Citation Nr: 1018475 Decision Date: 05/18/10 Archive Date: 06/04/10 DOCKET NO. 10-05 401 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a left foot neuroma. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for bilateral fibrocystic breast disease. 4. Entitlement to service connection for osteoarthritis of the lumbar spine. 5. Entitlement to service connection for left eye disability with defective visual acuity. 6. Entitlement to service connection for right eye disability with surgery for myopia and astigmatism. 7. Entitlement to service connection for an abdominal myomectomy with infertility and endometriosis. 8. Entitlement to service connection for muscle and joint pain to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Patricia Veresink, Associate Counsel INTRODUCTION The Veteran had active duty for training from August 1987 to December 1987, and from January 1990 to June 1990. She had active duty service from November 1990 to October 1991, including service in the Southwest Asia theater of the Persian Gulf War. She had additional service in the Army Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). FINDINGS OF FACT 1. Left foot neuroma was not manifested during active service, nor is it causally or etiologically related to the Veteran's active service. 2. Sleep apnea was not manifested during active service, nor is it causally or etiologically related to the Veteran's active service. 3. Bilateral fibrocystic breast disease was not manifested during active service, nor is it causally or etiologically related to the Veteran's active service. 4. Lumbar spine osteoarthritis was not manifested during active service or until more than a year after service, nor is it causally or etiologically related to the Veteran's active service. 5. Abdominal myomectomy with infertility and endometriosis was not manifested during active service, nor is it causally or etiologically related to the Veteran's active service. 6. Muscle and joint pain was not manifested during active service, and has been attributed to diagnosed disorders. CONCLUSIONS OF LAW 1. Left foot neuroma was not incurred in or aggravated by the Veteran's active service, nor is it otherwise related to service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2009). 2. Sleep apnea was not incurred in or aggravated by the Veteran's active service, nor is it otherwise related to service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2009). 3. Bilateral fibrocystic breast disease was not incurred in or aggravated by the Veteran's active service, nor is it otherwise related to service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2009). 4. Lumbar spine osteoarthritis was not incurred in or aggravated by the Veteran's active service, nor is it otherwise related to service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2009). 5. Abdominal myomectomy with infertility and endometriosis was not incurred in or aggravated by the Veteran's active service, nor is it otherwise related to service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2009). 6. Muscle and joint pain was not incurred in or aggravated by the Veteran's active service, nor is it otherwise related to service including as due to an undiagnosed illness resulting from service in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 Duty to Notify Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet.App. 183, 187 (2002). The record shows that through VCAA letters dated March 2008, June 2008, and February 2009 the appellant was informed of the information and evidence necessary to warrant entitlement to the benefits sought on appeal. The appellant was also advised of the types of evidence VA would assist her in obtaining as well as her own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet.App. 183 (2002); Charles v. Principi, 16 Vet.App. 370 (2002). The United States Court of Appeals for Veterans Claims decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. The VCAA letters to the appellant were provided in March 2008, June 2008, and February 2009 prior to the initial unfavorable decision in June 2009. Further, the notice requirements apply to all five elements of a service connection claim: 1) Veteran status, 2) existence of a disability, 3) a connection between the 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). In the present appeal, the appellant was provided with notice of what type of information and evidence was needed to substantiate the claim. Further, the March 2008, June 2008, and February 2009 letters gave notice of the types of evidence necessary to establish a disability rating and effective date for the disabilities on appeal. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of her claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice, nor does the record otherwise demonstrate such prejudice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist The Board also finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, private treatment records, VA examination reports, and lay evidence. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c). No additional pertinent evidence has been identified by the claimant. The Veteran was afforded VA examinations in February 2009, April 2009, and May 2009 regarding her gynecological and undiagnosed illness claims. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the claims file was reviewed by the examiners and the examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examinations to be sufficient. Thus, the Board finds that a further examination is not necessary regarding these issues. The Board notes that the VA did not provide the Veteran with a VA examination for the purposes of determining the etiology of her left foot neuroma, sleep apnea, bilateral fibrocystic breast disease, or lumbar spine osteoarthritis. In light of the holding in McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Board feels that an examination is not necessary. McLendon provides that in disability compensation (service connection) claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. The standards of McLendon are not met in this case. There is no persuasive indication that the Veteran's left foot neuroma, sleep apnea, bilateral fibrocystic breast disease, or lumbar spine osteoarthritis is associated with the Veteran's service. No evidence, including the Veteran's statements, establishes an event, injury, or disease that occurred in service relating to those disabilities. The first evidence of any of those disabilities is dated after the Veteran's separation from active service with no indication that they may be associated with the Veteran's service. There is otherwise sufficient competent evidence to decide the claim. For all the foregoing reasons, the Board concludes that VA's duties to the claimant have been fulfilled with respect to the issues on appeal. Analysis Legal Criteria The issue before the Board involves a claim of entitlement to service connection. Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for Veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 U.S.C.A. § 101(24), 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 training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. In an April 2008 claim, the Veteran contends that her sleep apnea, muscle and joint pains, back disability, and infertility are a by-product of Gulf War illness. Service connection may be established for a chronic disability manifested by certain signs or symptoms 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 which, 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). Consideration of a Veteran's claim under this regulation does not preclude consideration of entitlement to service connection on a direct basis. Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2-5). Manifestations of an undiagnosed illness include, but are not limited to, fatigue, skin lesions, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. See 38 C.F.R. § 3.317(b). Compensation availability includes medically unexplained chronic multisymptom illnesses, such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome, as well as any diagnosed illness that the Secretary determines by regulation to be service-connected. See 38 C.F.R. § 3.317(a)(2)(i). Left Foot Neuroma On June 1988, December 1988, February 1989, September 1991, May 1994, and March 2000 reports of medical history, the Veteran marked no when asked whether she had (or had a history of) foot trouble. On March 1987, June 1988, December 1988, February 1989, May 1994, and March 2000 reports of medical examinations, the examiners noted the Veteran's feet as clinically normal. On a September 2004 report of medical examination, the examiner marked the Veteran's feet as clinically normal. He also noted exfoliation on the plantar surface of the left foot. In July 2005, the Veteran presented with complaints of pain in the ball of the left foot that hurt in the second sub metacarpophalangeal joint of the area. The examiner noted that it was swollen and painful to walk on. The Veteran reported no history of any trauma. The Veteran noted the duration of these complaints as eight months. The examiner diagnosed capsulitis of the second metacarpophalangeal joint of the left foot. In April 2006, the Veteran was given a permanent physical profile for neuroma of the left foot. In May 2006, the Veteran's physician noted problems associated with the Veteran's left foot since July 14, 2005. He diagnosed capsulitis and neuroma of the third interspace of the left foot. She has received orthotic inserts and injections. In December 2006, the Veteran underwent excision of the neuroma second interspace, left foot. In a February 2008 statement, the Veteran noted that her military service has aggravated her left foot. The Board finds that entitlement to service connection for left foot neuroma is not warranted. The Veteran's feet were noted as clinically normal through September 2004, thirteen years after the Veteran's prior active service. The Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Nor is a neuroma the type of disorder susceptible to lay opinion concerning etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) referred to Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) for guidance. In footnote 4 of Jandreau, the Federal Circuit indicated that the complexity of the claimed disability is to be considered in determining whether lay evidence is competent. As to a nexus opinion relating the Veteran's service to her present disability, the Board finds that the etiology of the Veteran's left foot neuroma is too complex an issue, one typically determined by persons with medical training, to lend itself to lay opinion evidence. The Veteran is certainly competent to testify as to symptoms such as foot pain, which are non-medical in nature; however she is not competent to render a medical diagnosis or etiology. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also, Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). No medical evidence of record shows a relation between active duty service and the Veteran's left foot neuroma. In fact, the Veteran consistently reported no foot trouble for over 10 years after her separation from active duty. Her service treatment records are silent as to any complaints, treatment, or diagnosis of a foot disability. Again, medical examiners have found the Veteran's feet to be clinically normal over the course of more than 10 years after the Veteran's separation from active duty. The Veteran herself noted the onset of the disability to be eight months prior to her July 2006 examination. She also noted no history of trauma. As such, the Board finds that entitlement to service connection for left foot neuroma is not warranted. Nor is there any competent evidence that the neuroma originated during a period of active duty for training or inactive duty training in the Reserves, or that the disorder was otherwise aggravated during such a period of service. Again, the Veteran is not competent in this case to offer an opinion as to the etiology of the neuroma In short, there is no competent or credible evidence that the left foot neuroma originated in active service, or during any period of active duty for training or inactive duty training. As such, the Board finds that a preponderance of the evidence is against the claim. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Sleep Apnea On June 1988, December 1988, February 1989, September 1991, May 1994, and March 2000 reports of medical history, the Veteran marked no when asked whether she had (or had a history of) frequent trouble sleeping. In September 1991, the Veteran completed a Southwest Asia Demobilization/Redeployment Medical Evaluation. At that time, the Veteran marked no when asked have you had any nightmares or trouble sleeping. In February 2007, the Veteran underwent a sleep study. She noted a history of snoring and respiratory difficulties while asleep. The examiner diagnosed mild obstructive sleep apnea syndrome with multiple spontaneous sleep disruptions and early REM onset. In April 2007 she received a CPAP machine. In an April 2008 letter, the Veteran noted that she has endured sleep problems for more than 14 years. The Board finds that entitlement to service connection for sleep apnea is not warranted. The evidence does not suggest the presence of a sleep disorder during active service and there is no competent evidence of a relationship between the Veteran's current sleep apnea and service. The Veteran was first diagnosed with sleep apnea in February 2007, over 15 years after separation from active duty. Again, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson, supra. The Veteran notes that she has had difficulty sleeping for over 14 years in an April 2008 letter. This statement is inconsistent with the contemporaneous evidence including May 1994 and March 2000 reports on which the Veteran specifically noted no frequent trouble sleeping as well as the Veteran's February 2008 claim in which she noted the onset of her sleep apnea as 2006. As the Veteran has been inconsistent in her reports concerning the onset of her sleep apnea, the Board finds her account of symptoms to lack credibility. The Board notes that even if the Veteran's account was credible, she would have dated the onset of symptoms in 1994, several years after her separation from active service. The Board also finds that sleep apnea is not the type of disorder a lay person would be competent to provide an etiological opinion concerning. As there is no competent or credible evidence of sleep apnea during active service or for over 15 years after her discharge from active service, or during a period of active duty for training, and as there is no competent evidence linking any sleep apnea to active service, active duty for training or inactive duty training, the Board finds that the preponderance of the evidence is against the claim. The Board also notes that the Veteran believes her sleep apnea should be service connected based on her service in the Southwest Asia theater during the Persian Gulf War. The Veteran's sleep disability has been diagnosed as sleep apnea. As such, she does not have an undiagnosed illness manifested by sleep disturbances. Sleep apnea is not included in the list of medically unexplained chronic multisymptom illnesses. As such, the Veteran is not entitled to service connection for sleep apnea on the basis of service in the Southwest Asia theater during the Persian Gulf War. The Board therefore finds that a preponderance of the evidence is against the claim. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Bilateral Fibrocystic Breast Disease On a March 1987 report of medical examination, the examiner noted the Veteran's breasts as within normal limits. On a June 1988 supplemental medical data record, the Veteran marked no when asked whether she had (or had a history of) breast lumps/breast discharge/fibrocystic breast disease. On a June 1988 report of medical examination, the examiner noted the Veteran's chest, including breasts, as clinically normal. On a June 1988 gynecological report, the Veteran's breasts were described as soft without masses. On the December 1988 report of medical examination, the examiner noted the Veteran's breasts as slightly tender with a dry discharge on both nipples. He diagnosed mild mastitis, not considered disabling. On the February 1989 report of medical examination, the examiner noted the Veteran's chest, including breasts, as clinically normal. A February 1990 gynecological examination showed no masses, pain, discharge, or skin changes of the breasts. On a September 1991 report of medical examination, the examiner noted the Veteran's chest, including her breasts, as clinically normal. On a May 1994 report of medical history, the Veteran marked no when asked have you ever been treated for a female disorder. On the May 1994, March 2000, and September 2004 reports of medical examinations, the examiners noted the Veteran's breasts as clinically normal. In February 2006, the Veteran received a right diagnostic mammogram, right breast sonogram, and focused physical examination. The examiner noted the presence of a dominant circumscribed mass in the lateral right breast. The examiner diagnosed moderately severe fibrocystic changes with a dominant 2.5 centimeter asymptomatic cyst in the right breast. In April 2007, the Veteran received another mammogram. The report showed no evidence of malignancy or other significant abnormality and no interval change as compared with previous mammograms. In September 2008, the Veteran's mammogram showed large simple cysts in the upper- outer right breast diagnosed as bilateral fibrocystic breast change. The Veteran was afforded a VA gynecological examination in February 2009. The examiner reported a right breast lump found in March 2001 and surgically removed in April 2001. It was determined to be a benign fibrocystic mass. Upon physical examination, the examiner noted small soft breasts with bilateral fibrocystic changes. She found no dominant masses, nipple discharge, or skin changes. She did note a well-healed scar on the right breast. The examiner diagnosed fibrocystic breasts. The Board finds entitlement to service connection for bilateral fibrocystic breast disease is not warranted. Both the Veteran's claim and her medical history show that her fibrocystic breast disease was diagnosed in March or April 2001. The diagnosis came almost 10 years after the Veteran's separation from active service. Once again, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Additionally, the Veteran's breasts were consistently deemed clinically normal throughout and after the Veteran's active service. Specifically in May 1994, March 2000, and September 2004, spanning the entire 10 years between active service and the diagnosis of fibrocystic breast disease, the Veteran's breasts were considered normal. In sum, service treatment records are silent as to any fibrocystic changes. The first diagnosis or complaint of fibrocystic breast disease came almost 10 years after separation from active service. Absolutely no evidence of record, other than the Veteran's own statements, relates the Veteran's fibrocystic breast disease to any aspect of her active service, or to a period of active duty for training or inactive duty training. The Board notes that internal disease process such as fibrocystic breast disease is clearly not the type amenable to lay opinion concerning etiology. As such, the Board finds that a preponderance of the evidence is against the claim of entitlement to service connection for fibrocystic breast disease. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Lumbar Spine Osteoarthritis On a June 1988, a December 1988, a February 1989, a September 1991, a May 1994, and a March 2000 report of medical history, the Veteran marked no when asked whether she had (or had a history of) arthritis, rheumatism, or bursitis, bone, joint, or other deformity, or recurrent back pain. On a March 1987, a June 1988, a December 1988, a February 1989, a September 1991, a May 1994, a March 2000, and a September 2004 report of medical examination, the examiner noted the Veteran's spine as clinically normal. Additionally, on a December 1988 applicant medical prescreening form, the Veteran marked no when asked have you ever had or have you now back trouble. A September 2007 record showed pain in the back for two months. In November 2007, a physical therapist provided an evaluation of the Veteran. He diagnosed low back pain with menstrual induced hormone arthritis exacerbations that impaired her gait and locomotion. An October 2007 record showed mild degenerative changes, but no herniated nucleus pulposus. A January 2008 record showed that the Veteran was released from physical therapy with a diagnosis of back strain. The Board finds that entitlement to service connection for lumbar spine osteoarthritis is not warranted. From December 1988 to March 2000, the Veteran specifically noted no back pain or trouble. From March 1987 to September 2004 the Veteran's back was considered clinically normal by medical examiners. The Board notes that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. As seen by her lack of complaints, treatment, or diagnosis and the evidence indicating a clinically normal back, the Veteran did not suffer an injury or disease in service that affected her back. Additionally, the first record of back pain is dated September 2007, over 15 years after the Veteran's separation from active service. As noted regarding the above issues, a prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). As there is no evidence of a disability resulting from an injury or disease incurred in service, a period of active duty for training, or a period of inactive duty training, and the first evidence of a current disability is dated over 15 years after the Veteran's separation from active service, the Board finds that entitlement to service connection for lumbar spine osteoarthritis is not warranted. In an April 2008 statement the Veteran contended that her arthritis in her back was a by-product of Gulf War illness. The Veteran was afforded a VA examination to address her Gulf War claims in April 2009. The examiner noted complaints of back pain and anterior right thigh pain that begins at the time of her menstrual periods and lasts for 12 days. The examiner noted that the process began insidiously about seven years prior without intense pain. The pain became intense in September of 2007. The Veteran denied any injury to her back and has not had any treatment for her back while on active duty. Upon physical examination, palpation of the lumbar spin showed tenderness with slight retraction with deep palpation on the right side L4-L5, right SI area, and right buttocks. There was no midline tenderness and no left-sided tenderness. The examiner diagnosed chronic back pain and right thigh pain related to endometriosis. He also noted no evidence of fibromyalgia and no evidence of any condition related to exposures in the Gulf War. As the Veteran's lumbar pain is related to a diagnosed illness that is not service connected, it may not be included in the undiagnosed illness category listed under 38 C.F.R. § 3.317. The Board also acknowledges that osteoarthritis and endometriosis are not included in the list of medically unexplained chronic multisymptom illnesses. As such, the Veteran is not entitled to service connection for a lumbar disability on the basis of service in the Southwest Asia theater during the Persian Gulf War. As such, the Board finds that a preponderance of the evidence is against the claim of entitlement to service connection for lumbar spine osteoarthritis. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Abdominal Myomectomy with Infertility and Endometriosis On a June 1988, a February 1989, and a May 1994 report of medical history, the Veteran marked no when asked have you ever been treated for a female disorder. On a March 1987, a June 1988, a December 1988, a February 1989, a September 1991, and a May 1994 report of medical examination, the examiners noted the Veteran's vaginal pelvic examination as clinically normal. In June 1988, the Veteran received normal gynecological examination results. In December 1990, the Veteran's pap smear was normal and the examiner noted no problems. A January 2004 medical record showed pelvic pain. A January 2004 letter from the Veteran's gynecologist showed normal pap smear results and two fibroids that are benign growths that may account for her symptoms of abnormal menses and pelvic pain. A November 2005 record showed the pathology of the removed fibroids. In November 2006, a gynecologist noted a one and a half year history of infertility. The examiner noted a November 2005 myomectomy that was done by a laparotomy and removed a 6 cm. intramural fibroid along with two smaller fibroids. The Veteran noted moderate dysmenorrhea. An August 2007 record showed spasm and cramping in the rectal area post-menses. The examiner noted a previous myomectomy. In November 2008, the Veteran underwent a laproscopic evaluation for chronic pelvic pain. The Veteran was diagnosed with chronic pelvic pain. In December 2008, the Veteran was diagnosed with fibroids, endometriosis, and chronic pelvic pain. The Veteran was afforded a VA gynecological examination in February 2009. At that time, the Veteran reported sharp pelvic pains for three years that have become progressively worse with severe dysmenorrhea. The examiner performed a complete physical examination. He diagnosed pelvic pain due to uterine fibroids and endometriosis and infertility. The examiner noted that the Veteran was diagnosed with uterine fibroids and endometriosis during her military service. The examiner provided an opinion in an addendum dated May 2009. She noted that following careful review of the Veteran's records, there is no evidence for the Veteran having either endometriosis or uterine fibroids during the time of her active duty in the military. Nothing in her medical records indicates that she ever had proven endometriosis. The examiner cited a November 2005 report specifically stating that there was no gross evidence of any endometriosis. Her claimed endometriosis/abdominal myomectomy/infertility are not caused by the irregular periods she had during military service. The examiner then provided evidence from the Veteran's claims file. The Board finds that entitlement to service connection for abdominal myomectomy with infertility and endometriosis is not warranted. The evidence fails to show any uterine fibroids or endometriosis during the Veteran's active service. Pelvic pain was not noted until January 2004, over ten years after the Veteran's separation from service. As seen above, a prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran is not competent to offer an opinion concerning something that is clearly within the realm of medical expertise such as internal gynecological conditions. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board finds that the etiology of the Veteran's abdominal myectomy for uterine fibroids with infertility and endometriosis is too complex an issue, one typically determined by persons with medical training, to lend itself to lay opinion evidence. The Veteran is certainly competent to testify as to symptoms such as pelvic pain, which are non-medical in nature; however she is not competent to render a medical diagnosis or etiology. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also, Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). No medical evidence of record finds a relation between active duty service and the Veteran's abdominal myectomy for uterine fibroids with infertility and endometriosis. The only medical opinion in the file was provided by the VA examiner in May 2009. The examiner opined that there is no evidence for the Veteran having either endometriosis or uterine fibroids during the time of her active duty in the military. The examiner specifically cited a November 2005 report specifically stating that there was no gross evidence of any endometriosis. The examiner stated that the Veteran's claimed endometriosis/abdominal myomectomy/infertility is not caused by the irregular periods she had during military service. There is no contrary medical opinion of record. In an April 2008 statement the Veteran contended that her infertility was a by-product of Gulf War illness. The Board again notes that certain chronic undiagnosed illnesses or medically unexplained chronic multisymptom illnesses are entitled to a presumption of service connection based upon service in Southwest Asia during the Persian Gulf War. 38 C.F.R. § 3.317. As the Veteran's infertility is related to a diagnosed illness, specifically the Veteran's endometriosis, that is not service connected, it may not be included in the undiagnosed illness category listed under 38 C.F.R. § 3.317. The Board also acknowledges that infertility, endometriosis, and uterine fibroids are not included on the list of medically unexplained chronic multisymptom illnesses. As such, the Veteran is not entitled to service connection for an abdominal myomectomy with endometriosis and infertility on the basis of service in the Southwest Asia theater during the Persian Gulf War. As such, the Board finds that a preponderance of the evidence is against the claim. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Muscle and Joint Pain On June 1988, December 1988, February 1989, September 1991, May 1994, and March 2000 reports of medical history, the Veteran marked no when asked have you ever had or have you now swollen or painful joints, cramps in your legs, arthritis, rheumatism, or bursitis, bone, joint, or other deformity, lameness, painful or "trick" shoulder of elbow, recurrent back pain, "trick" or locked knee, or foot trouble. On a December 1988 applicant medical prescreening form, the Veteran marked no when asked have you ever had or have you now any painful or "trick" joints or loss of movement in any joint, or impaired use of arms, legs, hands, and feet. On March 1987, June 1988, December 1988, February 1989, September 1991, May 1994, March 2000, and September 2004 reports of medical examinations, the examiners noted the Veteran's upper extremities, lower extremities, spine, and other musculoskeletal as clinically normal. On a March 2000 report of medical history, the Veteran marked yes when asked have you ever had or have you now cramps in your legs. She marked no regarding swollen or painful joints, broken bones, arthritis, rheumatism, or bursitis, bone joint, or other deformity, painful or "trick" shoulder or elbow, recurrent back pain, "trick" or locked knee, or foot trouble. The Veteran was afforded a VA examination in April 2009 to address her contention that her muscle and joint pain is due to her service in Southwest Asia during the Persian Gulf War. The examiner noted lumbar pain, side pain, and bilateral leg pain. The examiner noted that the Veteran does not meet any criteria for fibromyalgia. The examiner performed a thorough physical examination. He diagnosed chronic back pain and right thigh pain related to endometriosis, no evidence of fibromyalgia, no evidence of any condition related to exposures in the Gulf War, and chronic foot pain related to surgery for Morton's neuroma. As noted above, service connection may be established for a chronic disability manifested by certain signs or symptoms 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 which, 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). The Veteran's joint and muscle pain are attributable to known clinical diagnoses, specifically Morton's neuroma and endometriosis. Additionally, neuroma and endometriosis are not included on the list of medically unexplained chronic multisymptom illnesses. As such, the disabilities may not be diagnosed under 38 C.F.R. § 3.317 as an undiagnosed illness. The examiner made clear the Veteran did not evidence of an undiagnosed illness accounting for her symptoms. As consideration of a Veteran's claim under this regulation does not preclude consideration of entitlement to service connection on a direct basis, the Board also considered entitlement to service connection for muscle and joint pain on a direct basis. The only noted muscle or joint pain relates to the Veteran's left foot, low back, and right thigh. The issues of entitlement to service connection for a left foot disability and low back disability are separately addressed above. The complaints of pain in the right thigh are related to the Veteran's endometriosis which is also addressed above. As such, the Veteran is not entitled to service connection for muscle and joint pain due to service in the Persian Gulf or on a direct basis. ORDER Entitlement to service connection for a left foot neuroma is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for bilateral fibrocystic breast disease is denied. Entitlement to service connection for osteoarthritis of the lumbar spine is denied. Entitlement to service connection for an abdominal myomectomy with infertility and endometriosis is denied. Entitlement to service connection for muscle and joint pain to include as due to an undiagnosed illness is denied. REMAND As to the claimed right and left eye disorders, on a June 1988 report of medical history, the Veteran noted that she wore glasses and had an astigmatism in her left eye. On a June 1988 report of medical examination, visual acuity was measured as 20/60 in the left eye, and as 20/25 in the right eye, both corrected to 20/20. On a December 1988 report of medical examination, the examiner noted the Veteran's eyes as abnormal. He noted mild pterygium of the left eye. On the February 1989 report of medical examination, the examiner noted the eyes as clinically normal with 20/20 left eye visual acuity. An optometry services exam revealed emmetropia. A December 1990 optometry services exam showed mixed astigmatism of the right eye. Given the evidence suggesting the presence of eye abnormalities other than mere refractive error, the Board is of the opinion that a VA examination is necessary. Accordingly, this case is REMANDED for the following actions: 1. The Veteran should be afforded a VA examination to determine the nature, extent and etiology of any right and/or left eye disorder. All indicated studies should be performed. With respect to each right and/or left eye disorder found, the examiner should be requested to provide an opinion as to whether it is at least as likely as not that the disorder is etiologically related to service or to any period of active duty for training or inactive duty training. The rationale for all opinions expressed should be explained. The Veteran's claims files must be made available to the examiner. 2. The RO should then readjudicate the issues remaining on appeal. If the benefits sought on appeal are not granted in full the RO must issue a supplemental statement of the case, and provide the Veteran and her representative an opportunity to respond. After the Veteran and her representative have been given an opportunity to respond to the supplemental statement of the case and the period for submission of additional information or evidence set forth in 38 U.S.C.A. § 5103(b) (West 2002) has expired, if applicable, the case should be returned to the Board for further appellate consideration, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until she is notified by the RO. The Veteran and her representative have the right to submit additional evidence and argument on the matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2009). ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs