Citation Nr: 1334531 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 10-18 359A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome, to include as secondary to a service-connected adjustment disorder with depressed and anxious mood with paranoid features and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for fibromyalgia, to include left and right side body pain, tight calves, sore and tight buttocks muscles. 3. Entitlement to service connection for memory loss. 4. Entitlement to service connection for C6-7 disc space narrowing with lower cervical spine uncalcified hypertrophy (claimed as a broken right collar bone with neck pain). 5. Entitlement to service connection for a left knee condition. 6. Entitlement to service connection for a left wrist fracture. 7. Entitlement to service connection for left wrist and hand, reflex sympathetic dystrophy; complex regional pain syndrome. 8. Entitlement to service connection for sleep apnea. 9. Entitlement to service connection for decreased sex drive; erectile dysfunction. 10. Entitlement to service connection for the residuals of a head injury. 11. Entitlement to service connection for myofascial pain syndrome. 12. Entitlement to an initial disability evaluation in excess of 30 percent for an adjustment disorder with depressed and anxious mood with paranoid features and PTSD. 13. Entitlement to an initial disability evaluation in excess of 10 percent for adhesive capsulitis axillary recess and small slap lesion (claimed as dislocated right shoulder with pinched nerve). 14. Entitlement to an initial disability evaluation in excess of 10 percent for a lumbar spine strain (claimed as a back condition and back strains). 15. Entitlement to an initial disability evaluation in excess of 10 percent for the residuals of left foot status post-fracture, first proximal phalanx (claimed as broken left foot with left foot and toe arthritis). 16. Entitlement to an initial disability evaluation in excess of 10 percent for right metatarsalgia and flat foot (claimed as broken right foot with arthritis). 17. Entitlement to an initial compensable disability evaluation for right eye twitching. 18. Entitlement to an initial compensable disability evaluation for allergic rhinitis (also claimed as head congestion, stuffy nose, sinus pressure, headaches and deviated septum). 19. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). 20. Entitlement to paragraph 30 benefits for left wrist and hand, reflex sympathetic dystrophy, complex regional pain syndrome. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD B. R. Mullins, Counsel INTRODUCTION The Veteran had active service from June 1970 to July 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The issues of entitlement to service connection for fibromyalgia, myofascial pain syndrome and decreased sex drive/erectile dysfunction, entitlement to increased disability evaluations for psychiatric disabilities, a right shoulder disability, a lumbar spine disability and bilateral disabilities of the feet, and entitlement to TDIU benefits, are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The Veteran does not suffer from a diagnosed disability of chronic fatigue syndrome that is separate and distinct from his impaired sleep related to his service-connected psychiatric disorders. 2. The Veteran has not been diagnosed with a disability manifested by memory loss. 3. The Veteran does not suffer from a cervical spine disability that manifested during, or as a result of, active military service. 4. The Veteran does not suffer from a chronic left knee disability that manifested during, or as a result of, active military service. 5. The Veteran does not suffer from the residuals of a left wrist fracture that manifested during, or as a result of, active military service, nor are any residuals caused by, or aggravated by, a service-connected disability. 6. The Veteran's reflex sympathetic dystrophy/complex regional pain syndrome manifested as a result of a non-service connected disability. 7. The Veteran's sleep apnea did not manifest during, or as a result of, active military service, nor is it secondary to a service-connected disability. 8. The Veteran has not been diagnosed with any chronic residuals associated with an in-service head injury. 9. The Veteran's right eye twitching has been manifested by intermittent symptoms of subjective twitching that is most appropriately characterized as mild. 10. The Veteran's allergic rhinitis has been manifested by bilateral nasal passage obstruction of 20 percent; it has not been manifested by obstruction of 50 percent or more on both sides, complete obstruction on one side or nasal polyps. 11. Benefits under Paragraph 30 are not warranted for left wrist and hand, reflex sympathetic dystrophy, complex regional pain syndrome, as this is not a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for chronic fatigue syndrome have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. The criteria for establishing entitlement to service connection for memory loss have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 3. The criteria for establishing entitlement to service connection for C6-7 disc space narrowing with lower cervical spine uncalcified hypertrophy have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 4. The criteria for establishing entitlement to service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 5. The criteria for establishing entitlement to service connection for the residuals of a left wrist fracture have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 6. The criteria for establishing entitlement to service connection for left wrist and hand, reflex sympathetic dystrophy; complex regional pain syndrome, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1151, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 7. The criteria for establishing entitlement to service connection for sleep apnea have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 8. The criteria for establishing entitlement to service connection for the residuals of a head injury have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 9. The criteria for establishing entitlement to a compensable disability evaluation for right eye twitching have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8103 (2013). 10. The criteria for establishing entitlement to a compensable disability evaluation for allergic rhinitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.97, Diagnostic Code 6522 (2013). 11. The criteria for establishing entitlement to paragraph 30 benefits for left wrist and hand, reflex sympathetic dystrophy, complex regional pain syndrome, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.30 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify VA has a duty to notify and assist veterans 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 Veteran 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 Veteran is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. 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. As for the Veteran's claims of entitlement to service connection, numerous letters sent to the Veteran throughout his claim have addressed all notice elements listed under 3.159(b)(1). Proper notice was also provided to the Veteran prior to the applicable initial RO decision. The letters informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. As for his claims for higher initial disability evaluations, these claims arise from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for these claims. Finally, a letter sent to the Veteran in November 2009 provided him with notice on how to establish a claim of entitlement to benefits under Paragraph 30. Regardless, this claim has been denied as a matter of law, as service connection is not established for this disability upon which these benefits have been claimed. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive the Board should deny the claim on the ground of the lack of legal merit or the lack of entitlement under the law); VAOPGCPREC 5-2004 (June 23, 2004) (VA is not required to provide notice of the information and evidence necessary to substantiate a claim where that claim cannot be substantiated because there is no legal basis for the claim or because undisputed facts render the claimant ineligible for the claimed benefit). Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA obtained the Veteran's service treatment records. Also, the Veteran received numerous VA examinations throughout the claims period for the disabilities being decided, and VA has obtained these records as well as the records of the Veteran's outpatient treatment with VA. Copies of multiple private treatment records have also been obtained. Significantly, neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the claim that has not yet been obtained. The Board recognizes that the Veteran has not been afforded a VA examination for his right eye twitching since April 2009 or his allergic rhinitis since June 2009. In Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992), the Court held that fulfillment of the VA's duty to assist included thorough and contemporaneous examination be provided when the record before the Board contained no evidence of the then-current level of disability. See also Caffrey v. Brown, 6 Vet. App. 377 (1994). However, the Board has not found this to mean that the Court has established a specific time limit beyond which a new examination is required. Reexaminations are required if the evidence indicates there has been a material change in a disability or that the current rating is incorrect. 38 C.F.R. § 3.327 (2013). In the present case, VA has received no medical evidence to suggest that either of these disabilities has worsened. The Veteran has also not alleged such a worsening, despite his multitude of personal statements. As such, there is nothing of record to suggest that the current disability evaluation may be incorrect and the Veteran has not been prejudiced by VA's failure to obtain a more recent examination. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Claims Relevant Laws and Regulations Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). To establish service connection, there must be: (1) a medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)). Where a veteran has served for 90 days or more during a period of war, or during peacetime service after January 1, 1947, and a chronic disorder, such as arthritis, becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309 (2013). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). A recent decision of the United States Court of Appeals for the Federal Circuit (Federal Circuit Court), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be 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. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Chronic Fatigue Syndrome The Veteran contends that he is entitled to service connection for chronic fatigue syndrome. However, the preponderance of the evidence of record demonstrates that the Veteran does not suffer from a disability characterized as chronic fatigue syndrome that is separate from symptomatology already associated with his service-connected psychiatric disabilities. As such, service connection is not warranted. The Veteran's service treatment records fail to reflect that he suffered from chronic fatigue syndrome or any associated symptomatology. Likewise, the Veteran's post-service medical records fail to reflect that he currently suffers from a disability characterized as chronic fatigue syndrome that is separate and distinct from symptomatology associated with his already service-connected psychiatric disabilities. According to an April 2009 VA examination report, the Veteran was claiming chronic fatigue syndrome as secondary to adhesive capsulitis axillary recess and small SLAP lesion of the right shoulder. The Veteran was also claiming irritable bowel syndrome as secondary to this disorder, but the issue of entitlement to service connection for irritable bowel syndrome was not appealed to the Board. According to the examiner, chronic fatigue syndrome was less likely as not secondary to or permanently aggravated by the right shoulder disorder. The examiner explained that following a search and review of medical resources, the examiner could find no evidence, research or evidence-based medical literature to support that chronic fatigue syndrome was due to, or caused by, or permanently aggravated by, any isolated joint conditions such as adhesive capsulitis or SLAP lesions of a joint. Another VA examination was performed in July 2010. After performing an evaluation, the examiner concluded that at least 6 of the 10 chronic fatigue syndrome diagnostic factors had not been met. The examiner opined that chronic fatigue syndrome was less likely as not caused by, or aggravated by, the Veteran's service-connected PTSD. The examiner explained that a review of the Veteran's history as well as his medical records indicated that he had been diagnosed with insomnia as well as obstructive sleep apnea. The examiner further noted that while the Veteran had been prescribed a CPAP device, he typically did not wear the device. The examiner opined, therefore, that the Veteran's lack of sleep due to insomnia, as well as the nonrestorative sleep due to his obstructive sleep apnea, were major contributors to his complains of fatigue. Given that he had other clinical conditions (specifically insomnia and obstructive sleep apnea) which likely resulted in his currently claimed fatigue, the Veteran did not meet the VA criteria for a diagnosis of chronic fatigue syndrome. Furthermore, if the Veteran's PTSD and/or adjustment disorder conditions were resulting or contributing to symptoms of fatigue, then the specific diagnostic entity of chronic fatigue would therefore be excluded. In other words, although PTSD and/or adjustment disorder may have symptoms that result in some degree of fatigue, this would be considered part of the symptom complex that is PTSD and would not, therefore, constitute the specific and separate diagnostic entity of chronic fatigue syndrome. An additional VA examination opinion was obtained in August 2011. This time, the examiner opined that it was less likely as not that the Veteran's chronic fatigue syndrome was caused by, or aggravated by, his service-connected adjustment disorder with depressed and anxious mood with paranoid features and PTSD associated with bilateral hearing loss. The same rationale noted in the July 2010 VA examination was again used - namely, that the Veteran did not meet the criteria for a separate diagnosis of chronic fatigue syndrome. The Board finds that the preponderance of the above evidence demonstrates that the Veteran is not entitled to service connection for chronic fatigue syndrome. There is no evidence of this disability during military service. Likewise, there is no evidence of a current diagnosis of chronic fatigue syndrome that is either related to military service or that is secondary to an already service-connected disability. As explained by the VA examiner of record, the Veteran suffers from insomnia related to his already service-connected psychiatric disabilities. He also suffers from sleep apnea, which as outlined below, is not related to service or a service-connected disability. The examiner explained that it is these conditions that result in the Veteran's day time fatigue. As such, there is no evidence of a separate disability characterized as chronic fatigue syndrome. The Board notes that the record contains a hand-written statement from a private physician dated February 2009. According to this physician, the Veteran was treated by him from July 1978 to December 2004. The physician indicated that medical records for the past 10 years were kept and were available. Prior records had been shredded. The physician reported that the Veteran suffered from chronic fatigue during his care. While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). The Board does not find this statement to be probative. A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The record does not contain actual evidence of treatment for chronic fatigue syndrome. Furthermore, subsequent medical examiners have explained that the Veteran's symptoms of fatigue are related to his service-connected psychiatric disabilities and nonservice-connected sleep apnea and are not associated with any independent disability. As such, the Board does not find the single notation of this private physician to represent an actual diagnosis of chronic fatigue syndrome. The Board recognizes that the Veteran believes he suffers from chronic fatigue syndrome as a result of his service-connected disabilities. However, the record contains no evidence to reflect that the Veteran has the requisite training or expertise to offer a medical opinion as complex as diagnosing himself with chronic fatigue syndrome and relating it to a specific etiological origin. As such, the Veteran's assertions are not competent and they fail to reflect that service connection for chronic fatigue syndrome is warranted. Finally, the record contains a statement from an individual purporting to have known the Veteran since 1995. According to this individual, the Veteran had been experiencing chronic fatigue syndrome since 1995. While the Board has reviewed this statement, it is of no probative value. There is nothing of record to suggest that this individual has the requisite training or expertise to diagnose the Veteran with any disability. As such, the Board does not find this statement to be evidence of an actual diagnosis. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for chronic fatigue syndrome must be denied. Memory Loss The Veteran also contends that he is entitled to service connection for memory loss. However, as outlined below, there is no competent evidence of the Veteran ever having been diagnosed with a disability manifested by memory loss. Rather, the record reflects that this is merely a symptom of the Veteran's already service-connected psychiatric disabilities. As such, service connection is not warranted. The Veteran's service treatment records are silent regarding treatment for or a diagnosis of a disability manifested by memory loss. Likewise, post-service treatment records fail to reflect that the Veteran has ever been diagnosed with a chronic disability associated with memory loss. According to a May 2008 VA treatment record, the Veteran's scores on immediate and delayed memory tasks, as well as attention and language tasks, were essentially within normal limits. A May 2008 VA psychiatric examination also found remote, recent and immediate memory to be normal. The Veteran was afforded a VA psychiatric examination in June 2009. Examination revealed the Veteran's remote, recent and immediate memory to again be normal. The examiner explained that while the Veteran may subjectively complain of memory problems, there was no objective evidence and his reports were merely subjective. The preponderance of the evidence of record demonstrates that service connection is not warranted for memory loss. There is no evidence of record to demonstrate that the Veteran has been diagnosed with a specific disability associated with memory loss. There must be a current diagnosis of a disorder for service connection to be granted. Hickson v. West, 12 Vet. App. 247, 252 (1999). Without a medical diagnosis of a disability associated with memory loss, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Rather, the evidence of record suggests that this is merely a symptom of his already service-connected psychiatric disabilities. The Board notes that the Veteran has asserted on multiple occasions that he suffers from memory loss as a result of exposure to jet fuel. Initially, the Veteran has failed to provide evidence in support of this theory. Furthermore, there is no evidence of a current memory loss disability, and as such, the merits of the Veteran's assertions need not be further considered. Finally, the Board is aware that the Veteran has submitted dozens of statements from himself describing when he forgot something, be it a church sermon, to turn off the water or where certain places are in his town. However, random incidents of lapses in memory fail to demonstrate that the Veteran suffers from a separate and unique disability manifested by memory loss. He has also submitted numerous lay statements from other purporting to know him, including his wife. Again, however, mere assertions of forgetfulness fail to reflect an actual diagnosis. As such, the lay evidence of record fails to demonstrate that service connection for a disability manifested by memory loss is warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for a disability manifested by memory loss must be denied. C6-7 Disc Space Narrowing The Veteran also contends that he is entitled to service connection for a disability of the neck. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran does not suffer from a chronic disability of the neck that manifested during, or as a result of, active military service. As such, service connection is not warranted. The Veteran's service treatment records fail to reflect that he suffered from a chronic disability of the neck during active military service. According to an October 1973 in-service treatment record, the Veteran was experiencing pain in his neck since 12:00 that day. He was deemed to be suffering from a moderate cervical spasm. This was several months after the Veteran injured his right shoulder in June 1973. However, there is no evidence that the Veteran received follow-up treatment for this condition or that it was associated with a chronic disability. An evaluation of the neck was also deemed to be normal during the Veteran's National Guard enlistment examination of August 1978, as well as a subsequent examination in April 1994. The record does contain a statement from an individual at RehabVisions dated February 1998. According to this statement, the Veteran had a diagnosis of cervical strain. It was noted that the Veteran reported falling on ice four to five years earlier and getting hit with a falling object on the right shoulder that dislocated in 1970. The Veteran reported that his pain was intermittent. A March 1998 record reflects a diagnosis of cervical disc syndrome with right shoulder and arm radiculopathy. The Veteran reported having neck pain on and off since 1994. Another record prepared by a physical therapist dated September 1999 indicates that the Veteran's pain began approximately 8 days earlier. The Veteran described a history of recurring neck pain that occurred approximately once per year. Examination revealed cervical flexion to be within normal limits, but cervical rotation and lateral flexion were decreased. No chronic disability was diagnosed at this time. An October 1999 follow-up note reflects that the Veteran suffered from a cervical strain and trapezius spasms. Following therapy, the Veteran was noted to have a full range of motion within normal limits that was pain free. The Veteran was afforded a VA examination of the cervical spine in October 2008. The Veteran reported that he first began having problems with his neck in 1971 after he hit his head. The Veteran reported at this time that his right shoulder injury did not begin until 1972. The examiner diagnosed the Veteran with a cervical strain with minimal degenerative changes (evidenced by X-ray). This was noted to result in no significant occupational effects. The examiner opined that it was less likely as not that this condition was caused by or a result of a right shoulder disability. The Veteran actually described the history of the neck condition beginning prior to the right shoulder injury. Furthermore, a review of the medical resources and literature failed to demonstrate any evidence of shoulder conditions such as those suffered by the Veteran resulting in any cervical spine disabilities. A September 2009 note from Heartland Chiropractic reflects a finding of right greater than left C6 to T4 paraspinal muscle spasm and decreased C7-T1 joint play. A January 2010 private chiropractic note reflects neck pain and spasm. Cervical range of motion was within normal limits. The Veteran was assessed as having diffuse cervicobrachial syndrome and cervical segmental/somatic dysfunction. According to a July 2010 record from Sawyer Chiropractic, the Veteran reported a muscle spasm in the upper back that had been more severe. Cervicobrachial syndrome was again diagnosed by the Heartland Chiropractic Clinic in July 2011. There was noted to be movement with moderate joint fixation. None of these records related these symptoms to military service or a service-connected disability. The preponderance of the above evidence demonstrates that the Veteran is not entitled to service connection for a cervical spine condition. There is no evidence of a chronic neck condition during active service. While the Veteran was seen on one occasion for complaints involving the neck, this appears to have been an acute and transitory condition as there was no follow-up treatment and evaluations of the neck performed during subsequent examinations were deemed to be normal. Post-service treatment records also fail to relate a currently diagnosed cervical spine disability to military service. In fact, in March 1998, the Veteran reported that this condition did not begin until 1994. While the Veteran would have been in the Air Force Reserves in 1994, the Veteran has not asserted that he suffered any injury during a period of Active Duty for Training (ACDUTRA) or Inactive Duty for Training (INADUCTRA), and there is nothing of record to suggest that any such injury occurred. Finally, the VA examiner of record opined that it was less likely than not that a cervical spine disability was secondary to a service-connected right shoulder disability. The record contains no competent evidence suggesting that a cervical spine disability manifested during, or as a result of, military service. As such, service connection is not warranted. The Board again recognizes that the Veteran believes he is entitled to service connection for a neck condition. He has provided numerous arguments, alleging that this condition arose as a result of an in-service head injury or that it is secondary to his service-connected disabilities. As for the Veteran's theory of entitlement on a secondary basis, the Board again notes that the record does not reflect any medical training or expertise on the part of the Veteran. As such, his conclusion that a neck condition is related to a service-connected disability is not competent evidence of etiology. Furthermore, the VA examiner of record specifically concluded that there was no basis for relating this condition to a right shoulder disability. Finally, as for the Veteran's report that this arose due to an in-service head injury, the Board does not find this assertion to be credible. The service treatment records reflect that the Veteran indeed suffered a laceration to the head during military service. However, as will be discussed in a later section, the evidence demonstrates that there was no serious injury incurred as a result of the head injury and there are no present residuals. As such, his claim of a chronic neck disability arising from this laceration is not credible. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for C6-7 disc space narrowing with lower cervical spine uncalcified hypertrophy must be denied. Left Knee Condition The Veteran also contends that he is entitled to service connection for a left knee condition. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran does not suffer from a chronic left knee disorder that manifested during, or as a result of, active military service. As such, service connection for a left knee condition is not warranted. As an initial matter, the Board notes that the Veteran's service treatment records are silent for complaints or treatment involving the left knee. An evaluation of the lower extremities was also deemed to be normal during the Veteran's August 1978 National Guard enlistment examination, and the Veteran denied having, or ever having had, a "trick" or locked knee or bone, joint or other deformity in his report of medical history associated with this examination. Subsequent National Guard records also fail to reflect that the Veteran suffered any disease or injury involving the knee during a period of ACDUTRA or INACDUTRA. Post-service treatment records also fail to reflect that the Veteran suffers from a chronic disability of the left knee that manifested during, or as a result of, active military service. The Veteran was afforded a VA examination of the left knee in October 2012. X-rays revealed a normal left knee. The examiner opined that the Veteran's claimed left knee strain was less likely as not incurred in or caused by duties associated with the Veteran's military occupation as a traffic management supervisor. The examiner explained that the Veteran did not have any medical treatment while in service or since service and that he also did not have any current degenerative joint disease or traumatic findings. The preponderance of the above evidence demonstrates that the Veteran is not entitled to service connection for a left knee condition. The VA examiner concluded that the left knee was normal. While there was notation of a left knee strain, it was less likely than not that this was incurred during, or as a result of, military service. The examiner explained that in addition to no in-service medical treatment, there were no current degenerative or traumatic findings. Finally, the record contains no competent evidence relating any currently diagnosed left knee condition to a period of military service. As such, service connection for a left knee condition is not warranted. The Board again recognizes that the Veteran believes he suffers from a left knee disability that manifested as a result of military service. However, the Veteran is not competent to diagnose himself with any specific disability, nor is he competent to relate a current knee strain to active service decades earlier. As such, the Veteran's assertions fail to reflect that service connection for a left knee condition is warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for a left knee condition must be denied. Left Wrist Fracture/Complex Regional Pain Syndrome The Veteran also contends that he is entitled to service connection for a left wrist fracture, as well as left wrist and hand, reflex sympathetic dystrophy; complex regional pain syndrome. Specifically, he has argued that this condition initially arose as secondary to his service-connected PTSD. He has also argued that if not for improper VA treatment, he would not have incurred chronic impairment in his wrist and hand. However, as outlined below, the preponderance of the evidence of record reflects that this condition arose as due to a fall and that there is no evidence of the condition arising due to carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA. Initially, the Board notes that there is no evidence of a left wrist fracture during military service. In addition, the Veteran's August 1978 National Guard enlistment examination reflects that an evaluation of the upper extremities was deemed to be normal. As such, there is no evidence of an in-service event or injury associated with the left wrist. Rather, the Veteran has asserted that his left wrist fracture is secondary to his service-connected psychiatric disorders. The preponderance of the evidence of record contradicts this assertion. In a number of statements, the Veteran has alleged that due to his PTSD, he is unable to think clearly and he did not notice a dog, resulting in his original injury. However, an August 2009 VA treatment record clearly reflects that the Veteran was working outside of his home the previous night. It was dark outside at this time and a dog was walking around, and the Veteran lost his footing. He subsequently fell on his outstretched left hand and he then heard a crunching sound with immediate pain. There is nothing in this record to suggest any relationship to a service-connected disability and the Veteran made no allegation of being distracted at the time of treatment. Subsequent follow-up treatment notes also fail to relate this condition to a service-connected disability. The Board notes that the Veteran has since alleged he was startled by the dog as a result of his psychiatric disorders. While the Veteran is competent to offer this assertion, the Board does not find it to be credible. Treatment records from the time of injury reflect that the Veteran was working in his yard in the dark when he lost his footing and fell over a dog. The Veteran did not allege that he was startled by a dog at any time upon receiving initial treatment. His subsequent allegations of being startled due to his nerves are not credible. In fact, VA afforded the Veteran a VA examination in September 2009. The examiner noted the Veteran's history of falling over his dog. The examiner subsequently opined that the Veteran's fracture was less likely than not due to or aggravated by his service-connected adjustment disorder with depressed and anxious mood with paranoid features and PTSD. Medical records from the time of the injury did not reveal any mention of fear, PTSD, paranoia, depression or anxious behaviors causing or aggravating the Veteran's fall. The Veteran specifically reported to the examiner that he was walking down his steps outside of his home at night and his son's dog was on the sidewalk by the street and he did not see the dog. Therefore, based on the evidence of record, the Veteran's statements and X-ray evidence, the Veteran's fall resulting in a left distal radius fracture was less likely than not due to or aggravated by his service-connected conditions. The Board notes that the record does contain a statement dated October 2009 from a Licensed Clinical Social Worker/Licensed Massage Therapist with the initials K.L.R. According to this individual, the Veteran's "post traumatic symptoms probably contributed to his injury, and are interfering with his recovery as well." While the Board has considered this statement, it is of no probative value. As an initial matter, there is nothing of record to suggest that this individual has the requisite training or expertise to offer a medical opinion regarding the effects of a psychiatric disorder such as PTSD. The statement itself notes that the Veteran was seen by her for "therapeutic bodywork." There is no evidence of psychiatric training or expertise. Furthermore, this individual did not provide any discussion as to how she came to the conclusion that PTSD "probably" led to the Veteran's fall, aside to note that it has resulted in symptoms such as sleep difficulties and social withdrawal. Due to this individual's lack of psychiatric training and limited discussion in support of a medical opinion, the Board does not find the statement to be probative. Finally, in November 2009, the Veteran asserted that his wife informed him that he broke his left wrist while stationed in the Philippines between 1974 and 1976. However, there is no documentation of such an injury anywhere in the Veteran's service treatment records. An evaluation of the upper extremities was also deemed to be normal upon evaluation in August 1978. As such, the Board finds the Veteran's recount of what his wife remembered from 40 years earlier to be of little probative value, as there is nothing of record to support this assertion. In summary, there is no evidence of a left wrist fracture in service. The evidence of record clearly reflects that while working in his yard in the dark with a dog present, the Veteran lost his footing and suffered a left wrist fracture. There is no probative evidence of record suggesting any relationship between this fall and a service-connected disability. The Veteran is asking the Board to make a very speculative conclusion - in essence, the only reason he would possibly have fallen is due to a disability such as PTSD. The Board is not persuaded by this argument and service connection on a direct or secondary basis is not warranted. The Board recognizes that the Veteran asserted in a statement received in July 2007 that he broke his wrist during military service. However, a review of the evidence of record in its entirety reflects that the Veteran was referring to his right wrist at this time. A claim of service connection for a left wrist disability was not received until several years later after the Veteran fractured the left wrist in August 2009. Regarding the Veteran's assertion that this condition arose as due to carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA, the Board finds no competent evidence in support of this assertion. When a Veteran suffers an injury or an aggravation of an injury resulting in additional disability or death as the result of VA training, hospitalization, medical or surgical treatment, or an examination furnished by the VA, disability compensation shall be awarded in the same manner as if such disability or death were service connected. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. Amendments to 38 U.S.C.A. § 1151 made by Public Law 104-204 require a showing not only that the VA treatment in question resulted in additional disability but also that the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability was an event which was not reasonably foreseeable. Those amendments apply to claims for compensation under 38 U.S.C.A. § 1151 which were filed on or after October 1, 1997. VAOPGCPREC 40-97, 63 Fed. Reg. 31263 (1998). Therefore, as the Veteran's claim was received well after October 1997, this claim must be decided under the current, post- October 1, 1997 version of 38 U.S.C.A. § 1151, as enacted in Public Law No. 104-204. In determining whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the Veteran's condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the Veteran's additional disability. Merely showing that a Veteran received care or treatment and that the Veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2) (2012). Whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). In many statements, including a January 2012 statement, the Veteran asserted that he shattered his left wrist in August 2009 because of his PTSD and anxiety. The Veteran asserted that it took VA 6 attempts to repair the damage that he caused to his wrist and that it was still tight and stiff. The Veteran has alleged malpractice on the part of VA claiming that if surgery had been performed he would not currently suffer from residuals, including complex regional pain syndrome. VA has received no credible evidence in support of the Veteran's assertion. Furthermore, he has provided no evidence that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused his additional disability. For this to be established, it must be shown that the hospital care or medical or surgical treatment caused the Veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the Veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1) (2012). The record contains no evidence of such fault on the part of VA, and according to the December 2010 VA examination report, the Veteran received appropriate care and treatment with regard to his August 2009 injury. The examiner explained that there was no evidence of any carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing medical treatment. The Veteran's complex regional pain syndrome was at least as likely as not due to the inciting event or injury (left wrist fracture). The record also contains a VA examination dated January 2011. The examiner opined that the Veteran's current left wrist and hand reflex sympathetic dystrophy was not due to any carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing care relative to the Veteran' left wrist fracture. The examiner explained that the record reflected the Veteran sustained a fracture in August 2009. The Veteran was subsequently placed in a splint and he returned the following day for reevaluation. He then underwent a closed reduction of the fracture 2 days after the incident and was again placed in a splint. He was seen four days later and placed in a short arm cast. The Veteran was then seen in September with complaints of some pain and paresthesias, and following assessment, he underwent a cast removal and a short arm cast was reapplied by the orthopedic service. Additional complaints of pain were noted shortly thereafter and the Veteran's cast was bivalved, resulting in some relief. Four days later a diagnosis of reflex sympathetic dystrophy was noted. The examiner concluded that this condition arose as a result of the Veteran's initial fracture of August 2009. The Veteran received appropriate treatment for this condition and CRPS can occur following relatively minor instances. As such, the fracture sustained by the Veteran would certainly be sufficient to result in the development of CRPS. Therefore, the examiner concluded that the Veteran received appropriate care and treatment with regard to the injury that occurred in August 2009 and there was no evidence of any carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing medical treatment. Therefore, benefits under 38 U.S.C. § 1151 are not warranted. Finally, the Veteran has asserted that his complex regional pain syndrome is secondary to his service-connected PTSD. However, a VA examiner opined in November 2009 that it was less likely as not that this condition was due to, or a result of, or aggravated by, his service-connected PTSD. The examiner explained that a review of the evidence of record reflected that the Veteran sustained a fracture to the left wrist in August of 2009. This resulted in a decreased range of motion and persistent pain. The Veteran has since undergone significant physical and occupational therapy for the condition and a diagnosis of complex regional pain syndrome/reflex synthetic dystrophy of the left wrist and hand has been considered. The examiner also reviewed medical resources and literature regarding these conditions and was unable to find any medical basis to support that complex regional pain syndrome was due to, or a result of, or aggravated by, PTSD. Although the precise cause and pathophysiology of this condition was not fully understood, the examiner opined that it was less likely as not that the Veteran's complex regional pain syndrome was due to, a result of or aggravated by his service-connected PTSD. In summary, the Veteran has asserted multiple theories of causation for why he believes his initial left wrist fracture and his current complex regional pain syndrome should be service-connected. However, there is no evidence of in-service causation, and the preponderance of the evidence of record demonstrates that this injury arose due to an accident of the Veteran and not due to any service-connected disability. Furthermore, there is no evidence of any carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing medical treatment. As such, the preponderance of the evidence of record is against the claims of entitlement to service connection for the residuals of a left wrist fracture and complex regional pain syndrome, and as such, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The claims must be denied. Sleep Apnea The Veteran also contends that he is entitled to service connection for sleep apnea. Specifically, the Veteran has argued that this disability is secondary to his service-connected psychiatric disorders. However, as outlined below, the competent evidence of record fails to relate the Veteran's sleep apnea to either a service-connected disability or military service. As such, service connection is not warranted. The Veteran's service treatment records fail to reflect that he suffered from sleep apnea or any associated symptomatology during his active military service. There is no mention of such a condition in his Reserve enlistment examination and the Veteran has not alleged that this condition arose during a period of active duty. Post-service treatment records also fail to relate this condition to military service or a service-connected disability. The record contains a VA polysomnogram report dated January 2009. Testing revealed the presence of severe obstructive sleep apnea. No opinion was offered regarding the etiology of this condition. A January 2009 VA treatment note also reflects complaints of nocturnal myclonic jerks. A private treatment note dated April 2009 also indicates that the Veteran was unable to use his sleep machine and that he was unable to breathe through his nose due to a deviated septum. The Veteran also underwent a VA examination in June 2009. The examiner noted that the Veteran was diagnosed with sleep apnea in December of the previous year (according to the Veteran). A note from the Veteran's doctor did reflect a diagnosis of "severe sleep apnea." It was noted that the Veteran jerked and flailed a lot while sleeping and that the Veteran's wife slept on the couch. The examiner opined that it was less likely as not that the Veteran's sleep apnea was due to his service-connected PTSD. The examiner explained that sleep apnea is a condition caused by either an anatomical blockage in the posterior pharynx causing obstruction of the airway when a person is sleeping or by a malfunction in the brainstem controlling respiratory patterns. This Veteran's sleep apnea was deemed to have been of the obstructive variety, as evidenced by the prescribed CPAP machine. There is no medical evidence, according to the examiner, available to support a causal relationship between PTSD and sleep apnea of the Veteran's type. The preponderance of the above evidence demonstrates that service connection for sleep apnea is not warranted. There is no evidence of this disability during active duty and there is no competent evidence of record relating this condition to military service. Furthermore, there is no competent evidence suggesting any link between sleep apnea and a service-connected disability. Rather, the June 2009 VA examiner explained that there was no medical evidence to support the Veteran's asserted causal relationship between sleep apnea and PTSD. As such, service connection for sleep apnea is not warranted. The Board recognizes that the Veteran believes his sleep apnea is associated with his service-connected psychiatric disorders. Again, however, the Veteran is not competent to offer such a complex medical opinion. In support of his conclusion, the Veteran submitted an article in March 2013. However, this article suggested that sleep apnea often results in PTSD due to impaired sleep. The article did not suggest that PTSD resulted in sleep apnea. The Veteran also submitted an article from the Internet suggesting that mild head injuries could increase a person's risk of developing a sleeping disorder. However, the Board does not find this article applicable to the Veteran's claim. As will be discussed in the subsequent section, there is no evidence of a head injury in this case aside from a "minute" laceration incurred in military service. This was treated and resulted in no current residuals. As such, the Veteran's argument that his sleep apnea may be related to a head injury is without merit. Finally, the Board recognizes that a March 2013 statement prepared by a VA physician indicated that PTSD did result in a general decline in health. The physician stated that it would be hard to establish that the Veteran's insomnia was due to a condition other than his mental disorders, but the physician went on to state that the Veteran had a "reasonable claim" that his mental disorders likely impacted his general health, including the presence of sleep apnea. While the Board has considered this article, it finds the opinion of the June 2009 VA examiner to be more probative. The examiner discussed the Veteran's specific type of sleep apnea and explained in detail while such a condition would not caused by or aggravated by a psychiatric disorder. The March 2013 physician, however, merely alleged that the Veteran's claim was reasonable and that there could be some association. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for sleep apnea must be denied. Residuals of a Head Injury Finally, the Veteran also contends that he is entitled to service connection for the residuals of a head injury. However, as outlined below, there is no competent evidence of record of any current disability associated with an in-service head injury. As such, service connection is not warranted. The record reflects that the Veteran was treated in April 1971 for a "minute laceration of the forehead." There is no further evidence of head trauma, and an examination performed in November 1977 revealed the head to be normal. The Veteran indicated in an August 1978 examination report that he was in good health and was also not taking any medications. He also denied having, or ever having had, suffered from a head injury. An evaluation of the head was also deemed normal at this time. The Veteran also denied ever having suffered a head injury in reports of medical history associated with July 1986, March 1990 and April 1994 examinations. Post-service treatment records reflect no treatment for or diagnosis of any residuals of an in-service head injury. The Veteran was afforded a VA examination for his alleged condition in September 2007. The examiner noted that while the Veteran endorsed a "major" laceration during service, he was unable to ascertain any suturing or other primary repair being required. While the Veteran described incidents of forgetfulness and memory problems over the years, there was no obvious memory impairment. There was no indication either by the Veteran's verbal history or by a review of the service medical records of a traumatic closed head injury causing any neurological deficits or loss of consciousness. The Veteran was diagnosed as status post laceration to the head, healed. This resulted in no significant occupational effects or effects on usual daily activities. The preponderance of the above evidence demonstrates that the Veteran is not entitled to service connection for the residuals of a head injury. Service treatment records reveal a laceration to the head. This was treated and there is no evidence of any follow-up treatment or chronic residuals. The Veteran himself repeatedly denied having ever suffered from a head injury in numerous subsequent examinations. Post-service treatment records reflect no diagnosis or treatment for a chronic head injury associated with service, and the September 2007 VA examiner was unable to find any evidence of a significant in-service head injury or any current residuals. As such, the preponderance of the evidence of record demonstrates that service connection for the residuals of a head injury is not warranted. The Board recognizes that the Veteran believes he is entitled to service connection for the residuals of a head injury. He has described an incident where he was being chased in service and hid under a trailer. He subsequently rose and struck his head. The Board is not questioning this event. However, there is simply no evidence of any chronic residual resulting from said incident. The Board is not disputing that the Veteran suffered a laceration during service. However, the evidence demonstrates that this injury was not significant and it resolved upon treatment. There is no evidence of any chronic residual associated with this event, and as such, the Veteran's testimony fails to reflect that he is entitled to service connection. Furthermore, the Veteran's more recent assertion of a major head injury is not credible, as he himself repeatedly denied ever having suffered a head injury throughout his service with the Air Force Reserve. The Veteran also submitted an article related to postconcussive syndrome and traumatic brain injury. While the Board has reviewed this article, it is of no relevance to the Veteran's claim. There is no competent and credible evidence of a head injury in service that resulted in any chronic residuals, to include postconcussive syndrome or a traumatic brain injury. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for the residuals of a head injury must be denied. Increased Rating Claims Relevant Laws and Regulations Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings will be applied, the higher rating will be assigned if the disability picture more closely approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7 (2011). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2 (2011). As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, in Fenderson v. West, 12 Vet. App. 119, 126 (1999), the Court noted that where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" is required. Right Eye Twitching The Veteran contends that he is entitled to a compensable disability evaluation for twitching of the right eye. For historical purposes, he was originally granted service connection for right eye twitching in a February 2008 rating decision. A noncompensable (0 percent) disability evaluation was assigned under Diagnostic Code 8103, effective as of December 14, 2007. According to a December 2007 VA examination report, the Veteran suffered from intermittent right eye twitching since 1980. This occurred approximately 3 to 4 days concurrently every 1 to 2 months. In January 2008, the Veteran underwent an additional VA examination for this condition. It was determined that this was not secondary to a report traumatic brain injury, as there was no evidence of twitching within a decade of the reported event. It was the examiner's opinion that PTSD appeared to be the primary causative etiology for the subjectively reported lid twitching. In the absence of PTSD, it was unlikely that this twitching would persist. The Veteran was afforded another VA examination for this condition in May 2008. The Veteran reported right eye twitching for the past 8 months. The Veteran reported that his twitching occurred between 0 and 2 times per day. The condition was noted to be intermittent with remissions. It was noted that eyelid twitching was not observed upon examination and that there was no visual disability due to the Veteran's lid twitching. It was felt that this was most likely associated with PTSD and there was no clear evidence of this being related to a reported head injury. Rather, it was most consistent with benign lid myokymia which can be exacerbated by stress, anxiety, lack of sleep, dry eye and caffeine. The Veteran underwent another VA examination of the right eye in April 2009. The Veteran reported right eye twitching for the last two years occurring two to three times per week when he would get nervous. These episodes would last for approximately 30 minutes. The Veteran described it as an annoyance but denied any actual effect on his daily activities. The examiner noted that there was no twitching evident on examination and the condition was stable, requiring no treatment. The Veteran was diagnosed with a history of intermittent right eye twitching. An additional VA examination was provided in August 2011. It was noted that although the Veteran's eyelid twitching had never been observed in multiple examinations, it was as likely as not caused by his adjustment disorder. The examiner stressed that the Veteran had clearly stated to previous examiners that this condition was of minimal impact on his activities of daily living. The preponderance of the above evidence demonstrates that a compensable disability evaluation is not warranted for right eye twitching at any time during the pendency of this claim. Under Diagnostic Code 8103, a compensable disability evaluation of 10 percent is warranted when there is evidence of a convulsive tic that is "moderate" in severity. 38 C.F.R. § 4.124a. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6 (2013). In the present case, there is evidence of a tic occurring two to three times per week and only lasting for approximately 30 minutes. The Veteran himself denied any functional impact as a result of this tic, instead referring to it as an annoyance. As such, his tic has most appropriately been characterized as "mild" rather than as "moderate" throughout the pendency of this claim. The Board recognizes that the Veteran thinks he is entitled to a compensable disability evaluation for his right eye twitching. He has submitted numerous statements describing varying information for the frequency and length of his eye twitching. However, he has still failed to provide VA with any evidence to demonstrate any actual functional impact resulting from this condition. As such, there is no evidence of record to suggest that the twitching of the Veteran's right eye should be viewed as "moderate" rather than as "mild" at any time during the pendency of this claim. Finally, in a February 2009 statement, the Veteran asserted that he was in fact entitled to a 30 percent evaluation. It is unclear what evidence the Veteran was relying on when offering this assertion, as he has not provided any medical or lay evidence in support of this assertion. Under Diagnostic Code 8103, a 30 percent evaluation is warranted when there is evidence of a "severe" convulsive tic. In his February 2009 statement, the Veteran only reported "off and on" twitching. It was also noted during his April 2009 examination report that the twitching would only occur two to three times per week for approximately 30 minutes. The Veteran has provided VA with no subsequent evidence, lay or otherwise, to suggest a worsening of this disability. As such, there is no basis upon which to characterize the Veteran's right eye twitch as "severe." Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The preponderance of the evidence is against the appellant's claim of entitlement to service connection for hearing loss. The claim must be denied. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In this regard, to accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court specified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. VA's General Counsel has stated that consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular Veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that Veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extraschedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board is aware of the Veteran's complaints as to the effects of his service-connected right eye twitching on his activities of work and daily living. In the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. In this respect, the Veteran complains of intermittent twitching of the eye that does not impact his activities of daily living. His noncompensable rating contemplates this degree of impairment (a mild tic). In short, the Board finds that the assigned schedular evaluation is adequate. As such, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. 111, 114-15 (2008). Allergic Rhinitis The Veteran also contends that he is entitled to a compensable disability evaluation for his service-connected allergic rhinitis. For historical purposes, service connection was originally established for this condition in a February 2009 rating decision. A noncompensable disability evaluation was assigned under Diagnostic Code 6522, effective as of October 6, 2008. The Veteran was afforded a VA examination for this condition in November 2008. The Veteran described symptoms of nasal congestion and sinus tenderness. There was no breathing difficulty, however. Examination revealed no nasal obstruction and no nasal polyps. It was noted that the Veteran was currently employed and that this condition resulted in no significant occupational effects. The Veteran underwent another VA examination in June 2009. The Veteran complained of nasal obstruction all of the time. He reports that he was told by an ENT specialist that he needed to fix his deviated septum. There was no nasal discharge upon examination. The Veteran took no oral medications and could not identify any exacerbating factors. Rather, he simply said it was "bad all the time." The Veteran endorsed some postnasal drip and coughing occasionally because of this. Examination revealed nasal obstruction of 20 percent on both sides. There was no evidence of nasal polyps. The examiner diagnosed the Veteran with chronic nasal congestion and rhinitis, resulting in no significant occupational effects. The preponderance of the above evidence demonstrates that the Veteran is not entitled to a compensable disability evaluation for his service-connected allergic rhinitis. Under Diagnostic Code 6522, a 10 percent rating is warranted when there is evidence of allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97. The highest schedular evaluation of 30 percent is warranted when there is evidence of polyps. Id. According to the June 2009 VA examination report, there was only 20 percent nasal obstruction, bilaterally. There was no evidence of nasal polyps either. As such, the Veteran did not meet the criteria for a compensable disability evaluation at this time. The Veteran has not submitted any other lay statement indicating an increase in severity in this condition and there is no further medical evidence to suggest that the Veteran's allergic rhinitis has been of sufficient severity to warrant a compensable disability evaluation at any time during the pendency of this claim. The Board recognizes that the Veteran believes he is entitled to a compensable evaluation for his service-connected allergic rhinitis. However, the Veteran has not provided VA with any evidence or statement to demonstrate that he is entitled to a higher schedular rating. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to a compensable disability evaluation for allergic rhinitis must be denied. The Board has again considered whether referral for an extraschedular rating is warranted in this case. The Board notes the Veteran's complaints as to the effects of his service-connected allergic rhinitis on his activities of work and daily living. However, in the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. In this respect, the Veteran complains of a stuffed up nose and drainage. His noncompensable rating contemplates this degree of impairment. In short, the Board finds that the assigned schedular evaluation is adequate. As such, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. 111, 114-15 (2008). Paragraph 30 Benefits Lastly, the Veteran has asserted that he is entitled to a temporary total disability evaluation under paragraph 30 for his left wrist and hand, reflex sympathetic dystrophy, complex regional pain syndrome. A temporary total disability rating for convalescence purposes will be assigned, for up to three months, without regard to other provisions of the Schedule, when it is established that treatment of a service-connected disability results in: (1) Surgery necessitating at least one month of convalescence, (2) Surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body case, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight bearing prohibited), or (3) Immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30 (2012). In the present case, the Veteran is not service-connected for a disability of the left wrist or hand. The law is clear that in order to get a temporary total evaluation for convalescence, it must be based on a service-connected disability. Id. Accordingly, this claim is denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). ORDER The claim of entitlement to service connection for chronic fatigue syndrome is denied. The claim of entitlement to service connection for memory loss is denied. The claim of entitlement to service connection for C6-7 disc space narrowing with lower cervical spine uncalcified hypertrophy is denied. The claim of entitlement to service connection for a left knee condition is denied. The claim of entitlement to service connection for the residuals of a left wrist fracture is denied. The claim of entitlement to service connection for complex regional pain syndrome of the left wrist/hand is denied. The claim of entitlement to service connection for sleep apnea is denied. The claim of entitlement to service connection for the residuals of a head injury is denied. The claim of entitlement to a compensable disability evaluation for right eye twitching is denied. The claim of entitlement to a compensable disability evaluation for allergic rhinitis is denied. The claim of entitlement to a temporary total rating under the provisions of 38 C.F.R. 4.30, based on convalescence following the repair of a left wrist injury, is denied. REMAND Fibromyalgia The Veteran also contends that he is entitled to service connection for fibromyalgia and myofascial pain syndrome. Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the appellant's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that it is presently unclear whether the Veteran does or does not suffer from fibromyalgia and/or myofascial pain syndrome. According to an October 2008 private treatment record signed by an anesthesiologist with the initials J.E.C., the Veteran was suffering from myofascial pain and fibromyalgia. It is unclear whether these diagnoses were based on an actual examination or merely reported symptoms and/or history. In addition, the record contains a poorly photocopied document that appears to note fibromyalgia. Regrettably, it is unclear whether this is an actual diagnosis or merely an assessment. Furthermore, the date on the document is wholly illegible. Finally, a January 2009 VA polysonmograph report notes a history of fibromyalgia and myofascial pain syndrome. The Veteran has also reported a history of muscle tightness, including an October 2010 VA treatment record in which he described tight hamstrings. An August 2010 statement from a private anesthesiologist also notes that there was evidence in the literature that fibromyalgia can be initiated with traumatic injury causing chronic pain. In contrast, however, a June 2009 VA examination report notes that while the Veteran was reportedly diagnosed with fibromyalgia in 1978, this diagnosis was not confirmed in the records and the Veteran was not being actively treated for this condition. The examiner concluded that the Veteran's description of his chronic pain condition was not consistent with fibromyalgia and it was consistent with residual/chronic pain from a distant shoulder injury. The Veteran also suffered from chronic back pain. However, it was not consistent with fibromyalgia either. The examiner was unable to substantiate the diagnosis by reviewing the primary care physician's records as there existed no diagnosis of fibromyalgia. Similarly, a July 2010 VA examiner opined that it was less likely as not that fibromyalgia was caused by, or aggravated by, the Veteran's service-connected PTSD. The examiner noted that a review of the Veteran's medical records, as documented in the VA system, did not indicate that he had been specifically diagnosed or received treatment for fibromyalgia. Regardless, a review of the medical literature did not provide a medical basis to support that PTSD caused or served as the etiologic agent regarding fibromyalgia. The examiner noted that while some studies had indicated an association of fibromyalgia in individuals with PTSD, there was no medical support or evidence-based conclusions which demonstrated that PTSD was actually causative of fibromyalgia. Furthermore, in this Veteran's case, the examiner could not find any medical basis to support that any fibromyalgia that may have been diagnosed had been permanently aggravated or aggravated beyond a normal progression due to PTSD. Therefore, the examiner opined that any fibromyalgia or fibromyalgia like symptoms that the Veteran may experience would likely have presented and manifested independent of any service-connected PTSD. The Veteran was afforded an additional VA examination in July 2011. The Veteran reported that early in the 1970s he developed fairly widespread symptoms of pain, shakiness, tremblingness, insomnia, restless legs and episodes of abdominal cramping with diarrhea. In 1972, the Veteran dislocated his right shoulder. He reported that he then started developing right shoulder, neck and low back pain in the late 1970s or early 1980s. The examiner reviewed the evidence of record and was unable to find any record to suggest significant systemic widespread muscle aches and pains that would be consistent with the diagnosis of fibromyalgia at that particular time. There was also no such diagnosis made in the medical record. Upon examination, it was determined that the Veteran had a clinical pattern of chronic musculoskeletal pain syndrome which was more diffuse than one would see in either fibromyalgia or myofascial pain designations. However, the pathophysiology and clinical significance of all three entities (chronic musculoskeletal pain syndrome, fibromyalgia and myofascial pain syndrome) were all identical. The examiner concluded that the Veteran's current chronic musculoskeletal pain syndrome was not directly caused by his service-connected adhesive capsulitis and associated lesions of the shoulder or his right metatarsalgia or flat foot conditions or the lumbar spine strain. This opinion was based on the time course of the symptoms that were detailed both by the Veteran and by the available service records. The examiner conceded that any patient with diffuse chronic musculoskeletal pain syndrome (myofascial pain syndrome) did have an aggravation of those symptoms with secondary forms of traumatic or localized musculoskeletal problems. Thus, his chronic musculoskeletal pain could be aggravated by his adhesive capsulitis and, in particular, the traumatic events and recovery that occurred to his fracture on the left upper extremity with resultant complex regional pain syndrome. This opinion was noted to be based on standard literature available and rheumatological testing. Finally, the examiner concluded that while the Veteran's chronic musculoskeletal pain syndrome was certainly aggravated by any other persistent traumatic mechanical musculoskeletal events, it was impossible to fully determine what portion of his current symptom complex is made worse by that association. It would be reasonable to assume that a minority of his current symptom complex was due to any aggravation from the associated events that occurred in 2009. In light of the above, it is presently unclear whether the Veteran suffers from fibromyalgia, myofascial pain syndrome or any distinct disability associated with his complaints of pain (that are not associated with pain merely stemming from an already service-connected disability). As such, the Veteran should be scheduled for an additional VA examination to clarify whether he suffers from any disability associated with pain that is separate and distinct from pain merely arising from an already service-connected disability (such as back pain or right shoulder pain). In formulating an opinion, the examiner should specifically take into consideration the evidence of record diagnosing the Veteran with fibromyalgia and/or myofascial pain syndrome. If any such disability is diagnosed, the examiner should opine as to whether it is at least as likely as not that this disability(s) manifested during, or as a result of, active military service. If not, then the examiner should opine as to whether it is at least as likely as not that this disability(s) was either caused by or permanently aggravated by any of the Veteran's service-connected disabilities. Increased Rating Claims The Veteran also contends that he is entitled to increased disability evaluations for a number of disabilities, including adjustment disorder with depressed and anxious mood with paranoid features and PTSD, adhesive capsulitis axillary recess and small slap lesion (claimed as a right shoulder with pinched nerve), a lumbar spine strain, the residuals of a left foot fracture, first proximal phalanx, and right metatarsalgia. Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the appellant's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Regarding the Veteran's claim for a higher rating for his psychiatric disability, he was last afforded a VA examination for his service-connected psychiatric disabilities in July 2011. Since this examination, the Veteran has submitted a vast number of personal statements describing his psychiatric symptomatology, including a statement from March 2013 in which he asserted that his PTSD was best characterized as "moderate severe." He also endorsed symptomatology such as little social life, feelings of confusion, forgetfulness and hypervigilence. He also indicated in another March 2013 statement that his depression had increased. In an October 2012 statement, the Veteran also endorsed waking up 2 to 3 times per night with nightmares and panic attacks occurring once or twice per day. Finally, the Veteran's attorney argued in a July 2013 statement that a higher rating was warranted because the Veteran had symptomatology such as memory loss, serious sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. The attorney also noted GAF scores consistently below 60, as well as obsessional rituals and a difficulty in adapting to stressful circumstances. The duty to conduct a contemporaneous examination is triggered when the evidence indicates that there has been a material change in disability or that the currently assigned disability rating may be incorrect. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran is entitled to a new examination after a 2 year period between the last VA examination and the Veteran's contention that the pertinent disability had increased in severity). In the present case, it has been more than two years since the Veteran's last psychiatric examination, and he has certainly submitted evidence and statements to suggest a possible worsening of his condition. As such, he should be afforded the opportunity to appear for a more recent VA psychiatric examination to determine the current level of severity of this condition. As for the increased rating claims for joint conditions, the evidence of record reflects that the Veteran was last afforded VA examinations for his right shoulder and lumbar spine conditions in August 2009 - more than 4 years ago. Since that time, he has submitted dozens of statements outlining his symptomatology and allegedly worsening symptomatology. In addition, the record contains a number of records from Downtown Chiropractic from 2012. These records reflect diagnoses of lumbago and brachial neuritis and indicate that the Veteran underwent various therapies. None of these records note any of the Veteran's symptomatology or functional impairment. There are also records from Heartland Chiropractic from July 2012 reflecting a chief complaint of right lumbar pain after the Veteran twisted his back while bending down to get something the previous day. As such, he should be scheduled for more recent examinations to determine the current severity of his lumbar spine disability and his right shoulder disability as well. The Veteran was also last afforded a VA examination of the feet in April 2009. In July 2011, the Veteran requested that he be reevaluated for his right foot as he could not tie his shoes without pain and the right foot falling asleep. It is unclear from the handwriting, but the Veteran may have made a similar assertion about the left foot in another statement received in July 2011. As such, a new examination of the feet is necessary as well. Finally, the most recent record of VA Medical Center (VAMC) treatment within the Veteran's physical file or his electronic paperless file (Virtual VA) is dated July 2012. Records prepared since this time should be obtained and incorporated into the evidence of record. Decreased Sex Drive/Erectile Dysfunction The Veteran also contends that he is entitled to service connection for decreased sex drive and/or erectile dysfunction. Specifically, the Veteran has argued that this condition is secondary to his service-connected psychiatric disabilities. Regrettably, a remand is necessary regarding this issue as well. The Veteran has asserted on multiple occasions that he suffers from a decreased sex drive due to his service-connected mental disorders. According to a June 2009 VA examination report, the Veteran's complaints about arousal problems were less likely than not attributable to PTSD. The examiner noted that the Veteran had described a pattern more consistent with erectile dysfunction, rather than a libidinal issue. The Board finds the above rationale to be insufficient to permit appellate review to proceed in this case. The examiner provided no rationale as to why it was less likely than not that erectile dysfunction was neither caused by, nor aggravated by, a service-connected psychiatric disability. The Court has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). As such, the Veteran must be afforded the opportunity to appear for a new VA examination in which an opinion regarding etiology is provided and fully supported by a discussion of the rationale for the opinion provided and the evidence of record. See 38 U.S.C.A. § 5103(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Furthermore, the record contains a VA treatment record dated May 2009 in which it was noted that the Veteran's erection problems were likely secondary to stress. Again, no rationale was provided in support of the conclusion offered, but this is at least evidence suggestive of a possible correlation between erectile dysfunction and the Veteran's service-connected psychiatric disabilities. Finally, in support of his claim, the Veteran submitted an article from About.com in November 2012 suggesting that high levels of anxiety can interfere with sexual functioning. The examiner assigned to the Veteran's case should discuss this article, as well as any other piece of medical literature suggesting a relationship between erectile dysfunction and psychiatric symptomatology, when formulating an opinion. TDIU Lastly, the Veteran contends that he is entitled to TDIU benefits. Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2011). Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The record demonstrates that the Veteran has met the schedular requirements for TDIU since July 8, 2011. However, what is not clear is whether the Veteran is in fact rendered unable to obtain or maintain a substantially gainful occupation as a result of his service-connected disabilities. The record reveals that the Veteran has worked a number of jobs during the pendency of his claim, including work as a bus driver. In fact, a record submitted by the Veteran dated March 2013 reflects that he was fairly active with work and that he would walk and ride his bike there. As such, the Veteran should also be scheduled for a VA examination to determine whether it is at least as likely as not that his service-connected disabilities render him unable to obtain or maintain a substantially gainful occupation. Accordingly, the case is REMANDED for the following action: 1. VA treatment records prepared since July 2012 should be obtained and associated with the Veteran's claims file, either physically or electronically. 2. The Veteran should be scheduled for a VA examination before an appropriate physician to determine whether a diagnosis of fibromyalgia, myofascial pain syndrome or any distinct disability related to the Veteran's complaints of pain and muscle tightness is warranted. The claims file and a copy of this remand must be provided to the examiner for review in conjunction with this examination. All indicated tests and studies should be performed and the findings should be recorded in detail in the examination report. If the examiner determines that any diagnosis is warranted, then the examiner should opine as to whether it is at least as likely as not that (a) the disability manifested during, or as a result of, active military service, or (b) the disability was caused by or aggravated by a service-connected disability, to include a psychiatric disability or disabilities of the joints and the spine. For VA purposes, aggravation is a permanent worsening above and beyond the natural progression. A complete rationale for all opinions offered must be provided. 3. The Veteran should also be scheduled for a VA examination before an appropriate physician to determine the current level of severity of his service-connected psychiatric disabilities. The Veteran's claims file and a copy of this remand must be provided to the examiner for review in conjunction with the examination. The examination report should reflect review of these items. All indicated tests and studies should be performed, and the examiner is asked to describe in detail all symptomatology associated with the Veteran's service-connected PTSD and other psychiatric disorders. The Veteran's lay statements regarding the severity of his symptomatology should also be considered and discussed. Finally, the examiner is asked to opine as to whether the Veteran's psychiatric disabilities render him unable to obtain or maintain substantially gainful employment. A complete rationale must be provided for all opinions offered. 4. The Veteran should also be scheduled for a VA examination before an appropriate physician to determine the current level of severity of his service-connected lumbar spine disability. The Veteran's claims file and a copy of this remand must be provided to the examiner for review in conjunction with this examination, and the examination report must reflect review of these items. All indicted tests and studies should be performed, and the examiner should describe in detail all symptomatology associated with the Veteran's lumbar spine disability, including limitation of motion and any periods of incapacitation due to intervertebral disc syndrome. The examiner should also render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination associated with the lumbar spine. If pain on motion is observed, the examiner should indicate the point at which pain begins. In addition, the examiner should indicate whether, and to what extent, the Veteran likely experiences functional loss due to pain or any of the other symptoms noted above during flare-ups and/or with repeated use. The Veteran's lay assertions must also be considered and discussed. 5. The Veteran should also be scheduled for a VA examination before an appropriate physician to determine the current level of severity of his service-connected adhesive capsulitis axillary recess and small slap lesion. The Veteran's claims file and a copy of this remand must be provided to the examiner for review in conjunction with this examination, and the examination report must reflect review of these items. All indicted tests and studies should be performed, and the examiner should describe in detail all symptomatology associated with the Veteran's right upper extremity, including limitation of motion. The examiner should also render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination associated with shoulder. If pain on motion is observed, the examiner should indicate the point at which pain begins. In addition, the examiner should indicate whether, and to what extent, the Veteran likely experiences functional loss due to pain or any of the other symptoms noted above during flare-ups and/or with repeated use. The Veteran's lay assertions must also be considered and discussed. 6. The Veteran should also be scheduled for a VA examination before an appropriate physician to determine the current level of severity of his service-connected bilateral foot disabilities (left foot status post fracture, first proximal phalanx, and right metatarsalgia and flat foot). The Veteran's claims file and a copy of this remand must be provided to the examiner for review in conjunction with this examination, and the examination report must reflect review of these items. All indicted tests and studies should be performed, and the examiner should describe in detail all symptomatology associated with the Veteran's disabilities of the feet, including limitation of motion. The examiner should also render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination associated with either foot. If pain on motion is observed, the examiner should indicate the point at which pain begins. In addition, the examiner should indicate whether, and to what extent, the Veteran likely experiences functional loss due to pain or any of the other symptoms noted above during flare-ups and/or with repeated use. The Veteran's lay assertions must also be considered and discussed. 7. Finally, the Veteran should be scheduled for a VA examination before an appropriate physician (or physicians) to determine whether his service-connected disabilities, either individually or taken in their totality, render the Veteran unable to obtain or maintain a substantially gainful occupation. 8. The agency of original jurisdiction (AOJ) should then carefully review the medical opinions obtained to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, the AOJ should return the case to the examiner for completion of the inquiry. 9. The AOJ should then readjudicate the claims on appeal in light of all of the evidence of record. If an issue remains denied, the AOJ should provide the Veteran a supplemental statement of the case as to the issue on appeal, and afford him a reasonable period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs