Citation Nr: 1324658 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 09-23 198A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for sciatica. 2. Entitlement to service connection for fibromyalgia. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1997 to December 2000. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which denied the benefits sought on appeal. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in March 2011. A transcript of that hearing is of record. In October 2011, the Board remanded the Veteran's claims on appeal for further evidentiary development. FINDINGS OF FACT 1. The evidence of record does not support a finding that the Veteran has a current sciatica diagnosis. 2. The evidence of record does not support a finding that the Veteran's fibromyalgia is etiologically related to her active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sciatica have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 2. The criteria for entitlement to service connection for fibromyalgia have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran has received essential notice, has had a meaningful opportunity to participate in the development of her claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir. 2004). A September 2008 VCAA letter from the RO informed the Veteran of all elements required by 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of her claim. This duty includes assisting her in the procurement of service treatment records and pertinent post-service treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records (STRs), as well as post-service reports of VA and private treatment. Moreover, her statements in support of her claim are of record. The Veteran has additionally been afforded multiple VA examinations with respect to her claim, and the Board requested additional medical expert opinions from a health care professional in VA's Veterans Health Administration (VHA) in order to accurately address the lay and medical evidence of record pertaining to the Veteran's claims. See 38 C.F.R. § 20.901(a) (2012) (the Board may obtain a medical opinion from an appropriate health care professional in the VHA of VA on medical questions involved in the consideration of an appeal when, in its judgment, such medical expertise is needed for equitable disposition of an appeal); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (rev'd on other grounds by Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). Moreover, the Board finds that the RO/AMC substantially complied with the Board's October 2011 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). In this regard, the Board remanded the Veteran's claim in order to obtain medical records, including a copy of an electromyography (EMG) noted in the February 2010 VA examination report, to obtain recent VA treatment records, and to afford the Veteran a new VA examination and obtain an adequate medical opinion regarding the etiology of her claimed disabilities. The AMC subsequently requested authorization from the Veteran for VA to obtain private treatment records, including the EMG report, on her behalf. The Veteran provided this authorization in November 2011 and additional private treatment records were provided in December 2011. The AMC additionally obtained the Veteran's more recent VA treatment records and afforded her a new VA examination in November 2011. It is noted that the particular EMG study in January 2010 was not included in the documents received. However, the VHA expert examiner in February 2013 indicated that the EMG study would not be of any use, as it had no valid role in diagnosing either sciatica or fibromyalgia. Thus, given this new information from a medical source, the Board no longer finds it necessary to obtain the EMG study. Indeed, it would appear that additional development to this end would serve no useful purpose and would only delay the adjudication of the claim, with no benefit flowing to the Veteran. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). In light of the above, the Board finds that there has been substantial compliance with the prior remand directives. Additionally, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeal for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that VA employees have two duties in conducting hearings. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the Veteran's March 2011 Board hearing, the issues were adequately identified, and the VLJ and the Veteran's representatives asked specific questions directed at identifying outstanding evidence that could substantiate her claims, including most especially evidence to support her contentions regarding her current diagnoses and regarding the relationship of her claimed disabilities to her service. Testimony provided during her hearing led to the Board's remand to obtain additional medical records and an etiology opinion regarding her claimed disabilities on appeal. As such, the Bryant duties were met. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of her claims. 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). II. Service Connection The Veteran contends that she has fibromyalgia and sciatica that were incurred during active service. She further contends that her service-connected low back strain, and irritable bowel syndrome (IBS), as well as right hip pain and sciatica, are really manifestations of her diagnosed fibromyalgia. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Walker, 701 F.3d 133; Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). In making all determinations, the Board must fully consider the lay assertions of record. Davidson, 581 F.3d 1313. A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). The Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson, 2 Vet. App. at 618. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Sciatica Considering first to the current disability requirement for service connection for the Veteran's claimed sciatica, the evidence of record is very much in conflict with respect to whether a diagnosis exists. The record reflects that the Veteran has consistently complained of right hip pain over the last several years. Such complaints are also noted in her STRs and post service VA and chiropractic treatment records. A December 2005 VA examination report noted that the Veteran complained of spine pain that also radiated into her hips. In a June 2008 letter, the Veteran's private chiropractor, Robert Bigbie, D.C., indicated that after reviewing the Veteran's medical history, examining her, and reviewing X-rays, he believed she had a current sciatica diagnosis. In a subsequent December 2009 letter, the Veteran's private chiropractor indicated that she had sciatica that was secondary to her chronic lower back pain. He provided an additional letter in April 2011, wherein he again indicated that the Veteran's leg pain was caused by sciatica. Incidentally, a review of the Veteran's private chiropractic treatment records dated from April 2008 to April 2011 do not reveal a clear diagnosis of sciatica. From a review of the chiropractic records, a treatment note dated in December 2009 simply revealed that the Veteran presented with sciatic pain. There was no further indication that any specific diagnostic study or test led to a sciatica diagnosis. In contrast the chiropractor's findings, multiple VA examinations have failed to diagnose the Veteran's sciatica. During a December 2008 VA peripheral nerve examination, conducted in connection with her current claim on appeal, the VA examiner noted the Veteran's complaints of pain in her spine that also involved her right hip, which her chiropractor associated her pain with fibromyalgia. The examiner noted that the complaints did not suggest involvement of any nerve or nerve root. Palpation of the paraspinal muscle of the back showed no tightness of the muscles, no pain on palpation, and she had a normal range of motion of the lumbar spine. Examination of her right lower extremity demonstrated no muscle atrophy, no weakness, no reflex changes, and no sensory impairment. Based on these findings, the examiner diagnosed functional somatic syndrome. The examiner noted that there was no evidence that the Veteran's problem was related to military service, and that there was no neuropathy or radiculopathy upon examination. During a subsequent February 2010 VA examination, the same VA examiner observed that while the Veteran was noted to have right hip pain, previous treating physicians attributed her hip pain to separate right hip problems rather than typical back pain radiating to her hip which would lead to a diagnosis of either sciatica or lumbago. The examiner additionally observed that while the Veteran reported having pain all over, including pain in the muscles, abdomen, and pain in the joints, involving the ankles, knees, hips, shoulder, arms and back, she did not report a pattern of pain which seemed to radiate across her buttocks and into the back portion of the thigh and down the leg. The VA examiner further noted that a nerve conduction study of the right lower extremity, apparently performed in January 2010, revealed normal results. There was no evidence of any impairment in muscles enervated by the femoral, the abductor, and the sciatic nerve. Moreover, the Veteran's chiropractor diagnosed sciatica based on results of a thermogram. The examiner noted that such testing was of very low reliability in correlating with objective clinical signs. The examiner concluded that the distribution of complaints did not fit either a peripheral nerve or a nerve root pattern. Physical examination of the Veteran's lower extremity again revealed normal muscle mass, tone, and strength. Primary tendon reflexes were intact. After examining the Veteran and reviewing the record, the examiner diagnosed a chronic pain syndrome which most closely resembled a functional somatic syndrome. There was no evidence for sciatica. Thus, the examiner concluded that a diagnosis of sciatica was not appropriate, and therefore, she did not have sciatica that could have been caused by or a result of any chronic low back strain. In an effort to determine whether the evidence of record supported a diagnosis of sciatica, the Board sought an opinion through a VHA medical expert in December 2012. In February 2013, a VHA specialist in rheumatology reviewed the Veteran's claims file and opined that it was not at least as likely as not that the Veteran suffered from sciatica. The specialist did note that a general description of the Veteran's back pain radiation provided during her March 2011 Board hearing was consistent with sciatica. In response to questioning, she described the pain as sciatica travelling down through the buttocks, the outside of the thigh, and to the back of the knee and the calf to both feet. The specialist noted that in contrast, however, an immediately prior February 2011 VA examination report noted that the Veteran did not report a pattern of pain which seemed to radiate across her buttocks and into the back of the thigh and down the leg. Thus, the characteristic pain complaints associated with sciatica were not found during the examination, in spite of her later contentions. Similarly, the specialist noted that during the December 2008 VA examination, sciatica-type pain complaints were not present, and physical examination findings were negative for signs of nerve root impingement associated with sciatica. The specialist noted that the neurologic examination included a straight-leg raise (SLR) test which turned out negative. The specialist further noted that back pain and right hip pain had been documented during a number of provider interactions, but when SLR testing results were included, the results were always negative. The VHA specialist pointed out that evidence of record supporting a sciatica diagnosis was concerning. Notably, the Veteran's history of low back pain radiating in a manner consistent with sciatica was noted in only two instances. Namely, her STRs documented a pain centralized on the right side of the back with pain radiating down the leg. These records, however, were also accompanied by negative SLR tests and an absence of radiculopathy. The second instance of sciatic-type pain was reported by the Veteran during her Board hearing. The VHA specialist observed that in contrast to these two instances, a self-reported low back pain questionnaire dated in September 2000, during the Veteran's service, noted a negative response with respect to whether there was any pain, numbness, tingling in the legs, and with respect to whether there was any past pain, numbness or tingling in the legs. She also noted that the Veteran's chiropractic records and self-reported questionnaires were largely devoid of any indication that she reported pain radiating down the lower extremities. The VHA specialist additionally called attention to the fact that objective medical evidence of record documenting nerve root irritation was not supportive. A negative SLR test and a normal EMG were noted upon examination of the Veteran's right lower extremity for focal nerve abnormalities in January 2010. Finally, other neurologic testing by physical examination for sensory deficits and motor weakness was also negative, meaning no neurologic abnormalities were detected. The VHA specialist further supported her opinion that the Veteran lacked a sciatica diagnosis by pointing out that sciatica refers to pain that radiates along the path of the sciatic nerve, a structure composed of lumbosacral nerve roots L4, L5, and S1 to 3. Symptoms of sciatica include unilateral pain in the back, buttocks, posterior leg, and foot, as well as tingling and weakness. She noted that in some definitions of sciatica, the pain characteristically radiates below the knee. She additionally cited to medical literature for the premise that greater than 80 percent of lumbosacral radiculopathy (sciatica) cases involved the L5 and S1 nerve roots, which were typically aggravated when SLR testing was performed. Additionally, a distinct medical treatise on the subject of lumbar radiculopathy due to disc herniation with low back pain reported that SLR testing had a sensitivity of up to 90 percent. Based on the accumulated evidence, the VHA specialist noted that greater than 80 percent of sciatica patients should have a positive SLR test. Moreover, the VHA specialist noted that during her Board hearing, the Veteran affirmed having sciatica pain radiating into her outside toes, which would be typical of S1 root pathology. Yet, the classical physical examination finding that should accompany such nerve root involvement, a positive SLR test, was absent. She had consistently been documented as having negative SLR tests throughout her records. Thus, the Veteran's records supported the musculoskeletal diagnoses of low back pain, right hip and knee pain, but did not support a diagnosis of sciatica. Based on the abundant medical evidence of record, including most especially the VHA specialist's opinion regarding the absence of such diagnosis, the Board cannot make a finding that the Veteran has a current sciatica disability. The fully-informed, well reasoned, and fully-articulated opinion of the VHA specialist noted that based on all the medical evidence of record, there was insufficient basis to diagnose sciatica. Although the record indicated that the Veteran affirmed having sciatica-type pain, such reports were inconsistent and contradicted by other reports wherein she reported not having such pain. Moreover, even if the Board were to afford the Veteran the benefit of the doubt with respect to her sciatica reports, the VHA specialist has pointed out that the pain described by the Veteran should be identifiable through SLR testing, but in fact her SLR tests have consistently revealed negative results. The Board finds that the VHA specialist's opinion regarding the Veteran's lack of a sciatica diagnosis is of significant probative value. Additionally, the VA examiner that conducted the Veteran's December 2008 and February 2010 VA examinations also concluded that there was insufficient evidence to diagnose current sciatica. Rather, the VA examiner explained that the Veteran had a chronic pain syndrome that most closely resembled a functional somatic syndrome. Notably, the VA examiner explained in the February 2010 examination report that while the Veteran's chiropractor diagnosed sciatica, his diagnosis was made on the basis of a thermogram, which has a very low reliability in correlating with objective clinical signs. In reviewing the chiropractor's opinions, the Board observes that he did not clearly indicate how any specific studies or testing (i.e., X-rays, physical examination) led to the conclusion that the Veteran suffered from sciatica. Indeed, the VHA specialist also noted that the various chiropractic studies performed were documented in an April 2008 treatment note, and included a rolling thermal scan, static EMG scan, range of motion and a pulsewave profiler examination. The VHA specialist indicated that the validity of these tests was not established in the allopathic and osteopathic peer-reviewed literature. Therefore, she concluded that those modalities had no recognized role in diagnosing fibromyalgia or sciatica, or measuring the effectiveness of any therapy. Based on the noted inadequacies in the chiropractor's diagnostic testing, the Board will afford his opinion that the Veteran has a current sciatica diagnosis only minimal probative value. For this reason, the Board finds that the probative value of the December 2008 and February 2010 VA examination reports and the February 2013 opinion provided by the VHA specialist, all of which concluded that the Veteran did not have a sciatica diagnosis, far outweigh the probative value of the contrary findings of the Veteran's private chiropractor. Thus, a current diagnosis of sciatica is not warranted by the record. In order to be considered for service connection, a claimant must first have a current disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). In the absence of currently diagnosed sciatica, service connection may not be granted. See also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). While the Veteran may be sincere in her belief that she currently suffers from sciatica, she is not competent to diagnose this disability, as such requires medical expertise. See Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 469. Moreover, the diagnosis made by the Veteran's private chiropractor has been soundly refuted by the more fully supported opinions provided in the February 2010 examination report and the opinion provided by the VHA specialist that such a diagnosis is not warranted by the evidence of record. With respect to any noted diagnosis of possible somatic syndrome, in her February 2013 opinion, the VHA specialist indicated that the VA examiner's use of the term somatic syndrome was unclear, and that for some health care providers, the term meant a collection of symptoms associated with a psychological phenomenon. More recently, when the term is used with "functional," as done by the VA examiner, the term was used to refer to syndromes that are associated with fibromyalgia. Thus, the Board will proceed with considering whether service connection for fibromyalgia is warranted. Fibromyalgia After a thorough review of the evidence of record, the Board observes that a finding that the Veteran has a current fibromyalgia diagnosis is warranted. In addition to positive opinions regarding a fibromyalgia diagnosis provided by the Veteran's chiropractor in the June 2008, December 2009, and April 2011 letters, the VHA specialist's February 2013 opinion noted that the Veteran's chart documented signs, symptoms, and physical examination findings that supported a diagnosis of fibromyalgia. Accordingly, the Board finds that the first required element for service connection for fibromyalgia has been met. See Walker, supra. With respect to the other two required elements for service connection, evidence of any in-service incurrence of fibromyalgia, and a nexus between the Veteran's current fibromyalgia and her active service, the Board observes that, in addition to complaints of low back and hip pain, the Veteran's STRs additionally document instances of right knee pain and intestinal problems, including an assessment of possible irritable bowel syndrome (IBS) made in August 2000. She was additionally found to have inflammatory bowel disease in December 2000. Her STRs do not contain any specific treatment for, or a diagnosis of, fibromyalgia. Post-service treatment records also documented symptoms of a gastrointestinal disorder; however, an August 2003 VA examination report indicated that the Veteran was diagnosed with IBS after her separation from service. VA treatment records dated in October 2004 and January 2005 document an assessment of IBS and exertional dyspnea. The evidence of record reveals that fibromyalgia was noted as a diagnosis in the June 2008 letter provided by the Veteran's private chiropractor. During a July 2008 VA rheumatology clinical consultation, the Veteran reported being told she had been diagnosed with fibromyalgia and sciatica. She reported that her symptoms of low back pain and hip pain had been present for approximately 10 years, since the time of her active service. She did not assert having symptoms of memory or cognitive impairment at that time. In his December 2009 letter, the Veteran's chiropractor noted that her military records showed that she was tested for chronic right hip pain and low back pain that radiated down her right leg. He indicated that he had conducted a series of tests and X-rays to determine the Veteran's condition, and thereby reached a diagnosis of fibromyalgia. He then opined that this condition had its onset while the Veteran was on active duty. Later, in the subsequent April 2011 letter, the private chiropractor opined that the Veteran's pain and fatigue, caused by fibromyalgia, was secondary to and at least as likely as not related to her military service. The Veteran was afforded a VA fibromyalgia examination in January 2010. She reported having moderate severe discomfort all over, unexplained fatigues, sleep disturbance, paresthesias, and IBS. The VA examiner reaffirmed that the Veteran had a fibromyalgia diagnosis, but then opined that the fibromyalgia was not caused by or a result of her military service. Notably, neither the January 2010 VA examiner nor the Veteran's private chiropractor provided reasons for their etiology opinions. See Nieves-Rodriguez, 22 Vet. App. at 304. While pertinent evidence of record, including service treatment records, was reportedly reviewed neither clinician provided a rationale to explain their respective opinions. Further, neither clinician appeared to consider the Veteran's contentions that her low back strain and IBS, along with sciatica, memory and cognitive difficulties, heart palpitations, and headaches, were manifestations of fibromyalgia. On this record the Board sought an additional medical opinion from another VA examiner on the issues of whether the Veteran's reported symptoms of low back strain, IBS, sciatica, memory and cognitive difficulties, heart palpitations, and headaches were manifestations of her fibromyalgia and whether her fibromyalgia was incurred in or as a result of her active service. During a subsequent November 2011 VA examination, the same VA examiner again indicated that the Veteran had a diagnosis of fibromyalgia, made in 2009, and that she had widespread musculoskeletal pain, fatigue, headaches and IBS which were findings, signs or symptoms attributable to fibromyalgia. The examiner also noted that the Veteran experienced constant or nearly constant fibromyalgia symptoms and that she had tender points for pain in her low cervical region, and in the areas of the second rib, the occiput, the trapezius muscle, the supraspinatus muscle, the lateral epicondyle, the gluteal, the greater trochanter, and both knees. Bilateral symmetric pain was noted to be found in any place compression was made. In seeming contradiction to the reported examination findings, the examiner indicated that the Veteran had been evaluated by neurology in the past and was felt to have somatic syndrome, but that she had never been officially diagnosed with fibromyalgia. She had only been told by her chiropractor in 2009 that she had the condition. The examiner also indicated that the symptoms the Veteran reported in service did not meet the criteria for fibromyalgia. He did not, however, identify which specific symptoms he was referring to that did not equate to a fibromyalgia diagnosis. Because of the discrepancies noted in the November 2011 VA examination report, the Board requested the aforementioned VHA specialist opinion in December 2012, regarding the determinative factors of diagnosis and etiology of the Veteran's fibromyalgia. In her February 2013 opinion, the VHA specialist opined that it was at least as likely as not that the Veteran suffered from fibromyalgia. The specialist noted that fibromyalgia symptoms included chronic widespread pain, tender points, fatigue, waking unrefreshed, and cognitive symptoms, and that the record showed that the Veteran was found to have suffered from most of these symptoms. In response to the letter received in December 2009 from the Veteran's chiropractor, wherein he indicated that he conducted a series of tests and taken X-rays to determine the Veteran's diagnosed condition of fibromyalgia, the VHA specialist noted that there were no X-rays or tests that diagnosed fibromyalgia. Rather, she noted that it is a clinical diagnosis. As previously noted, she indicated that the validity of the tests used by the chiropractor was not established in the allopathic and osteopathic peer-reviewed literature. Thus, the VHA specialist indicated that her opinion was based on the documentation of the Veteran's history and physical findings, meeting the diagnosis of fibromyalgia as outlined. Moreover, the VHA specialist indicated that the letters provided by the Veteran's chiropractor regarding her diagnoses are incongruent with the progress notes of record. In short, the assessments made in chiropractic progress notes did not document either the Veteran's supposed fibromyalgia or sciatica diagnosis. The additionally did not document the objective data that would support these statements. In providing her favorable opinion regarding the Veteran's diagnosis of fibromyalgia, the VHA specialist concluded that it was not at least as likely as not that the Veteran's symptoms of low back strain, IBS, sciatica, memory and cognitive difficulties, heart palpitations, and headaches were manifestations of her fibromyalgia. In contrast, she indicated that the Veteran's memory and cognitive difficulties were indeed at least as likely as not associated with her fibromyalgia. Here, she noted that fibromyalgia symptoms recognized by the American College of Rheumatology did not include low back pain, IBS, sciatica, heart palpitations, and headaches. She further noted that diagnoses documented in assessments and plans in the multiple treatment reports of record lacked a fibromyalgia diagnosis and such directed therapy. Her symptoms were viewed by her medical care providers consistently as freestanding and thus were not noted to be associated with fibromyalgia. Temporally, the onset of her symptoms of low back pain, IBS, and right hip pain, are far removed from the constellation of fibromyalgia symptoms that the Veteran later reported. In other words, the VHA specialist indicated that these symptoms were unrelated events. While her STRs noted the onset of these symptoms, fibromyalgia-related symptoms were initially documented at a much later date in mid-2008. The VHA specialist pointed out that while symptoms reported by the Veteran have been observed in fibromyalgia patients, the relationship of these symptoms to fibromyalgia was still being debated in the medical literature. Thus, she chose to base her opinion regarding the Veteran's diagnosis on the symptoms that were widely recognized as standard criteria for the diagnosis of fibromyalgia. For these same cited reasons, the VHA specialist provided the opinion that it was not at least as likely as not that the Veteran's fibromyalgia had its clinical onset during service or was related to any in-service disease, event, or injury. Here, she further noted that "triggers" for fibromyalgia in the medical literature were referred to as "potential," "perceived," "may contribute to," "have been associated with," "have been implicated," "seem to be," etc. In the Veteran's case, her STRs documented low back pain, right hip and knee pain, and IBS. While patients with fibromyalgia may also have these conditions, the specialist noted that the relationship of these conditions has not been clearly established as causative, part of the diagnosis itself, or the sequella of fibromyalgia. Without signs and symptoms of widespread pain, non-restorative sleep, and fatigue, the diagnoses documented in the Veteran's STRs are free-standing or independent of a concomitant diagnosis of fibromyalgia. In reviewing the VHA specialist's opinion, the Board notes that the schedular rating criteria for fibromyalgia specifically recognize such symptoms as widespread musculoskeletal pain and tender points, fatigue, sleep disturbance, stiffness, paresthesias, headache, IBS, depression, and anxiety as clinical symptoms associated with a fibromyalgia diagnosis. See 38 C.F.R. § 3.303(a), Diagnostic Code 5025. Thus, in order to fairly adjudicate the Veteran's claim, the Board is bound to consider these symptoms as possible manifestations of the Veteran's diagnosed fibromyalgia unless the medical evidence were to clearly indicate otherwise in her particular case. See 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"). Accordingly, in March 2013, the Board sought clarification from the VHA specialist as to whether the Veteran's noted symptoms of IBS and headaches were manifestations of her fibromyalgia, and if not, why these symptoms could be dissociated from fibromyalgia in her particular case. Additionally, although the VHA specialist's opinion recognized the Veteran's memory loss and cognitive difficulties as likely manifestations of her fibromyalgia, the Board's initial request for a medical opinion did not expressly indicate the onset of those symptoms, and thus, the rationale provided as to why it was less likely than not that her fibromyalgia was related to her service was also silent with respect to consideration of the onset of those symptoms. Thus, the Board also sought clarification as to whether the Veteran's reported onset of fibromyalgia-specific symptoms, including memory loss and cognitive difficulties, and her symptoms of fatigue and widespread pain, which reportedly began primarily in 1999, indicated any likelihood that her fibromyalgia symptoms began during her service. In an April 2013 addendum opinion, the VHA specialist indicated that the Veteran's symptoms of IBS and headaches could be dissociated from her fibromyalgia as they were temporally freestanding for almost eight years. She noted that in her experience, patients with fibromyalgia do not wait eight years to "declare themselves." In other words, she noted, fibromyalgia patients present to healthcare providers with complaints of widespread pain and poorly restorative sleep, and fibromyalgia is diagnosed in a timely manner. She also noted that fibromyalgia is not a rare disease and that it is not difficult to diagnose. She observed that IBS and headaches occur in fibromyalgia patients and non-fibromyalgia patients alike. With respect to the likelihood that the Veteran's symptoms of memory loss and cognitive difficulties were related to service, the VHA specialist noted that it was her opinion that the Veteran was not diagnosed with fibromyalgia when she was on active service, and that her symptoms of memory loss and cognitive difficulties were not documented in her service records, and therefore were less likely as not service-related. Based on the foregoing, the Board cannot make a finding that the Veteran's current fibromyalgia was incurred during or as a result of her active service. While multiple clinicians have provided differing opinions regarding whether or not she even suffers from fibromyalgia, the fully informed, well-reasoned, and fully articulated opinion provided by the VHA specialist observed that while she did suffer from fibromyalgia, the evidence of record did not support a diagnosis until many years after her separation from service, and that any potentially related symptoms to fibromyalgia that she suffered from during service, such as IBS, back pain, hip pain, and knee pain, were in fact distinct disabilities, and not associated with fibromyalgia in her particular case. Moreover, the VHA specialist specifically noted that the Veteran was not found, per medical reports of record, to suffer from the classic fibromyalgia symptoms of memory and cognitive difficulties, wide-spread pain, and fatigue until nearly eight years after her service, and that if she indeed were suffering from fibromyalgia at an earlier time, it would be atypical, from her experience, for her not report these other, classic fibromyalgia symptoms at such time and be diagnosed in a timely manner. While the Veteran may be sincere in her belief that she began experiencing fibromyalgia symptoms during service, the evidence of record, including most especially the VHA specialist's opinion, clearly shows that her key fibromyalgia-related symptoms became manifest many years after her separation from service, and the specialist dissociated her fibromyalgia from the earlier potentially-related fibromyalgia symptoms. As such, her fibromyalgia cannot be found to be associated with her active service, to include any potentially related symptoms that may have manifest during service. Moreover, the Board observes that the Veteran is not competent to diagnose fibromyalgia or to opine as to the etiology of her fibromyalgia, as she lacks the medical expertise. See Jandreau, 492 F.3d at 1377. Where there is no competent or credible evidence of record showing that the Veteran has a current sciatica diagnosis and where there is no competent or credible evidence of record showing that her fibromyalgia had its onset during service or is otherwise related to any in-service disease, event, or injury, service connection for these disabilities must be denied. For the reasons and bases provided above, the Board finds that the preponderance of the evidence is against the Veteran's claims for service connection for sciatica and for fibromyalgia. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). The evidence in this case is not so evenly balanced so as to allow for application of the benefit of the doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107 (West 2002). Accordingly, the Veteran's claims for service connection for sciatica and for fibromyalgia are denied. ORDER Entitlement to service connection for sciatica is denied. Entitlement to service connection for fibromyalgia is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs