Citation Nr: 1037510 Decision Date: 10/04/10 Archive Date: 10/12/10 DOCKET NO. 08-13 232A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for residuals of a low back injury. 2. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for headaches. 3. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for bilateral shoulder disability. 4. Entitlement to service connection for fibromyalgia, to include consideration as a qualifying chronic disability under 38 C.F.R. § 3.317. 5. Entitlement to service connection for irritable bowel syndrome (IBS), to include consideration as a qualifying chronic disability under 38 C.F.R. § 3.317. 6. Entitlement to a compensable initial disability rating for hypertension. 7. Entitlement to an initial disability rating in excess of 20 percent for hypertensive retinopathy. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Harrigan Smith, Counsel INTRODUCTION The appellant served on active duty from May 1974 to September 1977 and from October 1990 to June 1991. He had active duty in Southwest Asia from November 1990 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a July 2007 rating decision, issued in August 2007, the RO, inter alia, reopened and denied the Veteran's claims for entitlement to service connection for residuals of a back injury, headaches, and cardiac arrythmia with a pacemaker. In a January 2009 rating decision, the RO, inter alia, granted service connection for hypertension and hypertensive retinopathy, assigning noncompensable disability ratings for each, and denied service connection for IBS, right and left shoulder disorders and fibromyalgia. In July 2009, the Veteran testified at a hearing before a Decision Review Officer (DRO hearing); the transcript of this hearing has been associated with the record. In a March 2010 rating decision, the RO increased the Veteran's disability rating for hypertensive retinopathy to 20 percent. As this rating does not represent the highest possible benefit, this issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). Service connection for cardiac arrhythmia with a pacemaker was granted and this was a substantial grant of the benefit sought with regard to that issue. The Board has a legal duty to address the "new and material evidence" requirement regardless of the actions of the RO. If the Board finds that no new and material evidence has been submitted it is bound by a statutory mandate not to consider the merits of the case. Barnett v. Brown, 8 Vet. App. 1, 4 (1995). The issue of entitlement to an initial disability rating in excess of 20 percent for hypertensive retinopathy is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran had military service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. An August 1995 rating decision denied service connection for a residuals of a back injury and headaches and found that the Veteran's clam for entitlement to service connection for a shoulder disorder was not well grounded; the Veteran filed a timely notice of disagreement with this decision and was issued a statement of the case in September 1995. As he did not file a substantive appeal, the decision is final. 3. Evidence added to the record since the August 1995 rating decision does not relate, by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the Veteran's service-connection claim for residuals of a back injury. 4. Evidence added to the record since the August 1995 rating decision relates, by itself or when considered with previous evidence of record, to unestablished facts necessary to substantiate the Veteran's service-connection claims for headaches and right and left shoulder disorders. 5. A preponderance of the evidence is against a finding that a headache disorder had its onset in or is otherwise related to service. 6. A preponderance of the evidence is against a finding that a right shoulder disorder had its onset in or is otherwise related to service. 7. A preponderance of the evidence is against a finding that a left shoulder disorder had its onset in or is otherwise related to service. 8. A preponderance of the evidence is against a finding that fibromyalgia had its onset in or is otherwise related to service. 9. A preponderance of the evidence is against a finding that IBS had its onset in or is otherwise related to service, and a chronic disability manifested by gastrointestinal disturbances resulting from an undiagnosed illness or a chronic multisymptom illness was not manifested during service and is not currently manifested to a compensable degree. 10. Hypertension is not manifested by diastolic pressure measurements predominantly 100 or more (or a history of these readings), or systolic pressure measurements predominantly 160 or more. CONCLUSIONS OF LAW 1. The August 1995 rating decision is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2009). 2. New and material evidence has not been received since the August 1995 rating decision sufficient to reopen the Veteran's claim for service connection for residuals of a low back injury. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3. 156 (2009). 3. New and material evidence has been received since the August 1995 rating decision sufficient to reopen the Veteran's claims for service connection for headaches and left and right shoulder disorders. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3. 156 (2009). 4. A headache disorder. to include a disability due to undiagnosed illness manifested by headaches, was not incurred in, or aggravated by, active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2009). 5. A right shoulder disorder. to include a disability due to undiagnosed illness, was not incurred in, or aggravated by, active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2009). 6. A left shoulder disorder. to include a disability due to undiagnosed illness, was not incurred in, or aggravated by, active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2009). 7. Fibromyalgia was not incurred in or aggravated by service, nor is it shown to be due to undiagnosed illness as a result of service in the Southwest Asia Theater during the Persian Gulf War. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 8. IBS. to include a gastrointestinal disturbance due to undiagnosed illness, was not incurred in, or aggravated by, active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2009). 9. The criteria for an initial compensable disability rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 4.1- 4.10, 4.104, Diagnostic Code 7101 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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). Proper notice from VA 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 in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the duty to notify was satisfied by way of letters sent to the appellant in March 2007, April 2007, August 2008 and October 2008, that fully addressed all notice elements and were sent prior to the respective initial AOJ decisions in the matters on appeal. The letters informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence. These letter also met the notice requirements in Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board has found that no new and material evidence has been presented in order to reopen the Veteran's claim for entitlement to service connection for residuals of a low back injury. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the U.S. Court of Appeals for Veterans Claims clarified VA's duty to notify in the context of claims to reopen. With respect to such claims, VA must both notify a claimant of the evidence and information that is necessary to reopen the claim and notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. To satisfy this requirement, the Secretary is required to look at the bases for the denial in the prior decision and to provide the claimant with a notice letter that describes what evidence would be necessary to substantiate those elements required to establish service connection that were found insufficient in the previous denial. The Veteran received this notice in March 2007. The Board has found that new and material evidence has been presented sufficient to reopen his clams for entitlement to service connection for headaches and right and left shoulder disorders. This is a full grant of the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist with respect to these claims, such error was harmless and will not be further discussed. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service treatment records, VA medical records and examination reports, non-VA medical records, the Veteran's DRO hearing transcript, and lay statements have been associated with the record. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Claims to Reopen The issues before the Board include whether the appellant has submitted new and material evidence to reopen his previously denied claims of entitlement to service connection for low back injury, headaches, and left and right shoulder disorders. As noted above, the requirement of submitting new and material evidence to reopen a claim is a material legal issue that the Board is required to address on appeal. Barnett v. Brown, 83 F.3d 1380, 1383-84 (Fed. Cir. 1996). When a claim to reopen is presented, a two-step analysis is performed. The first step of which is a determination of whether the evidence presented or secured since the last final disallowance of the claim is "new and material." See Elkins v. West, 12 Vet. App. 209, 218-19 (1999) (en banc); see also 38 U.S.C.A. § 5108; Hodge v. West, 155 F.3d 1356, 1359-60 (Fed. Cir. 1998). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Second, if VA determines that the evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist has been fulfilled. In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is not new and material, the inquiry ends and the claim cannot be reopened. In determining whether the evidence is new and material, the credibility of the newly presented evidence is presumed. Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curiam). The Board is required to consider all of the evidence received since the last disallowance, in this case, since the decision dated in August 1995. Hickson v. West, 12 Vet. App. 247, 251 (1999). With regard to the Veteran's claim for entitlement to service connection for residuals of a back injury, the Veteran's initial claim was denied because the RO found that chronic low back disability was not present in service and that post service findings of low back disability were not related to active duty. The RO noted that the Veteran was seen for pain in the lumbosacral area with negative objective findings during his first period of active duty, but that no back disorder was found at discharge from his first period of active duty or in his second period of active duty. The new evidence received since the August 1995 rating decision includes a February 2007 VA medical record which reflects the Veteran's reports of back pain since an injury in 1976, a June 2007 VA examination report which reflects that the examiner diagnosed degenerative joint disease and degenerative disc disease of the lumbar spine which included a February 2007 VA x-ray report which revealed arthritic changes in his lumbar spine with a grade I spondylolisthesis defect of L4 on L5, a September 2009 VA examination report reflecting degenerative disc disease/degenerative joint disease of the lumbar spine, which includes the VA examiner's opinion that the Veteran's spine is less likely than not related to his active duty. The Board finds that, while this evidence is new, it does not relate to an unestablished fact necessary to substantiate the Veteran's claim for entitlement to service connection for residuals of a low back injury. The Board notes that, in conjunction with a May 1995 VA examination, the Veteran underwent an x-ray which revealed the diagnosis of degenerative disc disease with osteophyte formation with narrowing of the intervertebral disk at L5-S1 level. As noted above, the RO, in a final decision, found that this disorder was not linked to the Veteran's active duty. The evidence submitted since the August 1995 rating decision confirms this diagnosis, but does not provide any nexus with this active duty. In fact, the new evidence contains a VA medical opinion that his back disorder is less likely than not that his back disorder is related to active duty. As such, this evidence, while new, is not material and is not sufficient to reopen the Veteran's claim for entitlement to service connection for residuals of a back injury. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. As such, the Veteran's claim for entitlement to service connection for residuals of a back injury is not reopened. In terms of the Veteran's claim for entitlement to service connection for headaches, his claim was initially denied because the RO found that the Veteran did not incur headaches in service and that they were not caused by service. The RO noted that the Veteran's service treatment records were negative for reports of headaches, and that he did not report for a neurological examination. The evidence received since the August 1995 rating decision includes a VA neurological examination report which shows that the Veteran has a diagnosis of cervicogenic headaches. This evidence is new since it was not part of the evidence of record when the August 1995 rating decision was adjudicated. In addition, as these records show that the Veteran has cervicogenic headaches, this evidence is considered material as it relates to an unestablished fact necessary to substantiate the Veteran's claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. As such, the Veteran's claim for entitlement to service connection for headaches has been reopened. The Veteran's claim for service connection for bilateral shoulder disability was found to be not well-grounded in the August 1995 rating decision. The RO noted that, while the Veteran had a record in service for a shoulder injury, no permanent residual or chronic disability was shown in service or following service. Evidence submitted since the August 1995 rating decision includes a VA examination report which reflects the diagnoses of minimal degenerative joint disease of the left shoulder and mild tendonitis of the right shoulder. This evidence is new since it was not part of the evidence of record when the August 1995 rating decision was adjudicated. In addition, as these records show that the Veteran has current left and right shoulder disorders, this evidence is considered material as it relates to an unestablished fact necessary to substantiate the Veteran's claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. As such, the Veteran's claim for entitlement to service connection for left and right shoulder disorders has been reopened. Service Connection Claims Under the applicable criteria, service connection may be granted for a disability resulting from disease or injury incurred or aggravated in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In order to prevail in a claim for service connection there must be medical evidence of a current disability as established by a medical diagnosis; of incurrence or aggravation of a disease or injury in service, established by lay or medical evidence; and of a nexus between the in-service injury or disease and the current disability established by medical evidence. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that an appellant had a chronic disorder in service or during the applicable presumptive period. Service connection also may 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). Medical evidence is required to prove the existence of a current disability and to fulfill the nexus requirement. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Court has also held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection may be established for chronic disabilities due to undiagnosed illnesses, if there is evidence that the claimant: (1) is a 'Persian Gulf Veteran;' (2) who exhibits objective indications of chronic disability resulting from an illness or combinations of illnesses manifested by one or more signs or symptoms; (3) 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 (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. A Persian Gulf Veteran is a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War. 38 C.F.R. § 3.317(d). In the present appeal, the Veteran served in Southwest Asia from November 1990 to May 1991, making him a Persian Gulf Veteran. Objective indications of chronic disability are described as either objective medical evidence perceptible to a physician or other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(2). Further, a chronic disability is one that has existed for 6 months or more, including disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period. 38 C.F.R. § 3.317(a)(3). The 6-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. Id. A qualifying 'chronic disability' includes: (A) an undiagnosed illness, (B) the following medically unexplained chronic multi symptom illnesses: chronic fatigue syndrome, fibromyalgia, and IBS, as well as any other illness that the Secretary of VA determines is a medically unexplained chronic multi-symptom illness; and (C) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). Compensation shall not be paid pursuant to 38 C.F.R. § 3.317(a), however, if there is affirmative evidence that an undiagnosed illness: (1) was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) was caused by a supervening condition or event that occurred between the 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) is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). When determining whether a qualifying chronic disability became manifest to a degree of 10 percent or more, the Board must explain its selection of analogous Diagnostic Code. Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). The Board notes that, in cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 is warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service connection - headaches The Veteran contends that he has headaches which he attributes to his service in the Gulf War. He has also contended that his headaches are related to his neck stiffness. While the Veteran has not contended that his headaches manifested during his first period of active duty, the Board notes that the Veteran was treated twice during his initial period of service. A June 1975 service treatment record shows that the Veteran had a frontal headache and dizziness. The impression was a question of a sinus tension headache. Service treatment records reflect that the Veteran reported a headache in March 1977. There is no other evidence that the Veteran was treated for headaches or diagnosed with a headache disorder in service. His May 1994 Report of Medical History reflected that he had frequent or severe headaches, but a contemporaneous Report of Medical Examination was normal. A May 1995 VA general medical examination report shows that the Veteran complained of severe headaches. No diagnoses were made and no nexus opinion was provided. A June 2007 VA neurological examination report shows that the Veteran reported that he had headaches which began seven to eight years prior and radiated from and involved his neck region. The examiner diagnosed cervicogenic headaches, based on restricted range of motion of his cervical spine and that the symptoms appeared musculoskeletal and were secondary to moderate cervical osteoarthritis. A September 2009 VA examination report shows that the Veteran reported that he had headaches since 1991. He had no history of head trauma or brain tumor, but had cervical spine disease. He reported headaches almost every day lasting five to seven hours. He indicated that he did not take any medication for his headaches. The diagnosis was chronic headaches, due to muscle tension associated with cervical spondylosis. Based on the evidence above, the Board finds that service connection cannot be granted for the Veteran's headaches. The Veteran has presented lay evidence that he has had headaches since active duty. Competent lay evidence is defined as any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran is competent to describe the incidence and severity of these headaches; however, competent medical evidence has linked his headaches to a non-service- connected cervical spine disorder. Competent medical evidence is provided more probative value with regard to the etiology of his headaches. Moreover, the Veteran's description of the onset and cause of his headaches has not been consistent. In June 2007, he reported headaches for 7-8 years, which would place the onset of those headaches at several years after service, which undermines the credibility of other descriptions of continuous headaches since service. Both the June 2007 and the September 2009 VA examiners found that the Veteran's headaches were due to his cervical spine arthritis, for which he is not service-connected. Without credible, competent evidence linking the Veteran's headaches to his active duty, service connection cannot be granted. Boyer. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Service connection - bilateral shoulder disability The Veteran contends that he injured his shoulders during his first tour of duty, in 1976. Service treatment records reflect that the Veteran was seen in May 1977, for back pain which radiated into his shoulders. He was given medication and instructed to take a hot shower. His separation Reports of Medical Examination and History from both periods of active duty and his Quadrennial Reports of Medical Examination and History do not reflect a diagnosis of a shoulder disorder, and the Veteran indicated that he did not have a painful or "trick" shoulder. A July 1992 service treatment record from the Veteran's active duty for training (ACDUTRA) reflects that he woke up with severe pain in his shoulder. He was diagnosed with right neck strain. His May 1994 Reports of Medical Examination and History do not reflect a shoulder disorder, and the Veteran indicated that he did not have a painful or "trick" shoulder. At his September 2009 VA examination, the Veteran indicated that both shoulders began bothering him during active duty in 1976, but he had no history of acute or severe trauma to either shoulder. The Veteran was vague about the details of his shoulder disorders. X-rays revealed a normal right shoulder and minimal degenerative changed in the left shoulder. The examiner diagnosed minimal degenerative joint disease of the left shoulder and mild tendonitis of the right shoulder. The examiner found that the Veteran's right and left shoulder disorders were not caused by or a result of an in-service event, injury or illness during active duty. He provided the rationale that the Veteran's service treatment records fail to document serious or ongoing shoulder disorder during service and that the Veteran's shoulder disorders are most consistent with the aging process and/or his years of civilian employment in the construction field. Based upon the evidence of record, the Board finds that service connection for right and left shoulder disorders is not warranted. While the Veteran was seen in May 1977 for pain in both his shoulders, this appears to have resolved since he was not diagnosed with a shoulder disorder at any time during active duty. None of his examination reports reflect a shoulder disorder and the Veteran himself reported, on several occasions, that he did not have a painful shoulder while in the service. The Board notes that the Veteran was treated for severe shoulder pain while on ACDUTRA in the Army Reserves. Service connection may be granted for a disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, for residuals of injury incurred or aggravated during INACDUTRA, or for residuals of an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1131; 38 C.F.R. § 3.6. However, this pain appears to have been transitory as well, since his May 1994 Reports of Medical Examination and History show no shoulder disorder. Lay evidence includes the Veteran's statements that he has had shoulder pain since his in-service injury and that he feels his right and left shoulder disorders are a result of this injury. However, while the Veteran is competent to report the incident and his symptoms, his statements are inconsistent with findings on the May 1994 examination, which did not reveal shoulder pathology and the Veteran's denial of having or having had a trick shoulder on the Report of Medical History on that date. On examination in May 1995, it was indicated that the Veteran denied a history of shoulder injury or pain while in service, but claimed that he started having problems after his return from Saudi Arabia. The September 2009 VA examiner opined that the Veteran's right and left shoulder disorders were not caused by or a result of an in-service event, injury or illness during active duty, linking his shoulder disorders instead to the aging process and/or his years of civilian employment in the construction field. With no competent, credible evidence linking the Veteran's right and left shoulder disorders to active duty or ACDUTRA, service connection cannot be granted. Boyer. Arthritis is a disorder for which presumptive service connection is available. However, as there is no evidence in the claims file that the Veteran's degenerative changes in his left shoulder manifested to a compensable degree within one year of his discharge, service connection on a presumptive basis is not warranted. 38 C.F.R. §§ 3.307, 3.309. As the shoulder disability has been attributed to diagnosed illnesses, the provisions of 38 C.F.R. § 3.317 are inapplicable. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. Gilbert. Service connection - fibromyalgia, to include consideration as a qualifying chronic disability under 38 C.F.R. § 3.317 Service treatment records do not show any treatment for or diagnosis of fibromyalgia. The Veteran was seen for right neck strain in July 1992, while serving on ACDUTRA. The Veteran's service treatment records do not show any treatment for or diagnosis of any neck, hand, knee, ankle, elbow or foot disorder. On his May 1994 Report of Medical History, the Veteran indicated that he had painful joints, cramps in his legs and foot trouble; however, a contemporaneous Report of Medical Examination revealed normal lower extremities and did not include a diagnosis of any joint disorder. VA medical records showing intermittent treatment for various health issues from January 1994 through July 2010 do not reflect any treatment for or diagnosis of fibromyalgia. A September 2008 VA examination report shows that the Veteran complained of pain in his joints, including his neck, hands, knees, ankles, elbows and feet. After reviewing the Veteran's medical records and examining the Veteran, the examiner diagnosed degenerative disc disease of the cervical spine at C5-C7, bilateral ankle strain, bilateral elbow osteoarthritis and olecranon spurs, bilateral patellofemoral syndrome, bilateral hand osteoarthritis with flexion deformity of the fifth digit, and bilateral foot hallux valgus deformity, osteoarthritis and pes planus. A December 2008 addendum shows that the Veteran noted that the Veteran does not meet the criteria for fibromyalgia, since his joint pains all have proven pathology as found on radiology reports. The examiner noted that fatigue is a very subjective symptom and if present was most likely from his carotid artery occlusion and stenosis and atrial fibrillation with pacemaker which can cause both decreased oxygen to the brain causing fatigue. Based upon the evidence of record, the Board finds that service connection for fibromyalgia is not warranted. As noted above, fibromyalgia is one of the medically unexplained chronic multi symptom illnesses for which service connection under 38 C.F.R. § 3.317 is warranted; however, in this case, the Veteran's symptoms of joint pain do not meet the criteria for fibromyalgia. As such, service connection cannot be granted for fibromyalgia. 38 C.F.R. § 3.317. While the evidence shows that the Veteran does not meet the criteria for a diagnosis of fibromyalgia, service connection under 38 C.F.R. § 3.317 may still be available for his joint pain and stiff joints if these were not linked to any diagnosed disorder, but were found to be due to an undiagnosed illness. The Veteran has complained of pain in his neck, hands, knees, ankles, elbows and feet. However, the Veteran's complaints of joint pains are related by competent medical evidence to various diagnoses. The September 2008 VA examiner diagnosed degenerative disc disease of the cervical spine at C5-C7, bilateral ankle strain, bilateral elbow osteoarthritis and olecranon spurs, bilateral patellofemoral syndrome, bilateral hand osteoarthritis with flexion deformity of the fifth digit, and bilateral foot hallux valgus deformity, osteoarthritis and pes planus. Since competent medical evidence shows that the Veteran's muscle and joint aches are related to diagnosed disabilities, the provisions for a presumptive disability, under 38 C.F.R. § 3. 317, as due to a qualifying chronic disability have not been met. On the question of direct service connection, the September 2008 VA examiner did not find that any of the Veteran's diagnosed disorders, relating to his joint and muscle pain, were linked to his time on active duty. The examiner opined that the Veteran's cervical spine disorder was not caused by or a result of a service related injury. The examiner noted that the Veteran had no chronic complaints of a neck disorder while in the service. He was seen and treated for an acute problem only and had a negative examination of the spine dated May 14, 1994. The examiner also found that the Veteran's bilateral ankle disorder was not the same as seen in the service and was not the result of a service-related injury. The examiner noted that the Veteran was seen for acute ankle problems only per the claims file and that no chronic disorder was noted. The Veteran had a negative examination of the joints on May 14, 1994. The examiner also found that the Veteran's bilateral elbow, knee, hand, and foot disorders were not the same as what was seen in service and were not caused by a service related injury. The examiner noted that there was no documented treatment for any elbow disorder and the Veteran had a negative joints examination on May 14, 1994. As such, there is no competent medical evidence linking the Veteran's diagnosed disorders of his joints to his time on active duty or ACDUTRA. Without medical evidence providing such a link, service connection on a direct basis cannot be granted. 38 C.F.R. § 3.303, Boyer. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (non-precedential). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). With regard to the Veteran's contentions that he has fibromyalgia as a result of his service in the Persian Gulf War, the Veteran, as a layperson, is not competent to render opinion regarding medical diagnosis or medical opinion on etiology. Even if he could diagnose fibromyalgia, the clinical opinion that he does not have fibromyalgia is afforded greater probative weight as it was made by a medical doctor after examining the Veteran and reviewing the clinical evidence. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. Gilbert. Service connection for IBS, to include consideration as a qualifying chronic disability under 38 C.F.R. § 3.317 Service treatment records do not show any treatment for or diagnosis of IBS. VA medical records showing intermittent treatment for various health issues from January 1994 through July 2010 do not reflect any treatment for or diagnosis of IBS. A September 2009 VA examination report shows that the Veteran reported constipation for about six to seven years, and that he used powdered fiber every one to two days, with good results. He had a colonoscopy in 2008, which revealed one small polyp but was otherwise unremarkable. There was no report of malignancy. The Veteran reported right and left lower quadrant pain, which was sharp and occurred in the mornings but resolved within one to two hours. The examiner noted that there was no listed diagnosis of IBS on the Veteran's active problem list in his VA medical records, and that recent progress notes did not mention IBS. The Veteran indicated that he did not think he was diagnosed with IBS. The examiner noted that the Veteran's service treatment records did not document any chronic intestinal disorder during active duty and that constipation symptoms began years after leaving active duty. The Veteran had a benign colon polyp removed in 2008; this clearly had no linkage to his active duty service. The Veteran had a tendency toward constipation which was most likely constitutional in origin and did not appear to represent a specific disease entity. The examiner found that IBS was not diagnosed at the time of the examination. Based upon the evidence of record, the Board finds that service connection for IBS is not warranted. There is no competent medical evidence which shows that the Veteran had IBS. As such, service connection under 38 C.F.R. § 3.317 cannot be granted for ibs. The Board notes that the Veteran has gastrointestinal complaints, including constipation and that, under 38 C.F.R. § 3.317, service connection might still be available if it is found that the Veteran had gastrointestinal symptoms which were not due to a diagnosed illness, were chronic in nature and rose to the level of a compensable disability rating under an appropriate Diagnostic Code. In this case, the examiner found that the Veteran's constipation was "constitutional" and not related to a specific disease. However, it does not appear that the Veteran's symptom of constipation have been chronic. As noted above, in order to be considered chronic, a disorder must have existed for six months or more, including disabilities that exhibit intermittent episodes of improvement and worsening over a six month period. 38 C.F.R. § 3.317(a)(3). In this case, the Veteran complained that his constipation had been present for 6 or 7 years on VA examination in September 2009. He also reported other gastrointestinal disturbance, including weekly nausea, and regular sharp pains in the right and left lower quadrants. However, he reported at his June 2007 VA Gulf War examination that he did not have any constipation, nausea, indigestion or any other gastrointestinal disturbance. Since the undiagnosed illness symptoms are not reported on a consistent basis and the Veteran's history of longstanding constipation is especially questionable, it cannot be said that he has gastrointestinal disturbance due to an undiagnosed illness that is either chronic or compensably disabling. It would not warrant service connection as due to an undiagnosed illness under 38 C.F.R. § 3.317. Evaluation of Initial Disability Ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects the ability to function under the ordinary conditions of daily life, including employment, by comparing the Veteran's symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Because this appeal involves initial ratings for which service connection was granted and an initial disability rating was assigned, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). Initial disability rating - hypertension The Veteran contends his hypertension warrants a compensable disability rating. The Veteran is service-connected under Diagnostic Code 7101 for hypertension. Under this code, hypertension with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control, warrants a 10 percent disability rating and hypertensive vascular disease with diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more, warrants a 20 percent disability rating. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Board finds that a compensable disability rating for the Veteran's hypertension is not warranted in the present case. At his September 2008 Gulf War examination, the Veteran's blood pressure was 104/82, 104/72 and 104/80. At his September 2009 VA hypertension examination, his blood pressure was 121/74, 117/81 and 116/77. The Board also notes that the evidence of record does not show that the Veteran's diastolic pressure has not been 100 or more and his systolic pressure had not been 160 or more at any time over the appeals period. For this reason, the Veteran's hypertension does not warrant a higher rating under Diagnostic Code 7101. 38 C.F.R. § 4.104, Diagnostic Code 7101. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the evidence reflects that his symptoms have remained constant throughout the course of the period on appeal and, as such, staged ratings are not warranted. Finally, the disability picture is not so exceptional or unusual as to warrant a referral for an evaluation on an extraschedular basis. For example, there is no competent evidence that the hypertension currently results in frequent hospitalizations or marked interference in his employment. The Board is therefore not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) (2007). See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As the preponderance of the evidence is against the Veteran's claims for increased ratings for hypertension, the "benefit-of- the-doubt" rule is not applicable and the Board must deny his claims. See 38 U.S.C.A. § 5107(b). ORDER As new and material evidence has not been received to reopen the previously denied claim of entitlement to service connection for residuals of a low back injury, the claim is denied. As new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for headaches, the claim is reopened. Service connection for headaches is denied. As new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for right and left shoulder disorders, the claim is reopened. Service connection for a right shoulder disorder is denied Service connection for a left shoulder disorder is denied. Service connection for fibromyalgia, to include consideration as a qualifying chronic disability under 38 C.F.R. § 3.317, is denied. Service connection for IBS, to include consideration as a qualifying chronic disability under 38 C.F.R. § 3.317 is denied. A compensable initial disability rating for hypertension is denied. REMAND After a review of the record, the Board has determined that further development is necessary before the Board adjudicates the claim of entitlement to an initial disability rating in excess of 20 percent for the Veteran's hypertensive retinopathy. The Veteran is rated under 38 C.F.R. § 4.79, Diagnostic Codes 6006 and 6080. Diagnostic Code 6080 pertains to loss of visual fields. The Veteran was provided with a VA eye examination in September 2009. The visual field test charts from this examination are of record; however, the graphical representations of the visual fields were not interpreted by the examiner in the VA examination report. While the February 2010 supplemental statement of the case and the March 2010 rating decision include interpretations of the visual field charts, it is not clear that such interpretations were provided by an appropriate specialist. In light of this, the Board finds that the September 2009 VA examination report does not contain sufficient detail for evaluation purposes. 38 C.F.R. § 4.2; see Kelly v. Brown, 7 Vet. App. 471, 474 (1995) (holding that neither the Board nor the RO may interpret graphical representations of audiometric data). The Board finds that interpretation of the visual field charts should be provided by an appropriate specialist. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should have a certified specialist interpret any graphical representations of visual field testing, to include the September 2009 charts. The results of such testing should be reported in terms of the applicable rating criteria. In this regard, for VA rating purposes, the normal visual field extent at the 8 principal meridians, in degrees, is: temporally, 85; down temporally, 85; down, 65; down nasally, 50; nasally, 60; up nasally, 55; up, 45; up temporally, 55. The total visual field is 500 degrees. The specialist should report the extent of the remaining visual field in each of the eight 45 degree principal meridians. 2. After ensuring that the above development, and any other development deemed necessary, is complete, re- adjudicate the claim. If not fully granted, issue a supplemental statement of the case before returning the claim to the Board, if otherwise in order. 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. 2009). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs