Citation Nr: 1329463	
Decision Date: 09/13/13    Archive Date: 09/20/13

DOCKET NO.  08-22 566	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Atlanta, 
Georgia


THE ISSUES

1. Entitlement to service connection for a skin disorder, 
including a lipoma, including as due to undiagnosed illness.

2. Entitlement to service connection for a disability 
manifested by chronic fatigue, to include chronic fatigue 
syndrome (CFS), including as due to undiagnosed illness or 
as secondary to service-connected posttraumatic stress 
disorder (PTSD). 

3. Entitlement to service connection for a gastrointestinal 
disability claimed as nausea and blood in the stools, to 
include irritable bowel syndrome (IBS), including as due to 
undiagnosed illness or as secondary to service-connected 
PTSD.

4. Entitlement to service connection for a disability 
manifested by joint pain, to include in the elbows and 
wrists, including as due to undiagnosed illness.

5.  Entitlement to service connection for a disability 
manifested by joint pain, to include in the ankles, 
including as due to undiagnosed illness.

6.  Entitlement to service connection for a disability 
manifested by joint pain, to include in the right foot, 
including as due to undiagnosed illness.

7.  Entitlement to service connection for a disability 
manifested by joint pain, to include in the left foot, 
including as due to undiagnosed illness.


REPRESENTATION

Appellant represented by:	Georgia Department of Veterans 
Services


WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

M. Zawadzki, Counsel


INTRODUCTION

The Veteran served on active duty from August 1981 to June 
1993, to include service in the Southwest Asia theater of 
operations during the Persian Gulf War.  

These matters come before the Board of Veterans' Appeals 
(Board) on appeal from a September 2005 rating decision 
issued by the Department of Veterans Affairs (VA) Regional 
Office (RO) in Decatur, Georgia.  The RO in Atlanta, Georgia 
certified the claims to the Board for appellate review.  

In October 2012, the Veteran testified before the 
undersigned Veterans Law Judge via videoconference; a 
transcript of the hearing is of record.  

In January 2013, the Board dismissed the Veteran's claim for 
service connection for sleep apnea which he had withdrawn 
during his October 2012 hearing.  The Board remanded claims 
for service connection for a skin disorder, including a 
lipoma; a disability manifested by chronic fatigue, to 
include CFS; a gastrointestinal disability claimed as blood 
in the stools, to include IBS; a disability manifested by 
joint pain, to include in the lower and upper back, neck, 
elbows, ankles, wrists, feet, and knees; and a respiratory 
disorder, including asthma, to the RO via the Appeals 
Management Center (AMC) in Washington, DC, for further 
development.  

In a May 2013 rating decision, the AMC granted service 
connection for mild degenerative disk disease (claimed as 
joint pain, low back), asthma (claimed as a respiratory 
disorder), a left knee sprain (claimed as joint pain), a 
right knee sprain (claimed as joint pain), and multilateral 
degenerative disk disease of the cervical spine (claimed as 
joint pain, neck, stiff neck).  This rating decision 
represents a full grant with respect to the benefits sought 
in regard to these claims.  

Also in May 2013, the AMC issued a supplemental statement of 
the case (SSOC) in which it continued to deny entitlement to 
service connection for a skin disorder, including lipoma; a 
disability manifested by chronic fatigue, to include CFS; a 
gastrointestinal disability, claimed as nausea and blood in 
stools, to include IBS; and a disability manifested by joint 
pain, to include the elbows and wrists.  These matters have 
been returned to the Board for further appellate review.  

While in the May 2013 SSOC, the AMC characterized the claim 
for service connection for a disability manifested by joint 
pain as including the elbows and wrists, the Board 
previously indicated in the January 2013 decision and remand 
that this issue included the ankles and feet as well.  
Although service connection for disabilities affecting the 
upper back, neck, and knees was granted in May 2013, the 
Veteran has not been awarded service connection for a 
disability manifested by joint pain affecting the ankles or 
feet.  Accordingly, the issues of entitlement to service 
connection for a disability manifested by joint pain, 
including in the ankles and feet, remain on appeal.  These 
issues were not addressed in the May 2013 SSOC; however, in 
light of the Board's favorable decision in regard to the 
claim for service connection for a bilateral ankle disorder 
and a right foot disorder, the failure to issue an SSOC 
regarding these claims does not result in any prejudice to 
the Veteran.  As will be discussed below, the claim for 
service connection for a disability manifested by joint 
pain, to include in the left foot, is being remanded for 
further development.  

The Board has reviewed the contents of the Veteran's Virtual 
VA file and found that it contains additional medical 
evidence, some of which was not considered by the AMC in the 
May 2013 SSOC.  Additional medical evidence has also been 
associated with the paper claims file since issuance of the 
May 2013 SSOC.  This evidence was not accompanied by a 
waiver of review by the agency of original jurisdiction 
(AOJ).  See 38 C.F.R. § 20.1304 (2012).  While this evidence 
is pertinent to the claims for service connection for a 
bilateral ankle disorder and a right foot disorder, as these 
claims are being granted, the Board finds that the Veteran 
is not prejudiced by consideration of these claims without a 
waiver of initial AOJ consideration.  See 38 C.F.R. § 
20.1102.  

The Board further notes that the Veteran has asserted that 
he has fatigue secondary to his service-connected PTSD.  He 
has also reported that the side effects of his medications 
for PTSD include diarrhea.  Accordingly, the Board has 
characterized the claims for service connection for a 
disability manifested by chronic fatigue and a 
gastrointestinal disability as reflected on the title page.  

In the June 2008 statement of the case (SOC) issued after 
the Veteran filed his notice of disagreement (NOD) with the 
September 2005 rating decision from which the current appeal 
stems, the RO denied a rating in excess of 50 percent for 
PTSD as well as service connection for multiple disorders, 
including pseudofolliculitis barbae, asthma, arch problems, 
low back and upper back, blood in stool, knees, elbows, 
ankles, lipoma, sleep apnea, nausea, dizziness, blurry 
vision, chronic fatigue, swelling of the feet and legs, 
aching temples, and a stiff neck.  In his July 2008 VA Form 
9, the Veteran indicated that he was only appealing the 
claims for service connection for sleep apnea, chronic 
fatigue, IBS, lipoma, joint pain, anemia, and asthma.  The 
Board notes that a claim for service connection for anemia 
has not yet been adjudicated.  

In his June 2009 VA Form 646, Statement of Accredited 
Representative in Appealed Case, the Veteran's 
representative listed the issues on appeal as a claim for an 
increased rating for PTSD and service connection for 
pseudofolliculitis barbae, asthma, arch problems, lower and 
upper back, blood in stool, knees, elbows, ankles, lipoma, 
sleep apnea, nausea, dizziness, blurry vision, chronic 
fatigue, swelling of the feet and legs, aching temples, and 
a stiff neck.  As indicated above, the Board dismissed the 
claim for service connection for sleep apnea in the January 
2013 decision.  The claims for service connection for 
asthma, a back disorder, right and left knee disorders, and 
a stiff neck were granted in the May 2013 rating decision, 
and the claims for service connection for elbow and ankle 
disorders, a gastrointestinal disorder, a skin disorder, and 
chronic fatigue, are presently on appeal.  The claim for an 
increased rating for PTSD was denied in a February 2012 
rating decision.  However, the Board finds that the June 
2009 VA Form 646 raises requests to reopen claims for 
service connection for arch problems, dizziness, blurry 
vision, swelling of the feet and legs, and aching temples.  

Also, in January 2013, the Board referred to the AOJ claims 
for increased ratings for a fracture of the left little 
finger, a patellar spur of the left knee, and residuals of a 
laceration of the left lower leg with retained metallic 
fragment.  There is no indication that these claims have yet 
been adjudicated.  

The issues of entitlement to increased ratings for a 
fracture of the left little finger, a patellar spur of the 
left knee, and residuals of a laceration of the left lower 
leg with retained metallic fragment, a claim for service 
connection for anemia, and requests to reopen claims for 
service connection for arch problems, dizziness, blurry 
vision, swelling of the feet and legs, and aching temples 
have been raised by the record, but have not been 
adjudicated by the AOJ.  Therefore, the Board does not have 
jurisdiction over these matters, and they are referred to 
the AOJ for appropriate action.  

The Board's decision granting service connection for a 
bilateral ankle disorder and a right foot disorder is set 
forth below.  The remaining issues listed on the title page 
are addressed in the REMAND portion of the decision below 
and are REMANDED to the RO via AMC.


FINDINGS OF FACT

1.  All notification and development action needed to fairly 
adjudicate the claims decided below has been accomplished.

2. Competent medical evidence indicates that the Veteran has 
a current bilateral ankle disorder, specifically, ankle 
sprains and calcific enthesopathy, that is related to 
service.

3.  Competent medical evidence indicates that the Veteran 
has a current right foot disorder, specifically, 
metatarsalgia, degenerative joint disease (DJD), a plantar 
calcaneal spur, and calcific enthesopathy, that is related 
to service.


CONCLUSIONS OF LAW

1.  A current bilateral ankle disorder, specifically, ankle 
sprains and calcific enthesopathy, is related to service.  
38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & 
Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012).  

2.  A current right foot disorder, specifically, 
metatarsalgia, DJD, a plantar calcaneal spur, and calcific 
enthesopathy, is related to service.  38 U.S.C.A. §§ 1110, 
1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. 
§§ 3.102, 3.159, 3.303 (2012).  






REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Duty to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA) describes 
VA's 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, 3.326(a) (2012).  The United States 
Court of Appeals for Veterans Claims (Court), in 
Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), has 
held that the VCAA notice requirements apply to all elements 
of a claim.

Given the favorable disposition of the claims decided here, 
the Board finds that all notification and development 
actions needed to fairly adjudicate these claims have been 
accomplished.  

Analysis

The Veteran asserts that he has disabilities manifested by 
joint pain, including in the ankles and right foot, related 
to service.  

Service connection may be established for disability 
resulting from personal injury or disease contracted in line 
of duty, or for aggravation of a pre-existing injury 
suffered or disease contracted in line of duty.  38 U.S.C.A. 
§§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012).  
Service connection may be granted for any disease diagnosed 
after discharge from service when all the evidence, 
including that pertinent to service, establishes that the 
disease was incurred in service.  38 C.F.R. § 3.303(d).

A three-element test must be satisfied in order to establish 
entitlement to service connection. Specifically, the 
evidence must show (1) the existence of a current 
disability; (2) in-service incurrence or aggravation of a 
disease or injury; and (3) a causal relationship between the 
current disability and the disease or injury incurred or 
aggravated during service (the "nexus" requirement). Walker 
v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (citing 
Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) 
(quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. 
Cir. 2004))). 

The evidence of record reflects that the Veteran served in 
the Southwest Asia theater of operations during the Persian 
Gulf War.  As a Persian Gulf Veteran, compensation may be 
established for objective indications of a "qualifying 
chronic disability" that became manifest during service on 
active duty in the Armed Forces in the Southwest Asia 
theater of operations during the Persian Gulf War, or to a 
degree of 10 percent prior to December 31, 2016 and by 
history, physical examination, and laboratory tests cannot 
be attributed to any known clinical diagnosis.  38 U.S.C.A. 
§ 1117; 38 C.F.R. § 3.317 (2012).

A "qualifying chronic disability" includes: undiagnosed 
illness and or medically unexplained chronic multi symptom 
illnesses such as chronic fatigue syndrome, fibromyalgia, 
and functional gastrointestinal disorders (excluding 
structural gastrointestinal diseases).  38 U.S.C.A. § 
1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i).

Objective indications of a chronic disability include both 
"signs," in the medical sense of objective evidence 
perceptible to an examining physician, and other, non 
medical indicators that are capable of independent 
verification.  38 C.F.R. § 3.317(a)(3).  Signs or symptoms 
that may be manifestations of undiagnosed illness or 
medically unexplained chronic multi-symptom 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) neurological 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).

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).

Despite his Persian Gulf War service, the Veteran's claimed 
bilateral ankle disorder and right foot disorder have been 
attributed to known diagnoses, specifically, ankle sprains 
and calcific enthesopathy in regard to the ankles and 
metatarsalgia, DJD, a plantar calcaneal spur, and calcific 
enthesopathy in regard to the right foot, as reflected on VA 
examination in March 2013.  Therefore, service connection 
for a bilateral ankle disorder or a right foot disorder as 
due to an undiagnosed illness related to the Veteran's 
service in the Persian Gulf War is not warranted.  

However, turning to review of his claims for service 
connection on a direct basis, and resolving all reasonable 
doubt in his favor, the Board finds that service connection 
for a bilateral ankle disorder and a right foot disorder is 
warranted.  

Service treatment records reflect that the Veteran was seen 
in August 1985 for right foot pain.  The assessment was 
acute sprain of the medial foot.  Later that month, he was 
seen for an acute right ankle sprain following a football 
injury.  He was seen in January 1988 for left ankle pain for 
24 hours after suffering indirect trauma.  He received 
treatment in February 1989 for pain in the right ankle and 
foot.  The assessment was rule out ankle sprain and 
extremity pain/joint pain.  He was seen for follow-up of a 
right ankle sprain in March 1989.  In April 1989 he 
presented with complaints of left ankle pain while running.  
The assessment was possible strain.  In October 1992, the 
Veteran presented with complaints of pain in the big toe of 
his right foot.  The assessment was subungual hematoma.  In 
his April 1993 Report of Medical History at separation, the 
Veteran reported foot trouble and the examiner commented 
that the Veteran's left knee and ankles were bothering him.  
Clinical evaluation of the lower extremities and feet on 
separation examination was normal.  

A July 2004 VA treatment record notes a past medical history 
of chronic ankle pain.  

On VA Gulf War examination in May 2005, the Veteran reported 
joint pains in both ankles.  He stated that he started 
noticing bilateral ankle pain while stationed in Germany and 
running on cobblestone streets.  He reported several ankle 
sprains during this time.  He added that his ankles were 
aggravated during bumpy tank rides and jumping off tanks in 
Kuwait.  The Veteran reported that he continued to have 
intermittent problems and his ankles easily twisted.  He 
also described pain in the arches of both feet if he stood 
for long periods of time.  X-rays of the ankles revealed 
right calcaneal spurs, but were otherwise negative.  X-rays 
of the feet revealed small calcaneal spurs on the right, but 
were otherwise negative.  The pertinent impression was 
bilateral ankle sprain by Veteran's history with normal 
ankle films but incidental note of a right calcaneal spur.  

During a June 2007 VA PTSD examination, the Veteran reported 
that he had twisted his ankles running on cobblestone 
streets in Germany and had current pain in both ankles 
related to these injuries.  

The Veteran presented at the Candler County Hospital 
emergency room in February 2010 with complaints of a 
twisted/sprained right foot after being hit by an inmate.  
The impression was right foot sprain.  X-ray of the right 
foot revealed no acute abnormality, although a calcaneal 
spur was noted.  

In February 2010, the Veteran received treatment at 
Southeastern Orthopedic Center for right foot pain and 
swelling following an altercation with an inmate in his work 
with the Sheriff's department.  He reported suffering an 
inversion-type injury.  He reported increasing swelling and 
persistent pain since his injury.  The assessment was grade 
2 right ankle sprain and right foot accessory navicula.  
Following physical therapy treatment, the Veteran returned 
in March 2010, reporting that he had responded well to 
physical therapy and only had a little bit of forefoot pain.  
The assessment was right ankle sprain and right forefoot 
sprain.  By the end of March 2010, the physician was unable 
to reproduce any pain with palpation over the angle of the 
forefoot.  There was no appreciable swelling and no obvious 
ecchymosis or deformity.  Range of motion was excellent; 
strength and sensation were normal; and gait was non-
antalgic.  The Veteran was released to work with no 
restrictions or limitations.  The Veteran returned in 
November 2010 with pain in his right foot.  The assessment 
was persistent right foot pain.  A November 2010 X-ray of 
the right foot revealed second tarsometatarsal arthritis.  

A May 2011 psychological evaluation obtained in conjunction 
with the Veteran's claims for Social Security Administration 
(SSA) benefits reflects that the Veteran reported problems 
with his joints, including the feet and ankles.  

In June 2011, the Veteran presented to the Candler County 
Hospital emergency room reporting that a car ran over his 
right foot/ankle.  The pertinent impression was contusion of 
the right foot/ankle.  X-ray revealed no acute right ankle 
abnormality.  

During VA treatment in August 2011, the Veteran reported 
arthralgias and muscle aches and pains in various locations, 
including the bilateral ankles.  An August 2011 VA nursing 
domiciliary note reflects that the Veteran described foot 
pain beginning in the military.  During VA treatment in July 
2012 the Veteran reported chronic pain in his right foot for 
20 years.  

During the October 2012 hearing, the Veteran testified that 
his ankles were a problem almost the entire time he was in 
the military, as he twisted his ankles all the time.  

On VA ankle examination in March 2013, the examiner noted 
that the Veteran had bilateral ankle sprain.  The Veteran 
gave a history of twisting both his ankles in 1983 when 
running on cobblestone in Germany.  He indicated that he had 
been treated at the local troop clinic.  X-rays of the 
ankles revealed calcific enthesopathy and bilateral 
calcaneal spurs.  

On VA foot examination in March 2013, the examiner noted 
that the Veteran had a foot condition, specifically, 
bilateral calcaneal spurs and bilateral metatarsalgia.  The 
Veteran reported that he began having pain in his feet when 
walking on cobblestone in Germany.  He reported being seen 
at the local troop clinic.  X-rays of the feet revealed mild 
DJD, plantar calcaneal spurs, and calcific enthesopathy, 
bilaterally.  

The examiner indicated that she had been asked to provide an 
opinion as to, "Whether the joint pain, back, and neck had 
its onset during active service."  The examiner indicated by 
checked box that the claimed condition was at least as 
likely as not (50 percent or greater probability) incurred 
in or caused by the claimed in-service injury, event, or 
illness.  In providing a rationale for her opinion, she 
stated that review of the claims file indicated that the 
Veteran was seen for these conditions during military 
service and he did have some limited range of motion in his 
back and knees on examination.  The diagnostic studies 
justified his claimed conditions, other than the claimed 
conditions of the elbows and wrists, which were normal.  

The foregoing evidence reflects that the Veteran has a 
current bilateral ankle disorder, specifically, ankle 
sprains and calcific enthesopathy, as reflected on VA 
examination in March 2013.  This VA examination also 
revealed a current right foot disorder, specifically, 
metatarsalgia, DJD, a plantar calcaneal spur, and calcific 
enthesopathy.  Thus, the first element of each successful 
service connection claim is satisfied.  The Veteran also 
received treatment for ankle pain on numerous occasions 
during service, with findings of right ankle sprains and a 
possible left ankle strain.  Service treatment records also 
document in-service treatment for right foot pain, with an 
assessment of an acute sprain of the medial foot as well as 
a subungual hematoma.  Thus, the second element of each 
claim is also satisfied.

The Board finds that the third element, the "nexus" 
requirement is also satisfied, as the March 2013 VA examiner 
opined that it was at least as likely as not that the 
Veteran's claimed joint pain condition was incurred in or 
caused by the claimed in-service injury, event, or illness.  
While the examiner did not specifically name the ankle or 
right foot condition as the condition related to service 
(despite specifically referring to the back, neck, and 
knees), the ankles and right foot were evaluated as part of 
his claim for service connection for joint pain; the 
examiner referred to the Veteran being seen for his claimed 
conditions in service (as stated above, he was seen in 
regard to his ankles and his right foot during service); and 
stated that the diagnostic studies justified his claimed 
conditions (X-rays performed in conjunction with the March 
2013 VA examination revealed calcific enthesopathy in the 
ankles as well as mild DJD, a plantar calcaneal spur, and 
calcific enthesopathy in the right foot).  Accordingly, the 
Board finds that, resolving all reasonable doubt in his 
favor, the March 2013 opinion satisfies the nexus 
requirement with respect to each claim.  

In reaching this conclusion, the Board has considered that 
the VA examiner did not specifically consider and address 
the February 2010 and June 2011 post-service injuries to the 
right foot/ankle.  However, she acknowledged review of the 
claims file.  Although additional evidence regarding 
treatment for the June 2011 right foot injury has been added 
to the claims file since the March 2013 opinion was 
rendered, there was evidence that the Veteran's right foot 
had been run over by a motor vehicle in June 2011 at the 
time of the March 2013 opinion.  Accordingly, the Board 
finds that the examiner's claims file review would have put 
her on notice of these post-service injuries.  Further, an 
in-service disease, event, or injury need not be the only 
cause of a current disorder to establish a relationship 
between the current disorder and service; rather, the in-
service disease, event, or injury must only be a 
contributing cause.  

For all the foregoing reasons, and with resolution of all 
reasonable doubt in the Veteran's favor, the Board concludes 
that the criteria for service connection for a bilateral 
ankle disorder, specifically, ankle sprains and calcific 
enthesopathy, and a right foot disorder, specifically, 
metatarsalgia, DJD, a plantar calcaneal spur, and calcific 
enthesopathy, are met.  


ORDER

Service connection for a bilateral ankle disorder, 
specifically, ankle sprains and calcific enthesopathy, is 
granted.    

Service connection for a right foot disorder, specifically, 
metatarsalgia, DJD, a plantar calcaneal spur, and calcific 
enthesopathy, is granted.  


REMAND

Remand is required to obtain additional VA treatment 
records.  The claims file and Virtual VA e-folder presently 
include VA treatment records dated from July to September 
2004 and from April 2010 to May 2013, however, the record 
indicates that the Veteran received VA treatment between 
September 2004 and April 2010.  Additionally, in June 2011, 
the Veteran submitted a VA Form 21-4142, Authorization and 
Consent to Release Information to the Department of Veterans 
Affairs (VA), in which he reported receiving treatment from 
the Dublin VA Medical Center (VAMC) from June 1993 to July 
2011.  There is no indication that additional VA treatment 
records, including dated prior to July 2004, were requested 
in response to this VA Form 21-4142.  

The Board remanded the claims in January 2013, in part, to 
obtain the Veteran's complete treatment records from the 
Dublin VAMC dated since August 2010.  A document in the 
claims file, dated February 8, 2013, indicates that 
treatment records from the Dublin VAMC, dated from August 2, 
2010 to February 1, 2013, were uploaded into the Veteran's 
Virtual VA e-folder.  Unfortunately, this set of records is 
not available in the e-folder.  While the SSA records 
include VA treatment records dated from June 2010 to August 
2011, and treatment records from the Dublin VAMC, dated from 
September 2011 to May 2013 were uploaded to the Veteran's e-
folder in June 2013, the Board must ensure that all 
available potentially pertinent VA treatment records are 
available for review.  Accordingly, any treatment records 
dated between August 2010 and September 2011 which are not 
already included in the Veteran's SSA records, should be 
obtained on remand.  

The record also indicates that there may be a VA vocational 
rehabilitation file or folder which is potentially pertinent 
to the claims on appeal, as Social Security Administration 
(SSA) records associated with the claims file indicate that 
the Veteran had been in contact with VA vocational 
rehabilitation.  Any VA vocational rehabilitation file or 
folder should be obtained on remand.  

The claims were also remanded in January 2013 to afford the 
Veteran VA examinations to evaluate his claimed 
disabilities.  The Veteran underwent VA examinations in 
March 2013.  Unfortunately, the VA examination reports are 
inadequate.  

In this regard, the examiner provided a negative nexus 
opinion regarding the relationship between the Veteran's 
claimed skin disorder and service, based on there being no 
documentation of the Veteran being seen and evaluated for a 
skin condition.  However, as will be discussed below, 
service treatment records do document in-service treatment 
for skin complaints.  

The examiner provided a negative opinion regarding whether 
the Veteran's fatigue represented an objective indication of 
chronic disability resulting from an undiagnosed illness 
related to his Persian Gulf War service.  Her opinion was 
based on a finding that the Veteran did not have fatigue 
based on his examination and the most recent diagnostic 
test.  It is unclear whether the examiner considered the 
Veteran's complaints of fatigue during the pendency of the 
appeal (including as documented during a prior, May 2005 VA 
examination).  She also did not adequately address whether 
the Veteran's reported complaints of fatigue since service 
can be attributed to a known diagnostic entity.  

In regard to the claimed gastrointestinal disability, the 
examiner provided a negative opinion regarding the Veteran's 
claimed gastrointestinal disability and service, based on a 
finding that he did not have any current gastrointestinal 
condition based on examination and an upper GI study.  She 
did not, however, address whether any gastrointestinal 
disorders noted during the pendency of the claim, to include 
diarrhea, constipation, and internal hemorrhoids, may be 
related to service.  Additionally, her opinion does not 
adequately address whether the Veteran's gastrointestinal 
complaints, including blood in his stool, constipation, and 
diarrhea, may represent objective indications of chronic 
disability resulting from an undiagnosed illness or a 
medically unexplained chronic multi-symptom illness related 
to the Veteran's Persian Gulf War service.  

In regard to the claimed disability manifested by joint 
pain, to include in the elbows and wrists, the March 2013 VA 
examiner provided a negative opinion regarding the 
relationship between the Veteran's claimed joint pain in the 
elbows and wrists and service, insofar as she stated that 
the Veteran's claimed disabilities manifested by joint pain 
in other locations were related to service, as diagnostic 
studies justified the claimed conditions, while the studies 
of the elbows and wrists were normal.  However, this opinion 
is confusing in light of the X-ray evidence of calcific 
enthesopathy in the bilateral elbows.  Additionally, this 
opinion does not adequately address whether the Veteran's 
complaints of joint pain in the elbows and wrists may 
represent objective indications of chronic disability 
resulting from an undiagnosed illness or a medically 
unexplained chronic multi-symptom illness related to the 
Veteran's Persian Gulf War service.  

In regard to the claim for service connection for a 
disability manifested by joint pain, to include in the left 
foot, a pre-service private treatment record, dated in June 
1980, reflects that the Veteran complained of left foot pain 
following a twisting injury.  The pertinent impression was 
soft tissue injury of the lateral left foot below the ankle.  
He denied foot trouble in his April 1981 Report of Medical 
History at enlistment and clinical evaluation of the feet at 
that time was normal.  In light of the documented pre-
service left foot injury, the Board finds that a 
supplemental medical opinion is needed in regard to this 
claim as well.  

Finally, as stated in the introduction, the Veteran has 
reported that the side effects of his medications for PTSD 
include diarrhea.  On remand, he should be provided 
additional VCAA notice regarding secondary service 
connection with respect to this claim.  

Accordingly, the case is REMANDED for the following action:

1. Provide the Veteran a corrective VCAA 
notice under 38 U.S.C.A. § 5103(a) and 
38 C.F.R. § 3.159(b), that advises him 
of the information and evidence 
necessary to substantiate his claim for 
service connection for a 
gastrointestinal disability claimed as 
nausea and blood in the stools, to 
include IBS, including as secondary to 
service-connected PTSD.  

2.  Request that the Veteran provide the 
names and addresses of any and all 
health care providers who have provided 
treatment for his claimed disabilities.  
After acquiring this information and 
obtaining any necessary authorization, 
obtain and associate any outstanding 
pertinent records with the claims file 
or Virtual VA e-folder.  

A specific request should be made for VA 
treatment records from the Dublin VAMC, 
dated (1) prior to July 2004; (2) 
between September 2004 and April 2010; 
(3) between August 2010 and September 
2011 (which are not already included in 
the Veteran's SSA records); and (4) 
since May 2013.  The records obtained on 
remand should include treatment in 
February 2009 for pain in the limb and 
an August 2005 colonoscopy report.

If any identified records are not 
obtainable (or none exist), the Veteran 
and his representative should be 
notified and the record clearly 
documented.

3. Associate with the claims file the 
Veteran's VA vocational rehabilitation 
folder.

4.  After all available records have 
been associated with the claims file or 
Virtual VA e-folder, forward the claims 
file to the examiner that conducted the 
March 2013 VA examinations, if 
available, for a supplemental medical 
opinion.  The claims folder must be made 
available to the examiner for review of 
the case.  A notation to the effect that 
this record review took place should be 
included in the report of the examiner.

Skin disorder

In regard to his claimed skin disorder, 
the examiner must provide an opinion as 
to whether it is at least as likely as 
not (50 percent or greater probability) 
that any skin disorder present at any 
time since the Veteran filed his claim 
for service connection in July 2004 (to 
include a lipoma, tinea pedis, 
folliculitis, tinea cruris, and 
scarring) had its clinical onset during 
active service or is related to any in-
service disease, event, or injury.  

The examiner must also clearly address 
whether or not there are any symptoms 
related to the Veteran's claimed skin 
disorder that cannot be attributed to a 
known diagnostic entity.  If there are 
any symptoms related to the Veteran's 
claimed skin disorder that cannot be 
attributed to a known diagnostic entity, 
the examiner should render an opinion as 
to whether it is at least as likely as 
not (50 percent or greater probability) 
that any such symptoms represent an 
objective indication of chronic 
disability resulting from an undiagnosed 
illness or a medically unexplained 
chronic multi-symptom illness related to 
the Veteran's Persian Gulf War service.

As indicated above, the examiner should 
review the record in conjunction with 
rendering the requested opinion; 
however, her attention is drawn to the 
following:

•  Service treatment records 
reflect that, in April 1993, the 
Veteran complained of a rash on the 
back of his neck for two months.  
He denied a history of skin 
problems.  The assessment was 
suspected folliculitis.  In May 
1993, the Veteran presented with a 
rash for three days.  The 
assessment was rash, caused from 
friction and heat.  The Physician 
Assistant, Certified (PA-C) noted 
that the Veteran's skin was 
irritated and cracked in the groin 
region.  His assessment was 
friction syndrome, groin.  In his 
Report of Medical History at the 
time of separation examination in 
April 1993, the Veteran denied skin 
diseases.  Clinical evaluation of 
the skin on separation examination 
was normal.  

•  On VA examination in November 
1993, the Veteran reported that he 
got athlete's foot while in Saudi 
Arabia and had not gotten rid of 
this condition.  The pertinent 
assessment was dermatitis of the 
bilateral feet, consistent with 
tinea.  

•  On VA Gulf War examination in 
May 2005, the Veteran reported that 
he developed a problem with 
athlete's foot in Saudi Arabia in 
1991.  He stated that he was never 
able to get rid of this condition, 
despite trying numerous over the 
counter medications.  He denied any 
other fungal skin problems or a 
history of a secondary bacterial 
infection of the skin on his feet.  
The Veteran also stated that he was 
diagnosed with folliculitis at the 
back of his neck in 1991.  He 
reported that he continued to have 
flare-ups of this condition 
intermittently, when he got his 
hair cut too short; although the 
condition had improved since he had 
let his hair grow out, and it was 
not currently bothering him.  
Examination revealed several 
hyperpigmented scars in the nape of 
the neck from previous 
folliculitis, but there was no 
evidence of active folliculitis.  
There were about 30 tiny 
hyperpigmented scars on the 
anterior chest and upper abdomen 
that were from "bumps" in the past.  
There was a small soft tissue mass 
over the left upper scapula 
consistent with a lipoma.  The 
pertinent impression was tinea 
pedis, bilaterally, onychomycosis 
of the toenails, and folliculitis 
by Veteran's history, asymptomatic 
at present.  

•  Private treatment records dated 
in April 2007 and February 2010 
reflect that the Veteran was 
treated for tinea pedis.  

•  On VA PTSD examination in June 
2007, the Veteran reported that he 
had a lipoma for a while; got 
folliculitis from showers in Saudi 
Arabia; had bumps in the back of 
his head from haircuts received in 
service; and had athlete's foot in 
Saudi Arabia.  

•  A January 2011 VA podiatry note 
reflects that the Veteran presented 
for follow-up for oral Lamisil 
therapy for fungal toenails.  The 
nails were clearing nicely, but the 
Veteran complained of itching feet 
without skin changes.  The 
assessment included resolving 
onychomycosis and itching feet 
(possible tinea).  

•  On VA general medical 
examination in March 2011, the 
Veteran stated that he was exposed 
to smoke, fuel, and burn-off in 
service and would develop lesions 
on his face, neck, and anterior 
chest.  He added that he felt his 
skin problem with his groin and 
feet developed in the community 
showering conditions in Iraq.  He 
described ongoing problems with a 
fungal infection of his feet and 
reported breaking out in itchy 
macules or papules on the head, 
neck, anterior chest, and back.  He 
also described chronic jock itch.  
The examiner stated that there was 
no present tinea cruris or tinea 
pedis, nor was there scarring.  The 
pertinent diagnosis was mild 
folliculitis of the anterior and 
posterior chest and across the 
hairline on the upper posterior 
neck.  The examiner reiterated that 
there was no noted jock itch or 
tinea pedis.  The examiner opined 
that the Veteran's foot fungus 
(tinea pedis) is not related to 
treatment in service for a skin 
rash of the head and neck and 
chest, nor was it related to jock 
itch.  She explained that tinea 
pedis, tinea cruris, and 
folliculitis are separate 
diagnoses.  She added that tinea 
pedis and tinea cruris are 
associated with fungal infections, 
but are not caused or transmitted 
from one area to another.  She 
stated that folliculitis is a 
separate diagnosis that has to do 
with bacterial infection of the 
hair follicle.  

•  On VA skin examination in March 
2013, the examiner indicated that 
the Veteran had tinea cruris, 
diagnosed in 1991.  The Veteran 
gave a history of noticing a rash 
on his face, feet, and genital area 
while stationed in Iraq in 1991.  
He stated that he was given an 
antifungal cream.  

•  The March 2013 VA examiner 
indicated that she had been asked 
to provide an opinion as to, 
"Whether the skin disability had 
its onset during active service."  
The examiner indicated by checked 
box that the claimed condition was 
less likely than not incurred in or 
caused by the claimed in-service 
injury, event, or illness.  In 
providing a rationale for her 
opinion, she stated that, based on 
review of file there was no 
documentation that the Veteran was 
seen and evaluated for a skin 
condition.  She acknowledged that 
he reported having to bathe in the 
same water with a diverse group of 
individuals; however, on exam he 
was noted to have a skin fungus on 
both groin and lower abdomen area 
(commonly known as jock itch).

The examiner is advised that the Veteran 
is competent to describe skin symptoms 
which are capable of his observation, 
such as breaking out, bumps, itching, 
and dryness.  

In rendering the requested opinion, the 
examiner must specifically consider and 
address the in-service treatment for 
skin problems in April and May 1993 
(discussed above).  She must also 
consider and address the Veteran's 
assertion that his athlete's foot began 
during and had continued since service, 
as well as his May 2005 report that he 
had experienced intermittent flare-ups 
of folliculitis since 1991.  She should 
specifically consider the May 2005 VA 
examination report revealing several 
hyperpigmented scars in the nape of the 
neck from previous folliculitis, about 
30 tiny hyperpigmented scars on the 
anterior chest and upper abdomen from 
"bumps" in the past, and a small soft 
tissue mass over the left upper scapula 
consistent with a lipoma.  


FATIGUE

In regard to his claimed disability 
manifested by fatigue, the examiner must 
clearly address whether the Veteran's 
complaints of fatigue since July 2004 
(when he filed his claim for service 
connection) can be attributed to any 
known diagnostic entity.  If so, the 
examiner must provide an opinion as to 
whether it is at least as likely as not 
(50 percent or greater probability) that 
the disorder had its clinical onset 
during active service or is related to 
any in-service disease, event, or 
injury; or in the alternative, whether 
it is at least as likely as not (50 
percent or greater probability) that the 
Veteran's disorder was caused or 
aggravated by service-connected PTSD, or 
medication used to treat service-
connected PTSD.  

The examiner must also clearly address 
whether or not there are any symptoms 
related to the Veteran's claimed fatigue 
that cannot be attributed to a known 
diagnostic entity.  If there are any 
symptoms related to the Veteran's 
claimed fatigue that cannot be 
attributed to a known diagnostic entity, 
the examiner should render an opinion as 
to whether it is at least as likely as 
not (50 percent or greater probability) 
that any such symptoms represent an 
objective indication of chronic 
disability resulting from an undiagnosed 
illness or a medically unexplained 
chronic multi-symptom illness related to 
the Veteran's Persian Gulf War service.

As indicated above, the examiner should 
review the record in conjunction with 
rendering the requested opinion; 
however, her attention is drawn to the 
following:

•  Service treatment records 
reflect that, during treatment in 
April 1993 the Veteran denied 
fatigue.  In his Report of Medical 
History at the time of separation 
examination in April 1993, he 
reported frequent trouble sleeping.

•  On VA Gulf War examination in 
May 2005, the Veteran reported that 
he noticed he was tired all the 
time after returning from his 
deployment to Kuwait in 1991.  The 
pertinent impression following 
examination was fatigue by 
Veteran's history.  The examiner 
commented that the final diagnosis 
was pending the results of a sleep 
study, as he was at risk for "this 
condition" based on his obesity.  
The examiner commented that the 
possible causes for the Veteran's 
fatigue included morbid obesity and 
depression.  In addition, the 
Veteran worked 12 hour swing shifts 
(two weeks of days and two weeks of 
nights), which could be causing 
problems with adequate sleep 
cycles.  The examiner also observed 
that the Veteran had very mild 
anemia, but opined that this was 
not the cause of his fatigue.  
There was no evidence of a thyroid 
disorder, diabetes, renal, or 
hepatic abnormality and complete 
metabolic panel was normal.  

•  The May 2005 VA examiner 
provided an addendum in July 2005, 
after a sleep study was performed.  
He noted that the Veteran had sleep 
apnea confirmed by sleep study with 
daytime fatigue.  He opined that 
the Veteran would benefit from 
weight loss and the use of CPAP.  
	
•  In August 2006, the Veteran 
stated that his fatigue was a 
byproduct of his sleep apnea and 
PTSD.  

•  During a VA PTSD examination in 
June 2007, the Veteran reported 
that the side effects of his 
medications for PTSD included 
drowsiness and fatigue.  

•  On Gulf War Registry Examination 
in November 2011 the Veteran 
reported fatigue since 1990.  He 
stated that CPAP had helped his 
symptoms.  He also added that his 
medications had been adjusted, 
which helped with his fatigue.  

•  An October 2012 VA treatment 
record reflects that the Veteran 
reported suffering from chronic 
fatigue despite using his CPAP 
properly.  

•  During the October 2012 hearing, 
the Veteran testified that his 
symptoms of fatigue started in 
service and had continued since.  

•  On VA examination in March 2013, 
the examiner indicated that the 
Veteran had not ever been diagnosed 
with CFS.  The Veteran reported 
that he began having chronic 
fatigue in 1991 after returning 
from Iraq.  The examiner commented 
that other clinical conditions that 
may produce similar symptoms had 
not been excluded.  The examiner 
commented that there was 
significant diagnostic testing, and 
included a hematology profile 
revealing low red blood cell count 
(RBC), hemoglobin (HGB), and 
hematocrit (HCT).
 
•  The March 2013 VA examiner 
indicated that she had been asked 
to provide an opinion as to, 
"Whether the fatigue represents an 
objective indication of chronic 
disability resulting from an 
undiagnosed illness related to the 
Veteran's Persian Gulf War service 
etc."  She indicated by checked box 
that that the claimed was less 
likely than not proximately due to 
or the result of the Veteran's 
service-connected condition.  In 
providing a rationale, she stated 
that the Veteran did not have 
fatigue based on his examination 
and the most recent diagnostic 
test.  

The examiner is advised that the Veteran 
is competent to describe fatigue.  She 
should consider and address his reports 
of fatigue since service (discussed 
above).  

In rendering the requested opinion, the 
examiner should specifically consider 
and address the May 2005 diagnosis of 
fatigue by history and that VA 
examiner's opinion that the possible 
causes for the Veteran's fatigue 
included depression.

Gastrointestinal disability

In regard to the claimed 
gastrointestinal disability, the 
examiner must clearly address whether 
the Veteran's gastrointestinal 
complaints, including diarrhea, 
constipation, and blood in his stool, 
since July 2004 (when he filed his claim 
for service connection) can be 
attributed to any known diagnostic 
entity, to include hemorrhoids.  If so, 
the examiner must provide an opinion as 
to whether it is at least as likely as 
not (50 percent or greater probability) 
that any disorder, to include 
hemorrhoids, had its clinical onset 
during active service or is related to 
any in-service disease, event, or 
injury; or in the alternative, whether 
it is at least as likely as not (50 
percent or greater probability) that the 
Veteran's condition was caused or 
aggravated by service-connected PTSD or 
medication used to treat service-
connected PTSD.  
 
The examiner must also clearly address 
whether or not there are any symptoms 
related to the Veteran's 
gastrointestinal complaints that cannot 
be attributed to a known diagnostic 
entity.  If there are any symptoms 
related to the Veteran's 
gastrointestinal complaints that cannot 
be attributed to a known diagnostic 
entity, the examiner should render an 
opinion as to whether it is at least as 
likely as not (50 percent or greater 
probability) that any such symptoms 
represent an objective indication of 
chronic disability resulting from an 
undiagnosed illness or a medically 
unexplained chronic multi-symptom 
illness related to the Veteran's Persian 
Gulf War service.

As indicated above, the examiner should 
review the record in conjunction with 
rendering the requested opinion; 
however, her attention is drawn to the 
following:

•  A private treatment record dated 
in January 1983 indicates that the 
Veteran complained of stomach pain, 
burping, nausea, vomiting, and 
loose stools.  

•  Service treatment records 
reflect that, in May 1983, the 
Veteran complained of nausea and 
vomiting, stating that the smell of 
food made him nauseated.  He 
reported body aches but denied 
diarrhea.  The assessment was rule 
out indigestion.  In July 1986, the 
Veteran described nausea, diarrhea, 
and a headache.  The assessment was 
viral gastroenteritis.  In May 
1991, the Veteran presented with 
complaints of an upset stomach, 
noting that he was receiving 
medication for flu.  The assessment 
was upper respiratory infection 
with probable side effects 
secondary to medication.  In 
October 1992, the Veteran 
complained of bloody stools for one 
week.  The PA-C was unable to 
complete a thorough examination.  
The assessment was probable anal 
fissure.  In April 1993, the 
Veteran reported diarrhea for two 
days after eating something.  The 
assessment was upset stomach.  In 
his Report of Medical History at 
the time of separation examination 
in April 1993, the Veteran denied 
stomach, liver, or intestinal 
trouble.  On separation 
examination, clinical evaluation of 
the abdomen and viscera was normal.  

•  On VA examination in November 
1993, the digestive system 
evaluation revealed a protuberant 
abdomen with bowel sounds present.  
There was no palpable mass or 
organomegaly, nor were there 
hemorrhoids.  

•  In August 2006, the Veteran 
reported that he still occasionally 
had blood in his stool.  

•  During a June 2007 VA PTSD 
examination, the Veteran stated 
that he was taking an anti-
depressant, Paroxetine HCL, but 
that this medication "destroys his 
stomach" and he could not take it 
unless he was close to a bathroom.  
The Veteran reported that the side 
effects of his medications for PTSD 
included diarrhea.  

•  During VA treatment in December 
2010, the Veteran reported that 
Wellbutrin had caused diarrhea; 
however, the assessment was 
diarrhea, possibly from Terbinafine 
and not Wellbutrin.  

•  VA treatment records reflect 
that the Veteran was afforded a 
Gulf War Registry Examination in 
November 2011.  He reported 
gastrointestinal problems since 
1989, with constipation in Germany.  
He described current constipation 
once or twice a month; adding that 
he normally had diarrhea once he 
had been constipated for several 
days.  He stated that he had been 
given stool softeners in 2003 to 
2004 and 2006 to 2007 with some 
improvement.  The nurse 
practitioner noted that the Veteran 
had a colonoscopy in 2005 for 
rectal bleeding with internal 
hemorrhoids.  The impression 
included chronic constipation and 
internal hemorrhoids.  

•  On VA examination in March 2013, 
the examiner indicated that the 
Veteran did not have, nor had he 
ever had, an esophageal condition.  
The Veteran gave a history of 
having blood in his stool and 
diarrhea when stationed in Iraq in 
1991, for which he was seen in a 
local troop clinic.  Upper 
gastrointestinal study was normal.
  
•  The March 2013 VA examiner 
indicated that she had been asked 
to provide an opinion as to, 
"Whether the gastrointestinal 
complaint is due to a disease 
entity or had its clinical onset 
during active service."  The 
examiner indicated by checked box 
that the claimed condition was less 
likely than not (less than 50 
percent probability) incurred in or 
caused by the claimed in-service 
injury, event, or illness.  In 
providing a rationale for her 
opinion, she stated that the 
Veteran was not found to have any 
current gastrointestinal condition 
based on both examination and 
diagnostic study (the upper GI 
report).  

The examiner is advised that the Veteran 
is competent to report symptoms such as 
diarrhea, constipation, and blood in his 
stools.  The examiner must consider and 
address the Veteran's November 2011 
report of gastrointestinal problems 
since 1989.  

In rendering the requested opinion, the 
examiner must specifically consider and 
address the documented complaints of 
stomach pain, burping, nausea, vomiting, 
loose stools, diarrhea, and bloody 
stools during service, as well as the 
October 1992 assessment of probable anal 
fissure.  



Elbows and Wrists

In regard to his claimed disability 
manifested by joint pain, to include in 
the elbows and wrists, the examiner must 
clearly address whether the Veteran's 
complaints of pain in the elbows and/or 
wrists since July 2004 (when he filed 
his claim for service connection) can be 
attributed to any known diagnostic 
entity, to include calcific 
enthesopathy, as found on X-rays in 
March 2013.  If so, the examiner must 
provide an opinion as to whether it is 
at least as likely as not (50 percent or 
greater probability) that any disorder, 
to include calcific enthesopathy, had 
its clinical onset during active service 
or is related to any in-service disease, 
event, or injury.  

The examiner must also clearly address 
whether or not there are any symptoms 
related to the Veteran's reports of pain 
in the elbows and/or wrists that cannot 
be attributed to a known diagnostic 
entity.  If there are any symptoms 
related to the Veteran's reports of pain 
in the elbows and/or wrists that cannot 
be attributed to a known diagnostic 
entity, the examiner should render an 
opinion as to whether it is at least as 
likely as not (50 percent or greater 
probability) that any such symptoms 
represent an objective indication of 
chronic disability resulting from an 
undiagnosed illness or a medically 
unexplained chronic multi-symptom 
illness related to the Veteran's Persian 
Gulf War service.

As indicated above, the examiner should 
review the record in conjunction with 
rendering the requested opinion; 
however, her attention is drawn to the 
following:

•  Service treatment records 
reflect that, in November 1984, the 
Veteran complained of pain in his 
shoulder and upper right arm after 
contact during football.  The 
assessment was rule out muscle 
sprain.  In March 1987, the Veteran 
was seen for a hematoma of the left 
arm near the distal humerus.  The 
assessment was soft tissue injury 
of the left arm, rule out fracture 
of the left elbow.  On separation 
examination in April 1993, clinical 
evaluation of the upper extremities 
was normal.  

•  During a November 1993 VA 
examination, the Veteran reported 
that he was hit in the left elbow 
around 1986 or 1987.  The pertinent 
assessment was history of old 
injury to the left elbow, normal 
physical examination.  

•  On VA Gulf War examination in 
May 2005, the Veteran stated that 
he injured his left wrist around 
1991 in Kuwait when loading a round 
into the chamber of a tank, which 
recoiled and hit his hand.  He 
described current left wrist pain 
if he tried to lift something over 
50 pounds.  In regard to his right 
elbow, the Veteran reported that, 
in service, he was helping change a 
track on a tank when another 
soldier accidentally hit him with a 
sledge hammer in 1992.  He 
described current "aches" in his 
right elbow if he "abuse[d] it a 
lot" and reported that the pain 
occurred about every three months.  
The pertinent impression was left 
wrist strain by Veteran's history 
with normal plain films and right 
elbow contusion by Veteran's 
history with large osteophyte noted 
on X-ray without evidence of 
previous fracture.    

•  On VA PTSD examination in June 
2007 the Veteran gave a history of 
injuring his right elbow working 
with a tank in service, and 
described right elbow pain due to 
this injury.  

•  On VA examination in March 2013, 
the examiner stated that the 
Veteran did not have nor had he 
ever had an elbow or forearm 
condition.  The Veteran reported 
being hit in the right elbow with a 
sledge hammer in 1987 when changing 
a track on a tank.  He reported 
that he was impacted by flare-ups 
in that lifting and carrying caused 
pain in the right elbow.  X-rays of 
the elbows revealed no acute 
fracture or dislocation, although 
there was calcific enthesopathy.  

•  In regard to the claimed wrist 
disorder, the March 2013 VA 
examiner also indicated that the 
Veteran did not have, nor had he 
ever had, a wrist condition.  The 
Veteran gave a history of injuring 
both wrists when changing a track 
in 1982.  He reported being seen at 
the local troop clinic.  He stated 
that he was impacted by flare-ups 
in that pushing up on his wrist 
caused pain.  X-rays of the wrists 
revealed no acute fracture or 
dislocation and negative ulnar 
variance.  

•  The March 2013 VA examiner 
indicated that she had been asked 
to provide an opinion as to, 
"Whether the joint pain, back, and 
neck had its onset during active 
service."  The examiner indicated 
by checked box that the claimed 
condition was at least as likely as 
not (50 percent or greater 
probability) incurred in or caused 
by the claimed in-service injury, 
event, or illness.  In providing a 
rationale for her opinion, she 
stated that review of the claim 
file indicated that the Veteran was 
seen for these conditions during 
military service and he did have 
some limited range of motion in his 
back and knees on examination.  The 
diagnostic studies justified his 
claimed conditions, other than the 
claimed conditions of the elbows 
and wrists, which were normal.  

The examiner is advised that the Veteran 
is competent to report injuring his 
elbows and wrists in service; however, 
while he has recently reported injuring 
his right elbow when he was hit with a 
sledge hammer in service, 
contemporaneous service treatment 
records document that his left elbow was 
injured in this manner during service.  
The examiner is also advised that the 
Veteran is competent to report symptoms 
of pain in his elbows and wrists.  

In rendering the requested opinion, the 
examiner must specifically consider and 
address the documented in-service 
injuries to the right arm and left elbow 
during service, as well as his May 2005 
report of injuring his left wrist around 
1991 in Kuwait.  

Left Foot

The examiner must provide an opinion as 
to whether any current disorders 
affecting the left foot, to include a 
calcaneal spur, metatarsalgia, DJD, 
and/or calcific enthesopathy, clearly 
and unmistakably preexisted his military 
service.  If so, the examiner should 
provide an opinion as to whether there 
is clear and unmistakable evidence that 
such disorder was not aggravated by 
service.  

If the examiner concludes that any 
current disorder affecting the left 
foot, to include a calcaneal spur, 
metatarsalgia, DJD, and/or calcific 
enthesopathy, did not preexist military 
service, she should provide an opinion 
as to whether it is at least as likely 
as not (50 percent or greater 
probability) that any such disorder had 
its clinical onset during active service 
or is related to any in-service disease, 
event, or injury.  

The examiner must also clearly address 
whether or not there are any symptoms 
related to the Veteran's complaints of 
left foot pain that cannot be attributed 
to a known diagnostic entity.  If there 
are symptoms of joint pain that cannot 
be attributed to a known diagnostic 
entity, the examiner should render an 
opinion as to whether it is at least as 
likely as not (50 percent or greater 
probability) that any such symptoms 
represent an objective indication of 
chronic disability resulting from an 
undiagnosed illness or a medically 
unexplained chronic multi-symptom 
illness related to the Veteran's Persian 
Gulf War service.

As indicated above, the examiner should 
review the record in conjunction with 
rendering the requested opinion; 
however, her attention is drawn to the 
following:

•  A June 1980 private treatment 
record reflects that the Veteran 
was seen with complaints of left 
foot pain following a twisting 
injury.  The assessment at that 
time as soft tissue injury of the 
lateral left foot below the ankle.  

•  In his April 1981 Report of 
Medical History at enlistment, the 
Veteran denied foot trouble and 
clinical evaluation of the feet on 
enlistment examination was normal.  

•  In his April 1993 Report of 
Medical History at separation, the 
Veteran reported foot trouble.  
Clinical evaluation of the lower 
extremities and feet on separation 
examination was normal.  

•  On VA Gulf War examination in 
May 2005, the Veteran described 
pain in the arches of both feet if 
he stood for long periods of time.  
X-rays of the feet revealed small 
calcaneal spurs on the right, but 
were otherwise negative.  

•  A May 2011 psychological 
evaluation obtained in conjunction 
with the Veteran's claim for SSA 
benefits reflects that the Veteran 
reported problems with his joints, 
including the feet and ankles.  He 
reported that he had tendonitis in 
his right foot and arthritis in 
both feet.  

•  An August 2011 VA nursing 
domiciliary note reflects that the 
Veteran described foot pain 
beginning in the military.  

•  On VA foot examination in March 
2013, the examiner noted that the 
Veteran had a foot condition, 
specifically, bilateral calcaneal 
spurs and bilateral metatarsalgia.  
The Veteran reported that he began 
having pain in his feet when 
walking on cobblestone in Germany.  
He reported being seen at the local 
troop clinic.  X-rays of the feet 
revealed mild DJD, plantar 
calcaneal spurs, and calcific 
enthesopathy, bilaterally.  

•  The March 2013 VA examiner 
indicated that she had been asked 
to provide an opinion as to, 
"Whether the joint pain, back, and 
neck had its onset during active 
service."  The examiner indicated 
by checked box that the claimed 
condition was at least as likely as 
not (50 percent or greater 
probability) incurred in or caused 
by the claimed in-service injury, 
event, or illness.  In providing a 
rationale for her opinion, she 
stated that review of the claim 
file indicated that the Veteran was 
seen for these conditions during 
military service and he did have 
some limited range of motion in his 
back and knees on examination.  The 
diagnostic studies justified his 
claimed conditions, other than the 
claimed conditions of the elbows 
and wrists, which were normal.  

In rendering the requested opinion, the 
examiner must specifically consider and 
address the June 1980 private treatment 
record documenting a soft tissue injury 
of the left foot.  The examiner must 
also consider and address the Veteran's 
August 2011 report of foot pain 
beginning in the military.  

A complete rationale for EACH opinion 
expressed MUST be provided.  

If further examination of the Veteran is 
deemed necessary, arrange for the 
Veteran to undergo VA examination(s) to 
obtain the above-noted opinions.  In 
conjunction with the examination, the 
claims folder must be made available to 
the examiner for review of the case.  A 
notation to the effect that this record 
review took place should be included in 
the report of the examiner.

All indicated tests and studies should 
be accomplished.  All examination 
findings, along with the complete 
rationale for all opinions expressed, 
should be set forth in the examination 
report.

5.  Next, review the claims file and 
ensure that all of the foregoing 
development actions have been conducted 
and completed in full.  If any 
development is incomplete, appropriate 
corrective action must be implemented.  
If any examination report does not 
include adequate responses to the 
specific opinions requested, it must be 
returned to the providing examiner for 
corrective action.

6.  Finally, after completing the 
requested actions, and any additional 
notification and/or development deemed 
warranted, readjudicate the claims on 
appeal in light of all pertinent 
evidence and legal authority.  If any 
benefit sought on appeal remains denied, 
furnish to the Veteran and his 
representative an appropriate SSOC that 
includes clear reasons and bases for all 
determinations, and afford them the 
appropriate time period for response 
before the claims file is returned to 
the Board for further appellate 
consideration.  

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

These claims 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).




______________________________________________
P.M. DILORENZO
Veterans Law Judge, Board of Veterans' Appeals



 Department of Veterans Affairs