that she twisted her ankle at work on the
13th and her ankle was tingling and painful.  Objectively, there
was no swelling and the left ankle was mildly tender over the
medial malleolus.  There was good range of motion without pain.
She was given a temporary profile to wear sneakers until ankle
pain decreased to allow her to wear boots again.  On February 23,
2005, the Veteran was seen again with complaints of left ankle
pain.  It was noted that she had a history of a prior left ankle
sprain in 2001 with difficulty recovering, including reflex
sympathetic dystrophy.  This improved after 1 year and she
returned to full work duty.  She recently reinjured her left
ankle, but there was no significant improvement over the last
week.  Assessment was status post left ankle sprain.  In March
2005, she was given a temporary profile for a severe sprained
ankle.  It was noted that she already had a permanent profile for
running.

The Veteran underwent a VA examination in October 2007.  The
examiner noted that physical examination of the left ankle was
within normal limits and there was no anatomic finding indicating
an injury.  X-ray showed posttraumatic changes at the collateral
ligament insertion; no acute osseous abnormality was seen.  This
could be signs and symptoms of reflex sympathetic dystrophy since
no other finding was discovered to explain her symptoms.  The
examiner further stated:

The veteran's findings (are) likely related
to her in-service injury.  There was no
finding to suggest arthritis, cannot
comment on the progression as to whether
her military service had affected her ankle
condition without resorting to mere
speculation since x-ray findings was
benign.

Evidence of record indicates the Veteran suffered a left ankle
injury in 2001 with resulting reflex sympathetic
dystrophy/complex regional pain syndrome.  Notwithstanding,
evidence also suggests that she improved following this injury
and thus, it is unclear whether a chronic left ankle disability
preexisted her periods of service beginning in July 2003 and
October 2004.  The medical opinion of record does not adequately
address the information needed to determine whether the
presumption of soundness has been rebutted and the Board finds
that additional examination is needed.  38 C.F.R. � 3.159(c)(4).

Finally, regarding the claim of service connection for a bridge
of the left bottom tooth, the Board notes that a claim for
service connection is also considered to be a claim for VA
outpatient dental treatment.  Mays v. Brown, 5 Vet. App. 302
(1993).  In the November 2007 rating decision on appeal, the RO
advised the Veteran that if she wished to claim dental treatment,
she should apply at a VA medical facility.  On review, it is
unclear whether the Veteran applied for VA treatment following
discharge from her last period of active service and if so, what
the outcome of the claim was.

Under current VA regulations, compensation is only available for
certain types of dental and oral conditions listed under 38
C.F.R. � 4.150, such as impairment of the mandible, loss of a
portion of the ramus, and loss of a portion of the maxilla.
Compensation is available for loss of teeth only if such is due
to loss of substance of body of maxilla or mandible.  Otherwise,
a veteran may be entitled to service connection for dental
conditions including treatable carious teeth, replaceable missing
teeth, dental or alveolar abscesses, and periodontal disease, for
the sole purposes of receiving VA outpatient dental services and
treatment, if certain criteria are met.  38 C.F.R. �� 3.381,
17.161 (2009).

In her January 2008 notice of disagreement, the Veteran reported
that she was having pain in her tooth ever since she got the
bridge.  She reported that a root canal became infected and they
had to pull her tooth out and replace it with a bridge.  She
indicated she was having constant aching pain that was worsening.
At her hearing, the Veteran testified that the root canal 2004
had been performed at the VA facility in Columbus.  She denied
any dental trauma.  In a corresponding statement, she reported
that the tooth was pulled in Kuwait.  She indicated that her gums
bleed and she has swelling of the lower jaw, which she thinks is
related to the bridge.

VA dental records dated in June 2004 indicate that the Veteran
was seen as a category 10-Class II.  (Thus, it appears that the
Veteran received VA dental treatment following discharge from her
third period of active service).  The Veteran was complaining
that the tooth associated with the root canal hurt.  X-rays
revealed slight overfill of the root canal tooth #19.  It was
noted that they could attempt to redo the root canal or extract.
They were supposed to finalize the treatment plan after perio
depths were taken.  It is unclear whether further VA dental
treatment was accomplished and thus additional VA dental records,
if any, should be obtained.  38 C.F.R. � 3.159(c)(2).

A Memorandum for Command dated in August 2004 indicates the
Veteran underwent an annual dental examination and was eligible
for duty.

A June 2006 statement from Major J. H. indicates that the Veteran
was treated at a Kuwaiti dental clinic to obtain a bridge for the
lower tooth in the summer to early fall of 2005.  He reported
that they had to appeal to the ASG-Kuwait Command Sergeant Major
so that he could authorize the treatment at the dental clinic.
The dental staff had apparently refused to treat the Veteran for
her missing tooth.

On review, it is unclear exactly when, where, and under what
circumstances the root canal and subsequent extraction were
performed.  Further, the claims file does not contain records
regarding the reported appeal and dental treatment in Kuwait.
Additional relevant records should thus be requested.

Accordingly, the case is REMANDED for the following action:

1.	The RO/AMC should schedule the Veteran for
a VA orthopedic examination to evaluate
the service-connected residuals of left
wrist fracture and the  residuals of left
ring finger fracture.  The claims folder
and a copy of this REMAND are to be made
available for the examiner to review.  In
accordance with the latest AMIE worksheets
for rating disabilities of the fingers and
wrist, the examiner is to provide a
detailed review of the Veteran's pertinent
medical history, current complaints, and
the nature and extent of left ring finger
and left wrist disability.  A complete
rationale for any opinions expressed must
be provided.

2.	The RO/AMC should schedule the Veteran for
a VA neurological examination to assess
the nature and etiology of her migraine
headaches.  The claims folder and a copy
of this REMAND are to be made available
for the examiner to review.

The examiner is advised that clear and
unmistakable evidence shows that migraine
headaches preexisted the Veteran's periods
of active duty beginning in July 2003 and
October 2004.  The examiner is requested
to opine whether there is clear and
unmistakable evidence to show that
migraine headaches were not aggravated
during her periods of active duty from
July 2003 to March 2004 and from October
2004 to February 2006.  The term
"aggravation" means an increase in
disability during active service beyond
the natural progress of the preexisting
condition.  The examiner is requested to
provide a complete rationale for any
opinion offered.

3.	The RO/AMC should schedule the Veteran for
a VA orthopedic examination to assess the
nature and etiology of her left ankle
disability.  The claims folder and a copy
of this REMAND are to be made available
for the examiner to review.

	The examiner is requested to opine whether
clear and unmistakable evidence shows that
a chronic left ankle disability preexisted
the Veteran's periods of active duty
beginning in July 2003 and October 2004.

If the examiner determines that a chronic
left ankle disability did not preexist,
he/she is requested to opine whether any
current left ankle disability is at least
as likely as not related to the February
2005 in-service left ankle injury.  In
making this determination, the examiner
should note the following:

? "It is due to" means 100 percent
assurance of relationship.
? "It is at least as likely as not"
means 50 percent or more.
? "It is not at least as likely as not"
means less than a 50 percent chance.

THE ISSUES

1.  Entitlement to an initial compensable evaluation for
residuals of left ring finger fracture.

2.  Entitlement to a compensable evaluation for residuals of left
wrist fracture, chronic sprain.

3.  Entitlement to service connection for hypertension.

4.  Entitlement to service connection for right arm injury.

5.  Entitlment to service connection for a low back disability.

6.  Entitlement to service connection for migraine headaches.

7.  Entitlement to service connection for tinnitus, claimed as
right ear injury.

8.  Entitlement to service connection for carpal tunnel syndrome.

9.  Entitlement to service connection for bilateral leg syndrome.

10.  Entitlement to service connection for a left ankle
disability.

11.  Entitlement to service connection for left bottom tooth.

REPRESENTATION

Appellant represented by:	Disabled American Veterans

WITNESSES AT HEARING ON APPEAL

Appellant and her spouse

ATTORNEY FOR THE BOARD

M. Carsten, Counsel

INTRODUCTION

The Veteran served on active duty from October 1981 to April
1982, October 1997 to February 1998, July 2003 to March 2004, and
October 2004 to February 2006.  She served in Kuwait from January
2005 to January 2006 and is a Persian Gulf veteran.  See
38 C.F.R. � 3.317(d) (2009).  She also had additional Reserve
service.

This matter comes before the Board of Veterans' Appeals (Board)
on appeal from a November 2007 decision by the Department of
Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio.

In March 2010, a hearing was held before the undersigned sitting
at the RO.  At that time, the Veteran submitted additional
evidence with a waiver of RO jurisdiction.  See 38 C.F.R.
� 20.1304 (2009).

The issues of entitlement to an initial compensable evaluation
for residuals of a left ring finger fracture; entitlement to a
compensable evaluation for residuals of left wrist fracture;
entitlement to service connection for migraine headaches;
entitlement to service connection for left ankle disability; and
entitlement to service connection for left bottom tooth are
addressed in the REMAND portion of the decision below and are
REMANDED to the RO via the Appeals Management Center (AMC), in
Washington, DC.

FINDINGS OF FACT

1.  Hypertension clearly and unmistakably existed prior to the
Veteran's periods of active duty beginning in July 2003 and
October 2004; however, there is no clear and unmistakable
evidence that it was not aggravated during active service.

2.  The preponderance of the evidence is against finding that the
Veteran has a current right arm disability that is related to
active military service or events therein; there is no evidence
of right arm arthritis manifested to a compensable degree within
one year following discharge from service.

3.  The preponderance of the evidence is against finding a
currently diagnosed low back disability; there is affirmative
evidence that an undiagnosed illness manifested by low back pain
was not incurred during service in Kuwait.

4.  Service records document complaints of ringing in the ears
during deployment and the Veteran has provided competent lay
testimony regarding continuing symptoms.

5.  The preponderance of the evidence is against finding a
confirmed diagnosis of carpal tunnel syndrome; there is
affirmative evidence that an undiagnosed illness manifested by
pain or neurologic signs and symptoms related to the wrists was
not incurred during service in Kuwait.

6.  The preponderance of the evidence is against finding that the
Veteran has a currently diagnosed disability of the bilateral
legs that is related to active military service or events
therein; there is affirmative evidence that an undiagnosed
illness manifested by pain or neurologic signs and symptoms
related to the bilateral legs was not incurred during service in
Kuwait.

CONCLUSIONS OF LAW

1.  Service connection for hypertension is warranted.
38 U.S.C.A. �� 1110, 1111, 1131, 5103, 5103A (West 2002 & Supp.
2009); 38 C.F.R. �� 3.159, 3.303, 3.304, 3.306, 3.307, 3.309
(2009).

2.  Service connection for a right arm disability is not
warranted.  38 U.S.C.A. �� 1110, 1131, 5103, 5103A; 38 C.F.R.
�� 3.159, 3.303, 3.307, 3.309.

3.  Service connection for a low back disability is not
warranted.  38 U.S.C.A. �� 1110, 1117, 1131, 5103, 5103A;
38 C.F.R. �� 3.159, 3.303, 3.307, 3.309, 3.317.

4.  Service connection for tinnitus is warranted.  38 U.S.C.A.
�� 1110, 1131, 5103, 5103A; 38 C.F.R. �� 3.159, 3.303.

5.  Service connection for carpal tunnel syndrome is not
warranted.  38 U.S.C.A. �� 1110, 1117, 1131, 5103, 5103A;
38 C.F.R. �� 3.159, 3.303, 3.317.

6.  Service connection for bilateral leg syndrome is not
warranted.  38 U.S.C.A. �� 1110, 1117, 1131, 5103, 5103A;
38 C.F.R. �� 3.159, 3.303, 3.317.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I. Veterans Claims Assistance Act of 2000 (VCAA)

Under the VCAA, when VA receives a complete or substantially
complete application for benefits, it is required to notify the
claimant and his or her representative, if any, of any
information and medical or lay evidence that is necessary to
substantiate the claim.  38 U.S.C.A. � 5103(a); 38 C.F.R. �
3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002).

VCAA notice consistent with 38 U.S.C.A. � 5103(a) and 38 C.F.R.
� 3.159(b) must inform the claimant of any information and
evidence not of record: (1) that is necessary to substantiate the
claim; (2) that VA will seek to provide; and, (3) that the
claimant is expected to provide.

The VCAA notice requirements apply to all five elements of a
service connection claim.  These are: (1) veteran status; (2)
existence of a disability; (3) a connection between a veteran's
service and the disability; (4) degree of disability; and (5)
effective date of the disability.  Dingess v. Nicholson, 19 Vet.
App. 473 (2006).

Notice must be provided prior to an initial unfavorable decision
by the agency of original jurisdiction (AOJ).  Pelegrini v.
Principi, 18 Vet. App. 112 (2004).  However, if VCAA notice is
provided after the initial decision, such a timing error can be
cured by subsequent readjudication of the claim, as in a
statement of the case (SOC) or supplemental statement of the case
(SSOC).  Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006).

In May 2007, prior to the decision on appeal, the RO sent the
Veteran a letter advising her of the evidence needed to
substantiate claims of service connection for right arm injury,
low back pain, carpal tunnel syndrome, and bilateral leg
condition, to include notice of what part of that evidence is to
be provided by the claimant and what part VA will attempt to
obtain.  This letter also provided notice as to how disability
ratings and effective dates are determined.

Under the VCAA, VA also has a duty to assist the Veteran in the
development of a claim.  This includes assisting with procuring
relevant records and providing a VA examination when necessary.
38 U.S.C.A. � 5103A; 38 C.F.R. � 3.159.

The claims file contains service treatment records, VA medical
center records, and private records.  The Veteran was provided a
VA examination in October 2007.  On review, the Board finds the
examination adequate and has determined no basis for further
examination or medical opinion with regard to the claims decided
herein.  See 38 C.F.R. � 3.159(c)(4); McLendon v. Nicholson, 20
Vet. App. 79 (2006).

As explained below, this decision grants entitlement to service
connection for hypertension and for tinnitus, claimed as a right
ear injury.  Therefore, a detailed explanation of how VA complied
with the VCAA is not necessary regarding these issues.

II. Analysis

In general, service connection will be granted for disability
resulting from injury or disease incurred in or aggravated by
active military service.  38 U.S.C.A. �� 1110, 1131; 38 C.F.R. �
3.303.  A preexisting injury or disease will be considered to
have been aggravated by active military 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 C.F.R. � 3.306(a).

The term "active military, naval, or air service" includes
active duty, any period of active duty for training during which
the individual concerned was disabled or died from a disease or
injury incurred or aggravated in line of duty; and any period of
inactive duty for training during which the individual concerned
was disabled or died (i) from an injury incurred or aggravated in
line of duty; or (ii) from an acute myocardial infarction, a
cardiac arrest, or a cerebrovascular accident occurring during
such training.  38 U.S.C.A. � 101(24) (West 2002); 38 C.F.R. �
3.6(a) (2009).

The term "active duty for training" is, inter alia, full-time
duty in the Armed Forces performed by Reserves for training
purposes or by members of the National Guard of any State.  38
U.S.C.A. � 101(22); 38 C.F.R. � 3.6(c).  The term "inactive duty
for training" means, inter alia, duty other than full-time duty
prescribed for Reserves or the National Guard of any State.  38
U.S.C.A. � 101(23); 38 C.F.R. � 3.6(d).

Service connection may be granted for any disease diagnosed after
discharge, when all the evidence, including that pertinent to
service, establishes that the disability was incurred in service.
38 C.F.R. � 3.303(d).

In order to establish service connection or service-connected
aggravation for a present disability the 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.  Shedden v.
Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).  Without a
currently diagnosed disability, service connection may not be
granted.  See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

Service connection will also be presumed for certain chronic
diseases, including hypertension and arthritis, if manifest to a
compensable degree within one year after discharge from service.
38 U.S.C.A. �� 1101, 1112 (West 2002 & Supp. 2009); 38 C.F.R. ��
3.307, 3.309.

Additionally, service connection can be established for a Persian
Gulf veteran who exhibits objective indications of a qualifying
chronic disability which became manifest either during active
service in the Southwest Asia theater of operations during the
Persian Gulf War, or to a degree of 10 percent or more not later
than December 31, 2011; and by history, physical examination, and
laboratory tests cannot be attributed to any known clinical
diagnosis.  38 U.S.C.A. � 1117; 38 C.F.R. � 3.317(a)(1).

Compensation shall not be paid under these provisions if there is
(1) affirmative evidence that an undiagnosed illness was not
incurred during active military service in the Southwest Asia
theater of operations during the Persian Gulf War; or (2) if
there is affirmative evidence that an undiagnosed illness was
caused by a supervening condition or event that occurred between
a veteran's most recent departure from active duty in the
Southwest Asia theater of operations during the Persian Gulf War
and the onset of the illness; or (3) if there is affirmative
evidence that the illness is the result of a veteran's own
willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. �
3.317(c).

A veteran is presumed to have been in sound condition when
examined, accepted, and enrolled for service except as to
defects, infirmities, or disorders noted at the time of
examination, acceptance, enrollment, or where clear and
unmistakable evidence demonstrates that the injury or disease
existed before acceptance and enrollment and was not aggravated
by such service.  38 U.S.C.A. � 1111; 38 C.F.R. � 3.304.

In cases where the disease or injury at issue is not noted on an
entrance examination, a two-pronged test is for consideration in
determining whether the presumption of soundness has been
rebutted.  First, VA must show by clear and unmistakable evidence
that the disease or injury existed prior to service.  Second, VA
must show by clear and unmistakable evidence that the preexisting
disease or injury was not aggravated by service.  See Wagner v.
Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July
16, 2003).

In determining whether a condition preexisted service, the
Veteran's medical history, accepted medical principles, evidence
regarding the basic character, origin and development of the
condition, and lay and medical evidence concerning the inception,
development and manifestations of the condition must be
considered.  38 C.F.R. � 3.304(b); see Quirin v. Shinseki, 22
Vet. App. 390, 396 (2009).

When there is an approximate balance of positive and negative
evidence regarding the merits of an issue material to the
determination of the matter, the benefit of the doubt in
resolving each such issue shall be given to the claimant. 38
U.S.C.A. � 5107(b) (West 2002); 38 C.F.R. � 3.102 (2009).

Hypertension

In March 2007, the Veteran submitted a claim of entitlement to
service connection for hypertension.  She reported that her
disability began in July 2003.  In November 2007, the RO denied
the claim, finding that hypertension existed prior to service and
that there was no evidence that the condition permanently
worsened as a result of service.  The Veteran disagreed with this
decision and subsequently perfected this appeal.

In her January 2008 notice of disagreement, the Veteran denied a
history of hypertension prior to service.  She asserted that her
hypertension was aggravated by being deployed on two occasions.
At the March 2010 hearing, the Veteran testified that she has had
hypertension for about five or six years.  She reported that in
2003 her blood pressure was very high and she needed medication
to bring it down.  It was her understanding that she would be
getting out on a medical discharge but when she tried to retire,
they sent her to the next war.

On VA examination in October 2007, the Veteran gave a history of
hypertension since 2002.  The examiner indicated that she had
severe hypertension that was uncontrolled under her current
medications.  Subsequent VA records show continued treatment for
hypertension and difficulties controlling the same.  A note dated
in June 2009 includes an assessment of uncontrolled hypertension.
Another note dated in February 2010 includes an assessment of
refractory hypertension.

Records associated with the Veteran's first and second periods of
service do not show any treatment for or diagnosis of
hypertension, and there is no evidence of hypertension manifested
to a compensable degree within one year following discharge from
either of these periods of service.

On review, it does not appear that the Veteran was afforded a
physical examination prior to entering service in July 2003 or
October 2004.  As hypertension was not noted, the Veteran is
entitled to the presumption of soundness.  The Board observes
that a pre-deployment health assessment was conducted in August
2003, after entry onto active duty.  At that time, the Veteran
denied any medical problems and she was considered deployable.

As to whether the presumption of soundness has been rebutted, the
Board finds that there is clear and unmistakable evidence that
the Veteran had hypertension prior to both her third and fourth
periods of service.  Indeed, a July 2002 private emergency room
record indicates that the Veteran was seen with complaints of a
headache.  At that time, she reported a history of being on blood
pressure medicines, which was stopped after about two weeks by
her primary care physician.  The diagnosis was migraine headache
with history of hypertension.  A private emergency room record
dated in November 2002 reflects complaints of abdominal pain, and
the examiner noted that the Veteran was known to have
hypertension.  Additionally, reserve records show that the
Veteran was seen in the emergency room in March 2003 with
complaints of a headache.  A history of hypertension was
documented and it was noted that she was on Norvasc.  A July 2003
record from the Veteran's private physician indicates that the
Veteran was going on active military duty and needed a 90 day
prescription for blood pressure medications faxed.

The foregoing constitutes clear and unmistakable evidence that
hypertension preexisted the Veteran's period of active service
that began in 2003.  As noted above, however, the Board can
conclude that the presumption has been rebutted only if there is
also clear and unmistakable evidence that the condition was not
aggravated by service.  Here, the Board finds no such evidence.

In making this determination, the Board observes that service
treatment records show frequently elevated blood pressure
readings and difficulties controlling hypertension.  For example,
on November 1, 2004, the Veteran's blood pressure was 165/104.
Medication was changed to Lisinopril.  A note dated November 11,
2004, indicates that blood pressure was still too high and
Lisinopril was increased.  Note dated December 8, 2004 indicates
that Inderal was discontinued and Norvasc was prescribed.  In
February 2005, it was noted that blood pressure control was
acceptable as gauged by home readings.  However, in October 2005,
it was noted that hypertension was minimally controlled with
Norvasc.  HCTZ was added and the physician was considering
increasing Norvasc at the next visit.  In November 2005, Norvasc
was increased to 10 mg a day in an attempt to control blood
pressure.  At that time, the Veteran was placed on a temporary
profile for high blood pressure.  A clinical record dated in
January 2006 indicates that the Veteran's medications were
altered at her last visit.  Norvasc was lowered to 5 mg a day and
Altace was added.

Additionally, various lay statements from individuals serving
with the Veteran during deployment indicate that she went to sick
call on multiple occasions for her blood pressure and that she
was forced to rest or be excused from work and others had to
fulfill her duties.

In light of the evidence of increased symptomatology during
service, such as the need for frequent treatment and medication
adjustments, the Board cannot conclude that the evidence
"clearly and unmistakably" (i.e., undebatably) refutes a
finding of aggravation.  Thus, the presumption of soundness is
not rebutted.

Accordingly, and because the Veteran was treated for hypertension
during active service and continues to have hypertension, the
claim of service connection is granted, based on in-service
treatment.

Right arm injury

In March 2007, the Veteran submitted a claim of entitlement to
service connection for a right arm injury.  She reported that the
injury had its onset in July 2003.  In November 2007, the RO
denied the claim, finding that there was no evidence that this
condition began in or was caused by her service.  It was noted
that service records were silent for any complaints, treatment or
diagnosis of any right arm condition in service.  The Veteran
disagreed with this decision and subsequently perfected this
appeal.

In her January 2008 notice of disagreement, the Veteran reported
that her right arm injury occurred on active duty due to her M16
butting against her shoulder.  He reported sharp pain in the
right shoulder to the tips of her fingers.  At the March 2010
hearing, she testified that her right arm injury was due to
weapons qualifications, physical fitness training, and lifting
100 pound bags of mail.  She reported that she was diagnosed with
a rotator cuff tear in 2004.  In a corresponding statement, she
reported that her shoulder injury was described as a right arm
injury and that her military service caused this injury and
aggravated and worsened the injury, ultimately causing a torn
rotator cuff.

Service records do not show treatment for a right arm injury or
right upper extremity disability.

VA primary care note dated in January 2007 indicates the Veteran
was seen with a chief complaint of right arm pain.  She reported
a two-month history of right arm pain located in the right
shoulder with radiation down the arm to the fingertips.  She
denied any trauma.  Assessment was right arm pain, bony vs.
ligamentous injury.  X-rays of the right shoulder showed no bony
abnormality.

The Veteran underwent a VA examination in October 2007.  The
examiner noted that the Veteran was there for evaluation of
bilateral shoulder condition, most likely secondary to rotator
cuff injury.  An MRI showed pan labral tear and AC joint
degeneration in the right shoulder.

VA records show the Veteran presented in December 2007 with
complaints of pain in the right upper extremity.  At that time,
she reported spontaneous onset of pain about one year ago.
Impression was right upper extremity pain, non-focal; consider
reflex sympathetic dystrophy.

The Veteran underwent a private neurological evaluation for right
arm pain in January 2008.  At that time, she reported pain in her
right arm for about two years.  Impression included right
shoulder and arm pain.

In March 2008, the Veteran underwent a right shoulder MRI for
chronic severe upper extremity pain.  The impression was atrophy
of the supraspinatus and infraspinatus muscles with early
degenerative arthritis of the glenohumeral joint.  There was
degeneration of the cartilaginous labrum with fragmentation and
small perilabral cysts, as well as atrophy with probable
tendinosis of the subscapularis muscle.

The Veteran underwent a pain clinic consult in June 2008.  It was
noted that she had chronic right shoulder pain from rotator cuff
tear complicated with reflex sympathetic dystrophy of the right
upper extremity, now worse because of right wrist fracture in
February 2008.  The assessment included chronic intractable pain
of right upper extremity and reflex sympathetic dystrophy right
upper extremity.

An orthopedic consult dated in July 2008 notes the Veteran's
complaints of right shoulder pain since December 2007 that
radiates down the arm into the hand.  She denied any trauma to
the shoulder except for firing her weapon in the military.
Assessment was right shoulder pain.

On review, evidence of record shows a current right arm/upper
extremity disability.  Service connection, however, requires that
such disability be related to active military service or events
therein.  As discussed, there is no evidence of right arm injury
or chronic upper extremity disability during any period of active
service.

The Board acknowledges the Veteran's contentions that she injured
her arm during military service.  The Veteran is competent to
report an in-service right arm injury and continuing symptoms of
right arm pain.  See Charles v. Principi, 16 Vet. App. 370, 374-
75 (2002) (appellant competent to testify regarding symptoms
capable of lay observation).  Notwithstanding, the Board does not
find the Veteran's reports supported by the overall evidence of
record.  In making this determination, it is observed that the
Veteran was not seen for right arm pain until approximately
January 2007, and at that time, reported a two-month history of
right arm pain without trauma.  This weighs against a finding of
in-service onset.  Moreover, in numerous in-service reports of
medical history, the Veteran failed to raise any complaints of
right arm pain, further weighing against his current contentions
of continuous symptoms.

In summary, evidence of record does not show that the Veteran has
a current right arm disability that is related to active military
service or events therein.  Furthermore, there is no evidence of
right arm/upper extremity arthritis manifested to a compensable
degree within one year following discharge from service.
Therefore, the preponderance of the evidence is against the claim
and the doctrine of reasonable doubt is not for application.  See
38 C.F.R. � 3.102.

Low back disability

In March 2007, the Veteran submitted a claim of entitlement to
service connection for lower back pain.  She reported that such
pain began in July 2003.  In November 2007, the RO denied the
claim, finding no currently diagnosed back condition.  The
Veteran disagreed with this decision and subsequently perfected
this appeal.

At his hearing, the Veteran testified that, to her recollection,
she first experienced back pain in 2003 while performing physical
fitness exercises.  She reported that after discharge she went to
VA.  She further testified that she had worse problems and wore a
back brace during her last tour of duty.

An active duty service record dated in October 2003 indicates
complaints of low back pain radiating down the right leg for 11/2
days.  The assessment was low back pain and right foot pain.  The
Veteran reported back pain on post-deployment questionnaires
completed in September 2005, October 2005, and June 2006.

On VA examination in October 2007, the Veteran reported a history
of low back pain since 2000.  Objectively, findings were normal,
as was an MRI.

VA x-rays of the lumbosacral spine taken in June 2008 showed no
significant degenerative change or acute abnormality.  An MRI of
the lumbar spine taken in December 2008 was normal.

In January 2009, the Veteran was seen for a VA physical therapy
consult.  She reported the insidious onset of low back pain in
2003 without relief since that time.  On examination, range of
motion was reduced.  Subsequent note indicates a diagnosis of
lumbago, which is low back pain.  The Veteran was issued a firm
density lumbar roll.

As detailed above, the evidence of record shows complaints of low
back pain during active duty in 2003 and the Veteran has reported
symptoms continuing to date.  The Board acknowledges that the
Veteran is competent to report symptoms of low back pain.  See
Charles.  However, the evidence of record does not show a
currently diagnosed low back disability.  As discussed above,
both MRI and x-ray testing of the lumbar spine was normal.  The
Board acknowledges the assessment of lumbago, but notes that pain
alone, without a diagnosed or identifiable underlying malady or
condition, does not in and of itself constitute a disability for
which service connection may be granted.  Sanchez-Benitez v.
West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and
vacated and remanded in part sub nom. Sanchez-Benitez v.
Principi, 259 F.3d 1356 (Fed. Cir. 2001).  Accordingly, service
connection is not warranted.

Having determined that there is no evidence of currently
diagnosed lumbar spine disability and observing that joint pain
may be a manifestation of undiagnosed illness, the Board has
considered whether 38 C.F.R. � 3.317 is for application.  The
Veteran has not claimed disability related to undiagnosed illness
and has clearly dated the onset of her low back pain to her
period of active duty beginning in 2003, which is prior to her
service in Kuwait.  Thus, there is affirmative evidence that an
undiagnosed illness manifested by back pain was not incurred
during active military service in the Southwest Asia theater of
operations during the Persian Gulf War.  See 38 C.F.R.
� 3.317(c).

For the above reasons, the preponderance of the evidence is
against the claim and the doctrine of reasonable doubt is not for
application.  See 38 C.F.R. � 3.102.

Tinnitus (claimed as right ear injury)

In March 2007, the Veteran submitted a claim of entitlement to
service connection for a right "ears" injury.  In November
2007, the RO denied the claim, finding that there was no evidence
that a right ear injury began in or was caused by service.  The
Veteran disagreed with this decision and subsequently perfected
this appeal.

In her January 2008 notice of disagreement, the Veteran reported
that she has constant ringing in her ear and lots of pain.  She
noted that there are times when she has to wear cotton in her
ears or put pressure on her ears to stop the constant ringing.
At the March 2010 hearing, the Veteran testified that she was
exposed to various loud noises during service.  The Veteran
agreed that "ringing in the ears" was an accurate description
of what her symptoms were.  She indicated that it was in both
ears and denied any drainage.  She testified that she had ringing
in her ears when she was in Kuwait.

The Board observes that the claim was certified on appeal as
entitlement to service connection for a right ear injury.  On
review and considering the Veteran's statements and testimony, it
appears that she is seeking entitlement to service connection for
tinnitus (ringing in the ears), bilaterally.  As such, the Board
has recharacterized the issue as stated above.  In light of the
favorable decision to grant service connection and the absence of
any additional right ear injury claimed, the Veteran is not
prejudiced by this action.  See Bernard v. Brown, 4 Vet. App. 384
(1993).

Post-deployment questionnaires dated in September 2005, October
2005, and June 2006 document complaints of ringing in the ears
during deployment and at that time.

VA records show that the Veteran called primary care in February
2009 and reported that she had ringing in her ears for many
years, and she thought it might be worsening.  The Veteran
underwent an audiology consult in March 2009.  She reported
bilateral tinnitus in both ears for years, but that it was
periodic.  She stated that in the last month, the tinnitus had
become constant.  She reported a history of military noise
exposure during service from 1981 to 2006, and denied
occupational or recreational noise exposure.

In sum, the Veteran reported ringing in her ears during active
military service and continuing to date.  The Board acknowledges
that the record does not show a confirmed diagnosis of tinnitus
related to active military service.  Tinnitus, however, is a
disability that lends itself to lay observation.  See Charles.
Additionally, lay testimony is competent when it regards the
readily observable features or symptoms of injury or illness and
"may provide sufficient support for a claim of service
connection."  Layno v. Brown, 6 Vet. App. 465, 469 (1994); see
also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

Considering the evidence of record and resolving any reasonable
doubt in the Veteran's favor, service connection for tinnitus is
warranted.  38 C.F.R. �� 3.102, 3.303.

Carpal tunnel syndrome

In March 2007, the Veteran submitted a claim of entitlement to
service connection for carpal tunnel syndrome.  In November 2007,
the RO denied the claim, noting an absence of a currently
diagnosed condition.  The Veteran disagreed with this decision
and subsequently perfected this appeal.

In her January 2008 notice of disagreement, the Veteran reported
that her carpal tunnel started in the military when her finger
was broken and she subsequently did administrative clerical work.
At the hearing, she testified that she was the acting first
sergeant in a postal unit and did considerable lifting and
typing.  She testified that she had not been diagnosed with
carpal tunnel syndrome, but the treatment providers did not know
exactly what it was.  She noticed pain in 2003 or 2004.

Service treatment records do not show treatment for,
manifestations of, or a diagnosis of carpal tunnel syndrome.

On VA examination in October 2007, the Veteran reported a history
of pain getting worse since 2003.  She described pain in her
wrist radiating down her arm.  The examiner noted that there were
no physical findings suggestive of carpal tunnel syndrome.  The
EMG was normal and physical examination was within normal limits.

VA records show that the Veteran underwent additional nerve
conduction studies in September 2009 to rule out carpal tunnel
syndrome.  At that time, she reported pain and stiffness in the
fingers and thumb of her left hand and noted that the pain
radiates up her forearm.  The impressions were normal nerve
conduction study of the left upper limb, and no evidence of
carpal tunnel syndrome. Although not clinically suspected, the
study did not rule out cervical radiculopathy.

On review, the record does not show a confirmed diagnosis of
carpal tunnel syndrome.  Thus, service connection for carpal
tunnel syndrome is not warranted.  See Brammer.

The Board acknowledges Jandreau v. Nicholson, 492 F. 3d 1372
(Fed. Cir. 2007), in which the Federal Circuit determined that
lay evidence can be competent and sufficient to establish a
diagnosis of a condition when (1) a layperson is competent to
identify the medical condition (noting that sometimes the
layperson will be competent to identify the condition where the
condition is simple, for example a broken leg, and sometimes not,
for example, a form of cancer), (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.  The relevance of lay evidence is not
limited to the third situation, but extends to the first two as
well. Whether lay evidence is competent and sufficient in a
particular case is a fact issue.

Here, however, none of the criteria set forth in Jandreau are for
application. Accordingly, the lay statements do not here serve to
establish any diagnosis and, as stated above, the claim must be
denied.

As noted, the Appellant is a Persian Gulf veteran.  Having
determined that there is no evidence of currently diagnosed
carpal tunnel syndrome and observing that neurologic signs and
symptoms and joint pain may be manifestations of undiagnosed
illness, the Board has considered whether 38 C.F.R. � 3.317 is
for application.  The Veteran has not claimed disability related
to undiagnosed illness and has clearly dated the onset of claimed
carpal tunnel syndrome prior to her service in Kuwait.  Thus,
there is affirmative evidence that an undiagnosed illness
manifested by neurologic signs or symptoms in the wrists was not
incurred during active military service in the Southwest Asia
theater of operations during the Persian Gulf War.  See 38 C.F.R.
� 3.317(c).

Regarding joint pain, the Board observes that the Veteran is
already service-connected for residuals of a left wrist fracture.
She suffered a right wrist fracture in 2008, after discharge from
active duty, with a subsequent diagnosis of reflex sympathetic
dystrophy.

Bilateral leg syndrome

In March 2007, the Veteran submitted a claim of entitlement to
service connection for bilateral leg syndrome.  She reported on
onset of disability in July 2003.  In November 2007, the RO
denied the claim, finding that she was treated only once during
service and that post-service VA examination findings were
normal.  The Veteran disagreed with this decision and
subsequently perfected this appeal.

In her January 2008 notice of disagreement, the Veteran stated
that the bilateral leg injury occurred in the military.  She
indicated that lying out in the field daily, weapons exercises,
and the cold damp weather all contributed to the problem.  At her
hearing, she testified that she first experienced problems around
2003 and was lying in bed with constant sharp burning pains in
her legs.  She added that she continued to experience problems
during her next tour.  She indicated that the doctors were still
not sure of the diagnosis.

A review of service treatment records for the Veteran's initial
two periods of active duty does not show any chronic disability
of the lower extremities.

Private medical records dated in October and December 2001
indicate diagnoses of reflex sympathetic dystrophy lower
extremity and complex regional pain syndrome, left lower
extremity, respectively.  These diagnoses appear related to a
September 2001 left ankle fracture.

In November 2003, the Veteran was seen with complaints of
shooting pain from the right hip to the right foot, of 2 days'
duration.  She had been seen in October for the same pain.   The
assessment was right leg pain of unclear etiology.  Sciatic pain
and possible piriformis inflammation was noted.  Physical therapy
record dated the same day indicates the Veteran was seen with
complaints of right lower extremity pain.  The assessment was
piriformis syndrome right lower extremity.  A treatment report
dated approximately one week later indicates that the Veteran was
taking ibuprofen for leg pain.

On VA examination in October 2007, the Veteran reported soreness
in her thigh.  She also had difficulty laying on it for a long
period.  This problem had been ongoing since 2003.  She described
the pain as severe.  Physical examination was within normal
limits.  There was no swelling and no distended veins.  Motor
strength was 5/5.  The examiner indicated that the examination
was within normal limits and that there were no abnormal
findings.

The Board acknowledges the Veteran's in-service complaints and
treatment related to reported leg pain.  The evidence of record,
however, does not show a currently diagnosed disability of the
bilateral legs that is related to her in-service complaints.
Moreover, the criteria for the Veteran's statements to satisfy
the requirement of a diagnosis per Jandreau have not here been
met.

The Board acknowledges the Veteran's testimony that the doctors
are not sure what the diagnosis is and has considered whether the
undiagnosed illness provisions are for application.  Again, the
Veteran has not claimed disability related to undiagnosed illness
and has clearly dated the onset of her bilateral leg pain to her
service beginning in July 2003, which is prior to her service in
Kuwait.  Thus, there is affirmative evidence that an undiagnosed
illness manifested by pain or neurologic signs and symptoms
related to the bilateral legs was not incurred during active
military service in the Southwest Asia theater of operations
during the Persian Gulf War.  See 38 C.F.R. � 3.317(c).

The preponderance of the evidence is against the claim and the
doctrine of reasonable doubt is not for application.  38 C.F.R.
� 3.102.

ORDER

Entitlement to service connection for hypertension is granted,
subject to governing criteria applicable to the payment of
monetary benefits.

Entitlement to service connection for right arm injury is denied.

Entitlement to service connection for a low back disability is
denied.

Entitlement to service connection for tinnitus, claimed as a
right ear injury, is granted, subject to governing criteria
applicable to the payment of monetary benefits.

Entitlement to service connection for carpal tunnel syndrome is
denied.

Entitlement to service connection for bilateral leg syndrome is
denied.

REMAND

With respect to the remaining issues on appeal, the Board has
determined that additional development is required.

Regarding the claims of entitlement to increased rating for
residuals of a left ring finger fracture and residuals of a left
wrist fracture, the Veteran most recently underwent a VA
examination in October 2007.  At the March 2010 hearing, she
reported constant sharp pain in her left wrist and described
various limitations, such as difficulty turning a knob, opening
doors, washing dishes, and washing and combing her hair.
Regarding her left ring finger, she testified that the pain is a
10/10 and that she is unable to use her finger at all.  She
indicated that it was basically in a fixed position.

Considering the Veteran's testimony regarding increased
symptomatology and functional impairment, as well as the length
of time since VA examination, the Board finds that additional
examination is necessary.  See 38 C.F.R. � 3.327 (2009); Green v.
Derwinski, 1 Vet. App. 121 (1991) (the duty to assist includes,
when appropriate, the duty to conduct a thorough and
contemporaneous examination of the Veteran); Schafrath v.
Derwinski, 1 Vet. App. 589 (1991) (where the evidence of record
does not reflect the current state of the Veteran's disability, a
VA examination must be conducted).

With respect to the claim of service connection for migraine
headaches, the Veteran has reported that migraines began on
active duty and still persist.  At the March 2010 hearing, the
Veteran testified that she had constant migraines beginning in
approximately 2003.

On review, there is no evidence of chronic migraines during the
Veteran's first two periods of active duty.  An examination
noting migraines at the time of entry onto active duty in July
2003 and October 2004 is not of record and therefore, the
presumption of soundness applies.  38 C.F.R. � 3.304.

In reviewing the claims file, private medical records clearly and
unmistakably show that migraine headaches existed prior to the
Veteran's third and fourth periods of active duty.  Specifically,
a record dated in October 2001 indicates that she was on
Propanolol every day and Midrin as needed for migraine headaches.
Another record dated in April 2003 indicates the Veteran had
frequent migraines and had already tried Maxalt and Imitrex.
Therefore, the relevant inquiry is
whether there is clear and unmistakable evidence that migraine
headaches were not aggravated during active military service.  In
this regard, a lack of aggravation may be shown by establishing
that there was no increase in disability during service or that
any increase in disability was due to the natural progress of the
preexisting condition.  Wagner, 370 F.3d at 1096; 38 U.S.C.A. �
1153 (West 2002).

Active duty records beginning in July 2003 show continued
treatment for migraine headaches.  On post-deployment
questionnaire dated in September 2005, the Veteran reported
increased migraines.  However, the medical opinions of record do
not adequately address the aggravation question.  Indeed, a
January 2008 statement from a VA neurologist clearly contains
misstatements of fact with respect to the Veteran's history of
medication use.  Therefore, an additional medical opinion is
needed to determine whether the presumption of soundness has been
rebutted.  38 C.F.R. � 3.159(c)(4).

Turning to the left ankle claim, there is no evidence of chronic
left ankle disability during the Veteran's first two periods of
active duty.  Examinations noting a chronic left ankle disability
at the time of entry on to active duty in July 2003 and October
2004 are not of record and therefore, the presumption of
soundness applies.  38 C.F.R. � 3.304.

A March 2002 private medical statement indicates that the Veteran
injured her left ankle in September 2001.  She had an ankle
sprain with avulsion fractures off the fibula.  She subsequently
developed reflex sympathetic dystrophy or more appropriately
called a complex regional pain syndrome.  She was treated and
responded quite nicely.  She was, however, left with decreased
strength and lack of flexibility in her foot and ankle.  The
physician did not believe that she would be able to perform the
running part of her physical training.

In July 2002, the Veteran was given a permanent profile (no
running or prolonged walking) due to left ankle pain.

On February 15, 2005, the Veteran was seen for pain in the left
ankle.  She reported that she twisted her ankle at work on the
13th and her ankle was tingling and painful.  Objectively, there
was no swelling and the left ankle was mildly tender over the
medial malleolus.  There was good range of motion without pain.
She was given a temporary profile to wear sneakers until ankle
pain decreased to allow her to wear boots again.  On February 23,
2005, the Veteran was seen again with complaints of left ankle
pain.  It was noted that she had a history of a prior left ankle
sprain in 2001 with difficulty recovering, including reflex
sympathetic dystrophy.  This improved after 1 year and she
returned to full work duty.  She recently reinjured her left
ankle, but there was no significant improvement over the last
week.  Assessment was status post left ankle sprain.  In March
2005, she was given a temporary profile for a severe sprained
ankle.  It was noted that she already had a permanent profile for
running.

The Veteran underwent a VA examination in October 2007.  The
examiner noted that physical examination of the left ankle was
within normal limits and there was no anatomic finding indicating
an injury.  X-ray showed posttraumatic changes at the collateral
ligament insertion; no acute osseous abnormality was seen.  This
could be signs and symptoms of reflex sympathetic dystrophy since
no other finding was discovered to explain her symptoms.  The
examiner further stated:

The veteran's findings (are) likely related
to her in-service injury.  There was no
finding to suggest arthritis, cannot
comment on the progression as to whether
her military service had affected her ankle
condition without resorting to mere
speculation since x-ray findings was
benign.

Evidence of record indicates the Veteran suffered a left ankle
injury in 2001 with resulting reflex sympathetic
dystrophy/complex regional pain syndrome.  Notwithstanding,
evidence also suggests that she improved following this injury
and thus, it is unclear whether a chronic left ankle disability
preexisted her periods of service beginning in July 2003 and
October 2004.  The medical opinion of record does not adequately
address the information needed to determine whether the
presumption of soundness has been rebutted and the Board finds
that additional examination is needed.  38 C.F.R. � 3.159(c)(4).

Finally, regarding the claim of service connection for a bridge
of the left bottom tooth, the Board notes that a claim for
service connection is also considered to be a claim for VA
outpatient dental treatment.  Mays v. Brown, 5 Vet. App. 302
(1993).  In the November 2007 rating decision on appeal, the RO
advised the Veteran that if she wished to claim dental treatment,
she should apply at a VA medical facility.  On review, it is
unclear whether the Veteran applied for VA treatment following
discharge from her last period of active service and if so, what
the outcome of the claim was.

Under current VA regulations, compensation is only available for
certain types of dental and oral conditions listed under 38
C.F.R. � 4.150, such as impairment of the mandible, loss of a
portion of the ramus, and loss of a portion of the maxilla.
Compensation is available for loss of teeth only if such is due
to loss of substance of body of maxilla or mandible.  Otherwise,
a veteran may be entitled to service connection for dental
conditions including treatable carious teeth, replaceable missing
teeth, dental or alveolar abscesses, and periodontal disease, for
the sole purposes of receiving VA outpatient dental services and
treatment, if certain criteria are met.  38 C.F.R. �� 3.381,
17.161 (2009).

In her January 2008 notice of disagreement, the Veteran reported
that she was having pain in her tooth ever since she got the
bridge.  She reported that a root canal became infected and they
had to pull her tooth out and replace it with a bridge.  She
indicated she was having constant aching pain that was worsening.
At her hearing, the Veteran testified that the root canal 2004
had been performed at the VA facility in Columbus.  She denied
any dental trauma.  In a corresponding statement, she reported
that the tooth was pulled in Kuwait.  She indicated that her gums
bleed and she has swelling of the lower jaw, which she thinks is
related to the bridge.

VA dental records dated in June 2004 indicate that the Veteran
was seen as a category 10-Class II.  (Thus, it appears that the
Veteran received VA dental treatment following discharge from her
third period of active service).  The Veteran was complaining
that the tooth associated with the root canal hurt.  X-rays
revealed slight overfill of the root canal tooth #19.  It was
noted that they could attempt to redo the root canal or extract.
They were supposed to finalize the treatment plan after perio
depths were taken.  It is unclear whether further VA dental
treatment was accomplished and thus additional VA dental records,
if any, should be obtained.  38 C.F.R. � 3.159(c)(2).

A Memorandum for Command dated in August 2004 indicates the
Veteran underwent an annual dental examination and was eligible
for duty.

A June 2006 statement from Major J. H. indicates that the Veteran
was treated at a Kuwaiti dental clinic to obtain a bridge for the
lower tooth in the summer to early fall of 2005.  He reported
that they had to appeal to the ASG-Kuwait Command Sergeant Major
so that he could authorize the treatment at the dental clinic.
The dental staff had apparently refused to treat the Veteran for
her missing tooth.

On review, it is unclear exactly when, where, and under what
circumstances the root canal and subsequent extraction were
performed.  Further, the claims file does not contain records
regarding the reported appeal and dental treatment in Kuwait.
Additional relevant records should thus be requested.

Accordingly, the case is REMANDED for the following action:

1.	The RO/AMC should schedule the Veteran for
a VA orthopedic examination to evaluate
the service-connected residuals of left
wrist fracture and the  residuals of left
ring finger fracture.  The claims folder
and a copy of this REMAND are to be made
available for the examiner to review.  In
accordance with the latest AMIE worksheets
for rating disabilities of the fingers and
wrist, the examiner is to provide a
detailed review of the Veteran's pertinent
medical history, current complaints, and
the nature and extent of left ring finger
and left wrist disability.  A complete
rationale for any opinions expressed must
be provided.

2.	The RO/AMC should schedule the Veteran for
a VA neurological examination to assess
the nature and etiology of her migraine
headaches.  The claims folder and a copy
of this REMAND are to be made available
for the examiner to review.

The examiner is advised that clear and
unmistakable evidence shows that migraine
headaches preexisted the Veteran's periods
of active duty beginning in July 2003 and
October 2004.  The examiner is requested
to opine whether there is clear and
unmistakable evidence to show that
migraine headaches were not aggravated
during her periods of active duty from
July 2003 to March 2004 and from October
2004 to February 2006.  The term
"aggravation" means an increase in
disability during active service beyond
the natural progress of the preexisting
condition.  The examiner is requested to
provide a complete rationale for any
opinion offered.

3.	The RO/AMC should schedule the Veteran for
a VA orthopedic examination to assess the
nature and etiology of her left ankle
disability.  The claims folder and a copy
of this REMAND are to be made available
for the examiner to review.

	The examiner is requested to opine whether
clear and unmistakable evidence shows that
a chronic left ankle disability preexisted
the Veteran's periods of active duty
beginning in July 2003 and October 2004.

If the examiner determines that a chronic
left ankle disability did not preexist,
he/she is requested to opine whether any
current left ankle disability is at least
as likely as not related to the February
2005 in-service left ankle injury.  In
making this determination, the examiner
should note the following:

? "It is due to" means 100 percent
assurance of relationship.
? "It is at least as likely as not"
means 50 percent or more.
? "It is not at least as likely as not"
means less than a 50 percent chance.
? "It is not due to" means 100 percent
assurance of non relationship.

If the examiner determines that a chronic
left ankle disability did preexist,
he/she is requested to opine as to whether
there is clear and unmistakable evidence
that any chronic left ankle disability was
not  aggravated during the Veteran's
periods of active duty from July 2003 to
March 2004 and from October 2004 to
February 2006.  The term aggravation means
an increase in disability during active
service beyond the natural progress of the
preexisting condition.  The examiner is
requested to provide a complete rationale
for any opinion offered.

4.	After the development requested has been
completed, the AMC/RO should review the
examination reports to ensure that they
are in complete compliance with the
directives of this REMAND.  If the reports
are deficient in any manner, the AMC/RO
must implement corrective procedures at
once.

5.	The RO/AMC should request all VA dental
records for the period from June 2004 to
the present.  All records obtained or
responses received should be associated
with the claims file.

6.	The RO/AMC should contact the Veteran and
ask her to provide additional information
regarding the dates of treatment for the
root canal, tooth extraction, and
replacement with bridge.  The dental
facilities providing the treatment should
be identified.  She should also be asked
to indicate whether she ever applied for
VA dental treatment following discharge
from her last period of service and if so,
when?

7.	The RO/AMC should request any medical
records (VA or service treatment records)
pertaining to the reported root canal,
extraction, and replacement with a bridge.
This should include any records relating
to the appeal to the ASG-Kuwait Command
Sergeant Major for authorization of dental
treatment.  Any negative search should be
noted in the record and communicated to
the Veteran.

8.	Upon completion of the above requested
development and any additional development
deemed appropriate, readjudicate the
following issues: (a) entitlement to an
initial compensable evaluation for
residuals of a left ring finger fracture;
(b) entitlement to a compensable
evaluation for residuals of a left wrist
fracture, chronic sprain; (c) entitlement
to service connection for migraine
headaches; (d) entitlement to service
connection for a left ankle disability;
and (e) entitlement to service connection
for a left bottom tooth (for VA outpatient
dental treatment and for compensation
purposes).  All applicable laws and
regulations should be considered.  If the
benefits sought on appeal remain denied,
the appellant and her representative
should be provided with a supplemental
statement of the case.  An appropriate
period of time should be allowed for
response.

The appellant has the right to submit additional evidence and
argument on the matter or matters the Board has remanded.
Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law
requires that all claims that are remanded by the Board of
Veterans' Appeals or by the United States Court of Appeals for
Veterans Claims for additional development or other appropriate
action must be handled in an expeditious manner.  See 38 U.S.C.A.
�� 5109B, 7112 (West Supp. 2010).

______________________________________________
ERIC S. LEBOFF
Acting Veterans Law Judge, Board of Veterans' Appeals

 Department of Veterans Affairs