Citation Nr: 1318323 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 06-03 222 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for multiple joint pain affecting the hands, wrists, fingers, knees, and ankles, to include bilateral carpal tunnel syndrome and to include as due to an undiagnosed illness. 2. Entitlement to service connection for hiccups and muscular twitching of the eyes, to include as due to an undiagnosed illness. 3. Entitlement to service connection for diabetes mellitus. REPRESENTATION Veteran represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran served on active duty from August 1983 to February 1992. He received the Army Commendation Medal. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from a January 2005 and May 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In the January 2005 decision, the RO, in relevant part, denied the Veteran's petition to reopen a claim for service connection for headaches as new and material evidence had not been received and denied service connection for hiccups and muscular twitching of the eyes, fatigue, and multiple joint pains. In the May 2007 decision, the RO denied the Veteran's petition to reopen a claim for service connection for diabetes mellitus as new and material evidence had not been received. In January 2010, the Board granted the Veteran's petition to reopen the claim for service connection for a headache disability and remanded the underlying claim as well as the other matters currently on appeal. In August 2011, the Board granted entitlement to service connection for a headache disability, namely migraine headaches, granted the Veteran's petition to reopen the claim for service connection for diabetes mellitus, and remanded the underlying claim as well as the other matters currently on appeal for additional development. A November 2011 rating decision granted service connection for vascular/migraine headaches in accordance with the August 2011 Board decision. As this represents a full grant of the benefits sought on appeal, the issue will not be considered herein. In August 2012, the Board granted entitlement to service connection for sleep apnea and fatigue. An August 2012 rating decision implemented this decision, and established service connection for a disability manifested by fatigue, sleep apnea, and obesity. This also represents a full grant of the benefits sought on appeal for those issues, and they are no longer on appeal to the Board. The August 2012 Board decision also remanded the remaining issues for further development. The requested development has been accomplished, and these issues have all been returned to the Board for further review. The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case. It does not contain any evidence not already in the claims folder or considered by the RO. The issue of entitlement to service connection for diabetes mellitus 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's service connected disabilities include fatigue, sleep apnea, and obesity. 2. The Veteran has a current diagnosis of bilateral ankle strain, and competent medical opinion states that this bilateral ankle strain is the result of obesity. 3. The Veteran has been diagnosed with bilateral patella tendonitis during the course of this appeal, and competent medical opinion indicates that this disability is the result of obesity. 4. The service treatment records are negative for a tear of the meniscus of the right knee, and the medical record shows that this occurred in 2011; there is no medical opinion that relates the meniscus tear to active service or to a service connected disability. 5. The Veteran's pain of the wrists, hands, and fingers has been attributed to bilateral carpal tunnel syndrome; competent medical opinion states that carpal tunnel syndrome is not related to active service. 6. The preponderance of the competent medical opinions reflect that the Veteran's twitching of the eyes and hiccups do not represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisystem illness. 7. The Veteran's twitching of the eyes and hiccups do not represent a chronic disability, and in any event was not shown in service or until many years after discharge from service and has not been related to service by a competent medical opinion. CONCLUSIONS OF LAW 1. Bilateral ankle strain is proximately due to the Veteran's service connected obesity. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303(a), 3.310(a) (2012). 2. Bilateral patella tendonitis is proximately due to the Veteran's service connected obesity. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.310(a) (2012). 3. A meniscus tear of the right knee was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303(a), 3.317 (2012). 4. Chronic pain of the wrists, hands, and fingers to include carpal tunnel syndrome was not incurred due to active service. 38 U.S.C.A. §§ 1110, 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303(a), 3.317 (2012). 5. A chronic disability manifested by hiccups and muscular twitching of the eyes, to include as due to an undiagnosed illness, was not incurred due to active service. 38 U.S.C.A. §§ 1110, 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303(a), 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must inform a claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. In this case, the Veteran was provided with letters in October 2003, January 2004, April 2004, and August 2004 that contained all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini. These letters were provided to the Veteran prior to the initial adjudication of his claims. Although the notification regarding the assignment of disability ratings and effective dates was not received until March 2006, which was after the initial adjudication of the claim, this does not result in any harm to the Veteran, as his claim has been readjudicated since receipt of the notification. Mayfield v. Nicholson, 444 F.3d 1328 (2006). The Board concludes that the duty to notify has been met. The Board further concludes that the duty to assist has also been met. The Veteran's service treatment records have been obtained. Private medical records and VA treatment records have been obtained. He was afforded appropriate VA examinations, and relevant opinions have been obtained from the examiners after a review of the claims folder. There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Service Connection The Veteran contends that he has developed several disabilities as a result of active service, especially his service in the Persian Gulf region. He argues that he has developed a disability manifested by hiccups and twitching of the eyes that represents an undiagnosed illness. The Veteran also argues that his joint pains of his hands, wrists, and fingers are due to either an undiagnosed illness or that he developed carpal tunnel syndrome as a result of active service. He also believes that his pain of the knees and ankles is due to an undiagnosed illness. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic disabilities noted in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Except for the diabetes mellitus that will be addressed in the remand section, the Veteran does not have a diagnosis of a disability listed in 38 C.F.R. § 3.309, and continuity of symptomatology need not be further addressed. With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). But, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999), and a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as tinnitus, hand pain, and shortness of breath, the Veteran is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). The Veteran argues that many if not all of his disabilities are the result of an undiagnosed illness that results from his deployment to the Persian Gulf. He believes that this is the result of exposure to various chemicals during the Gulf War and the ingestion of pills to protect against nerve agents and biological weapons such as Anthrax. For veterans with service in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of "a qualifying chronic disability" that became manifest during active military, naval or air 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. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2). Medically unexplained chronic multi symptom illnesses are defined by a cluster of signs or symptoms and include, but are not limited to, chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(i), (ii). "Objective indications of 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. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of a medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of 38 C.F.R. § 3.317, 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. 38 C.F.R. § 3.317(a)(4). Notwithstanding the foregoing presumption provisions, the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Joint Pains of the Hands, Fingers, Wrists, Knees, and Ankles The Veteran's DD 214 and service treatment and personnel records indicate that he served in the Southwest Asia Theater of operations during the Persian Gulf War from September 1990 to April 1991 and that he was treated for weight issues in service and was separated from service based on a failure to meet Army weight control standards. Although there is clinical evidence that he received numerous vaccinations in service, service treatment records do not reflect the use of any pills to protect against nerve agents and efforts by the agency of original jurisdiction (AOJ) to substantiate the use of such pills have been unsuccessful. The service treatment records show that the Veteran was seen for pain in his left foot in September 1986 and after twisting his right ankle in May 1990. The May 1990 assessment was a strain. There was no follow-up treatment on either occasion, and no additional complaints regarding either the left foot or right ankle during the remainder of active service. A discharge examination is not included in the service treatment records. The post service medical records include private treatment records from August 1992 to May 1994. The Veteran complained of left elbow pain in March 1994. The assessment was a questionable strain, but not palpable. The Veteran did not report any joint pain at VA general medical examinations conducted due to his reports of ongoing chest pain in June 1994 and July 1995. The July 1995 examination stated that the musculoskeletal system was within normal limits. In an October 1996 statement, the Veteran's wife described various medical problems the Veteran had experienced since his deployment to the Persian Gulf. These did not include joint pains. A January 1997 VA neurological examination shows that the Veteran's extremities had a full range of motion without cyanosis, clubbing, or edema. His gait was normal, and there was no mention of joint pain. A private X-ray study of the left femur was conducted in August 1999 after the Veteran reported severe leg pain. The impression was normal. The Veteran had a full range of motion of the upper extremities at a September 1999 VA general examination. He did not report any musculoskeletal complaints other than chest pain. A January 2004 statement from the Veteran's wife says that he has experienced joint pain since he came back from the Persian Gulf. The Veteran was afforded a VA Gulf War Guidelines examination in May 2004. He reported that he had experienced numbness in his hands and wrist and pain in his hands, thumbs, knuckles, wrists, ankles and knees from after the Gulf War. The knee pains were said to be particularly bad. After a complete musculoskeletal examination, the diagnoses included neuropathy of the bilateral wrists and hands, carpal tunnel symptoms; bilateral patella tendonitis; and bilateral ankle tendonitis, with normal X-ray results. The examiner added that at this juncture he could not determine a clinical diagnosis for the joint pain of the knees and ankles. An additional Gulf War examination was conducted in December 2004 partly in response to the Veteran's symptoms of the upper extremities. Bilateral upper extremity sensory and motor nerve conduction studies showed normal laboratory reference values. However, due to the difference between the latency of the median sensory nerve action potential (SNAPS) and the ulnar SNAPS, the interpretation was of a mildly abnormal examination. The findings were consistent with a very early distal median sensory neuropathy as seen in carpal tunnel syndrome. He was to be seen for prosthetics. VA treatment records dated January 2005 indicate the Veteran was wearing splints due to bilateral carpal tunnel syndrome. These same records state that the musculo-skeletal examination showed that there was no arthritis, knee or joint swelling, redness, tenderness, limitations in range of motion, back pain, or gout. In the Veteran's January 2006 substantive appeal, he states that he began to experience his symptoms within nine months of returning from the Gulf War. The Veteran underwent a series of VA examinations in January 2012 to address all of his complaints, including his musculo-skeletal symptoms. The claims folder was reviewed by the examiner. The Veteran reported chronic ankle pain, and said he was unable to walk on them during flare-ups. The ankles received a diagnosis of ankle strain secondary to obesity. The examiner opined that it was at least as likely as not that the Veteran's chronic ankle pain was the result of his morbid obesity. The rationale was that this was because there was no radiologic evidence of structural ankle disease. On the knee examination conducted at this time, the Veteran was found to have a meniscal tear of the right knee. This had happened acutely in August 2011. However, the Veteran reported bilateral knee pain even prior to this injury, although a 2010 examination had been negative. On examination, there was no objective evidence of painful motion of either knee. X-ray studies were negative for arthritis. A magnetic resonance imaging study (MRI) of the right knee confirmed the presence of truncation of the midportion of the right medial meniscus. The examiner stated that it was at least as likely as not that the Veteran's chronic knee pain prior to the meniscal tear was the result of his morbid obesity. The rationale was that this was because there was no radiologic evidence of structural knee disease. The meniscal tear was unrelated to the previous knee pain. The examination of the wrists confirmed the diagnosis of carpal tunnel syndrome. The examiner opined that it was at least as likely as not that the Veteran's chronic wrist and hand pain was the result of the diagnosis of carpal tunnel syndrome. The rationale was that the Veteran had electromyography (EMG) studies that had diagnosed carpal tunnel syndrome, the symptoms were consistent with this disability, and the Veteran had a high risk for this disability due to the daily typing required of his job. In an August 2012 addendum, the same VA doctor who authored the January 2012 opinions stated that the Veteran's reports of finger pain were also attributable to carpal tunnel syndrome. It was less likely than not that the carpal tunnel syndrome was related to active service. The rationale was that there were no reports of hand or wrist problems in the military, and the diagnosis was made in 2004. This doctor also added that the knee symptoms were attributed to a diagnosis of meniscal tear of the knee. This condition was less likely than not related to a disease or injury in service, as the tear had occurred in 2011. Prior to that time the Veteran had not displayed any pathology. Finally, the VA doctor opined in his August 2012 addendum that the symptoms of the ankles were attributable to morbid obesity. It was less likely than not related to a disease or injury in service and less likely than not had its onset in service. The 1990 right ankle sprain was less likely than not the cause of any longstanding effects. The Board first finds that entitlement to service connection for bilateral ankle strain is warranted. The January 2012 VA examiner opined that this disability was the result of the Veteran's obesity. He expressed the same opinion in the August 2012 addendum. The Veteran's obesity is included in the disability for which service connection was granted in August 2012, effective from May 2003. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). As the January 2012 VA examiner opined that the Veteran's bilateral ankle strain was the result of his obesity, as he repeated this opinion in August 2012, and as there is no contradictory medical opinion, entitlement to service connection for bilateral ankle strain is established. Similarly, the Board finds that entitlement to service connection for bilateral patella tendonitis is also warranted. The May 2004 VA examiner made a diagnosis of bilateral patella tendonitis. The January 2012 examiner stated that it was at least as likely as not that the Veteran's chronic knee pain prior to the meniscal tear was the result of his morbid obesity. The Board notes that the January 2012 examiner did not expressly make a diagnosis of any knee disability other than the meniscus tear of the right knee, and further notes that this examiner seemingly contradicted himself in August 2012 by stating that the Veteran had not displayed any knee pathology prior to the 2011 tear. However, this examiner failed to note the May 2004 diagnosis of bilateral patella tendonitis. The Court has held that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Resolving all benefit of the doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise, which means that service connection is warranted. However, the Board finds that entitlement to service connection for a torn meniscus of the right knee is not merited. As this is a known diagnosis confirmed by MRI, there is no basis for presumptive service connection as an undiagnosed illness. 38 C.F.R. § 3.317. There is no evidence of a torn meniscus during service or until many years after discharge from service, and the Veteran does not contend that he sustained a torn meniscus during service. The evidence states that this injury happened acutely in August 2011. The January 2012 examiner opined that it was unrelated to the previous knee pain, which was due to the Veteran's service connected obesity. At this juncture, the Board notes that no opinion has been obtained as to whether or not the meniscal tear may have been the result of the Veteran's service connected obesity. However, the Veteran does not contend that this is the case, and there is no competent medical opinion whatsoever suggestive that the tear is due to obesity or any other service connected disability. Therefore, an additional opinion is not necessary. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As there is no evidence of a torn meniscus during service or until many years after discharge from service, and no competent medical opinion that relates a torn meniscus to service, there is no basis for service connection for this aspect of the Veteran's claims. The Board also finds that entitlement to service connection for chronic pain of the wrists, hands, and fingers is not supported by the evidence. The Veteran's pains of the wrists, hands, and fingers have been attributed to bilateral carpal tunnel syndrome since December 2004, and there is no competent medical evidence to the contrary. As this is a known diagnosis, there is no basis for presumptive service connection as an undiagnosed illness. 38 C.F.R. § 3.317. There is also no basis for service connection for carpal tunnel syndrome on a direct basis. The service treatment records are negative for evidence of this disability, and the initial evidence of pain of the wrists, hands, and fingers was not shown until 2004. The Veteran reports having experienced joint pains within nine months of his return from the Persian Gulf, but the Board notes that these reports did not specifically include the wrists, hands, and fingers. More importantly, he did not make these reports until 2004, and they are contradicted by the consistent findings of a normal musculo-skeletal system on both histories and examinations obtained prior to 2004. Therefore, the Board finds that it cannot credibly construe any general contentions as to joint pain prior to 2004 to include the wrists, hands, or fingers. Medical opinion states that the carpal tunnel syndrome is not related to active service, and there is no competent medical opinion to the contrary. Therefore, service connection is not established for chronic pain of the wrists, hands, and fingers to include carpal tunnel syndrome. In reaching this decision, the Board notes the Veteran's sincere belief that his joint pains are the result of an undiagnosed illness, and further notes the various medical articles and studies he has submitted that address Persian Gulf Syndrome. However, there is no evidence that the Veteran has any medical training or expertise, and he is not competent to provide evidence as to a complex medical question such as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Competent medical opinion has related the Veteran's symptoms to a known cause, and the opinion is supported by laboratory testing. Competent medical opinion has also found that this known cause is not related to service. Therefore, service connection is not warranted. Hiccups and Muscular Twitching of the Eyes The service treatment records are negative for a reference to a disability manifested by hiccups or twitching of the eyes. The post service medical records are also negative for complaints or treatment pertaining to hiccups or twitching of the eyes until many years after discharge. VA general examinations conducted in June 1994, July 1995, and September 1999 were normal in this regard. Of particular note is a January 1997 VA neurological examination, on which facial sensibility and other relevant testing was normal. The Veteran did not supply a history of eye twitching or hiccups on any of these occasions, and these symptoms are not shown in contemporaneous private records dating through 2003. A January 2004 statement from the Veteran's spouse says that the Veteran began to have problems with his health within two years of returning from the Gulf War. His symptoms included a nervous condition with facial tics and hiccup-like noises. At the May 2004 VA Gulf War Guidelines examination, the Veteran reported that while he was in the Gulf, and for six months to a year after returning to the states, he had a nervous condition that was manifested by twitching of both eyes and involuntarily making an unusual noise similar to a hiccup every few seconds. He had not received any treatment for this condition. On examination, the Veteran did note minimal involuntary movement of the upper and lower eyelids on the left, and he constantly cleared his throat at intervals. The neurological evaluation did not report any abnormal findings. The clinical diagnoses included involuntary twitching of the left eye on assessment and occurring since approximately 1992 per the Veteran's history. The examiner stated that the left eye movement was unresolved, and that it was as likely as not associated with ingestion of Anthrax. The Veteran underwent an additional series of VA examinations in January 2012. A respiratory examination states that the Veteran had a history of hiccups, which the examiner believed most likely represented a tic disorder. The Veteran reported experiencing hiccups since he came back from Iraq, which seemed like a nervous habit. The Veteran could suppress the hiccups for a short time if needed. The examiner noted that this problem was not mentioned in any of the Veteran's medical notes, and the chest X-ray is normal. The examiner opined that it was less likely than not that the hiccups were an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's Persian Gulf War service or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms. The rationale was that hiccups were not recognized as a component of Gulf War syndrome and in the Veteran's case represented a benign symptom not diagnosed as a disease. On an eye examination that was also conducted in January 2012, it was noted that the Veteran had never been diagnosed as having an eye disability other than developmental or refractive error. The examiner found that this did not affect the Veteran's ability to work. At the conclusion of the examination, the Veteran was said to have an intermittent tic on the left with partial eyelid closure, with no ocular pathology or sequelae. An additional January 2012 note from the examiner states that the Veteran did not have any complaints of eye twitching and did not have any such symptoms. The Veteran reported that observers said his eyelid twitches at times. The examiner said that the Veteran did not have any symptoms or disability. A September 2012 addendum to the January 2012 eye examination notes that the claims folder was reviewed by the examiner. The previous diagnoses of involuntary twitching of the left eye as well as the opinion that related this with ingestion of Anthrax were noted. The examiner noted that eyelid twitching is a relatively common condition and can last for days to weeks. It was distinguished from other disorders by the absence of facial weakness. It was usually a benign condition and could be related to the use of caffeine, alcohol or stress. The opinion was that the Veteran's current muscle twitching was not due to any specific disease entity or entities. The eye examination was normal without any weakness of the facial muscle and/or ocular abnormalities. The muscle twitching did not represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisystem illness. Finally, the examiner said that the Veteran's report of muscle twitching had been noted in the neurologic examination but was neither noted nor observed in eye examinations conducted in 2005, 2006, 2009, or 2011. The Board finds that entitlement to service connection for a disability manifested by hiccups and muscular twitching of the eyes, to include as due to an undiagnosed illness, is not warranted. Entitlement to service connection for a disability manifested by hiccups and muscular twitching of the eyes, to include as due to an undiagnosed illness, is not merited as the January 2012 examiners opined that neither hiccups nor twitching of the eyes was an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisystem illness. The rationale was similar for both symptoms in that the examiners noted that they were not among the symptoms commonly associated with Gulf War syndrome, and opined that neither symptom represented a disability. In fact, the most recent eye examination indicates that the Veteran did not currently have any twitching of the eyes. The Board concludes that service connection for a disability manifested by hiccups and muscular twitching of the eyes, to include as due to an undiagnosed illness, is not established. In reaching this decision, the Board has considered the May 2004 VA Gulf War Guidelines examination in which the examiner stated that the left eye movement was unresolved, and that it was as likely as not associated with ingestion of Anthrax. However, as there is no evidence that the Veteran was ever exposed to Anthrax, this opinion is of no probative value. The Board observes that Anthrax is an extremely deadly disease that is usually lethal. The Veteran does not contend that he was exposed to Anthrax, and there is no other evidence to suggest otherwise. The Veteran does argue that the various vaccines and pills he was administered in conjunction with his deployment as well as the different chemicals and other factors present in the Persian Gulf environment have combined to make him ill. He does not argue and there is no evidence that he was exposed to Anthrax itself. As the opinion is limited only to unverified Anthrax exposure, it is of little probative value. Similarly, the Board recognizes the Veteran's sincere belief that he has a chronic disability manifested by twitching of the eyes and a tic that is similar to hiccups. While the Veteran is competent to report these symptoms, there is no evidence that he has any medical training in the area of systemic diseases, and he is not competent to provide evidence as to a complex medical question such as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Competent medical opinion has found that the Veteran's symptoms are not representative of an undiagnosed illness and do not represent a disease or disability. Therefore, service connection is not warranted. The Board has also considered entitlement to service connection on a direct basis but this is not demonstrated by the record. The Veteran reports having experienced hiccups and eye twitching that began even before he returned from the Gulf region. However, he did not make these reports until 2004, and they are contradicted by the consistent findings of normal neurological histories and evaluations prior to 2004. Although the Veteran and his spouse have each stated that eye twitching and hiccups began within a few months of returning from the Persian Gulf, their statements are not supported by their prior descriptions of symptoms that began in the Gulf in letters and statements dated before 2004. Their statements are also not supported by the contemporaneous medical records and are contradicted by the normal findings of the VA January 1997 neurological examination. Finally, these symptoms have not been related to active service by a competent medical opinion. The Board concludes that there is no basis for service connection on a direct basis. ORDER Service connection for bilateral ankle strain is allowed. Service connection for bilateral patella tendonitis is allowed. Service connection for a meniscus tear of the right knee is denied. Service connection for chronic pain of the wrists, hands, and fingers to include as due to an undiagnosed illness and carpal tunnel syndrome is denied. Service connection for hiccups and muscular twitching of the eyes, to include as due to an undiagnosed illness, is denied. REMAND The Veteran contends that his diabetes mellitus was incurred secondary to either his service connected hypertension or his service connected obesity. The January 2012 VA examiner opined that the Veteran's diabetes mellitus was neither caused nor aggravated due to his service connected hypertension. The examiner further opined that it was less likely than not that the Veteran's diabetes was caused by obesity. At the time of the January 2012 opinion, service connection for obesity was not yet established. This opinion addressed only whether or not the obesity noted in service could have caused the Veteran's diabetes mellitus. Service connection for a disability that includes obesity was not established until the August 2012 rating decision that implemented the decision of the Board. As previously noted, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). However, secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In this instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In this case, while the January 2012 opinion excludes obesity as the primary cause of the Veteran's diabetes, it did not address the possibility that the diabetes has been aggravated by obesity. In fact, the opinion suggests that aggravation is possible when it states that if obesity was the "main" causative factor, there would be a more clear correlation between the Veteran's weight and the severity of the disease. The Board notes that obesity need not be the primary cause of the diabetes in order to aggravate this disability. Therefore, the Board finds that the claims folder should be returned to the examiner who provided the January 2012 opinion in order to obtain an addendum that addresses the possibility of aggravation. Accordingly, the case is REMANDED for the following action: 1. Forward the claims file and a copy of this remand to the examiner who conducted the January 2012 VA examination for diabetes mellitus, if available, in order to obtain an opinion regarding the possibility of aggravation of diabetes mellitus by the Veteran's service connected obesity. If the January 2012 examiner is unavailable, provide the Veteran with a new examination. Review of the claims folder should be reflected in the completed examination report or in an addendum. After the claims folder has been reviewed, to include the report of the January 2012 VA examination, the examiner should express the following opinions: a) Is it as likely as not that the Veteran's diabetes mellitus was aggravated by his service connected obesity? If aggravated, specify the baseline of diabetes mellitus disability prior to aggravation, and the permanent, measurable increase in diabetes mellitus resulting from the aggravation. The reasons and bases for all opinions should be provided. 2. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the Veteran and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The Veteran 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. 2012). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs