Citation Nr: 1648089 Decision Date: 12/27/16 Archive Date: 01/06/17 DOCKET NO. 12-28 605 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as due to an undiagnosed illness, to include as secondary to service-connected irritable bowel syndrome (IBS). 3. Entitlement to service connection for left shoulder pain, also claimed as joint pain due to undiagnosed illness. 4. Entitlement to service connection for undiagnosed illness manifested by muscle pain, to include as secondary to hepatitis C. 5. Entitlement to service connection for an undiagnosed illness manifested by fatigue, to include as secondary to hepatitis C. REPRESENTATION Appellant represented by: Colin E. Kemmerly, Attorney at Law ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1975 to February 1976 and from September 1990 to May 1991, with additional periods of Reserve service. This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This case was previously before the Board in February 2015, when four of the issues were reopened following prior final denials, and all five issues were then remanded for additional development of the evidence. The Veteran requested a Board hearing in his September 2012 VA Form 9 substantive appeal. However, in June 2013 the Veteran's attorney submitted a written statement explaining that the Veteran desired to withdraw the hearing request and have his claims decided on the basis of the evidence of record. The Board notes that earlier AOJ adjudications of this appeal listed, as a separate issue: "Service connection for undiagnosed illness." The Board finds that the Veteran's claim of entitlement to service connected disability benefits on the basis of an undiagnosed illness features reported symptom manifestations including gastro-esophageal reflux symptoms, left shoulder and general joint pain, muscle pain, and fatigue. The Veteran's contentions with regard to disability due to undiagnosed illness are contemplated in the separate issues seeking service connection for disabilities associated with those symptoms, with each including consideration as potentially due to undiagnosed illness. As there is no separately available benefit for undiagnosed illness beyond that associated with the claimed disabling manifestations of such illness, the Board finds that it is not necessary to address the "undiagnosed illness" issue as distinct from the claims of service connection for GERD, left shoulder and general joint pain, muscle pain, and fatigue (with each issue adjudicated with consideration of the Veteran's contention that the claimed symptoms may be due to undiagnosed illness). Accordingly, the undiagnosed illness issue is not here separately listed; rather, it is addressed as part of the GERD, left shoulder and general joint pain, muscle pain, and fatigue issues on appeal at this time. Finally, the Board also notes that earlier AOJ adjudications of this matter included an issue characterized as entitlement to service connection "for muscle pain and fatigue." The Board notes that a prior RO rating decision (not currently on appeal) denied service connection for "dizzy spells, muscle pain and bad nerves" in March 2004. The February 2015 Board remand explained that the Board has found it most appropriate to split that matter into two issues such that the muscle pain and fatigue issues may be addressed separately. In November 2016, the Veteran's representative submitted additional evidence to the Board with a waiver of initial RO review. See 38 C.F.R. § 20.1304(c) (2016). FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. 2. Hepatitis C was not manifested in service and is not shown to be related to any disease, injury, or event during service. 3. The Veteran's acid reflux symptomatology is entirely attributed to the known clinical diagnosis of GERD; it was not manifested in service, and it is not shown to be related to his service nor to have been caused or aggravated by his IBS. 4. The Veteran's left shoulder and joint pain symptomatology is entirely attributed to known clinical diagnoses including impingement syndrome, rotator cuff tendonitis, and residuals of glenohumeral joint dislocation; it was not manifested in service, and it is not shown to be related to his service. 5. The Veteran is not shown to have objective or independently verifiable signs of a disability manifested by muscle pain (aside from the diagnosed left shoulder disability); he is not shown to meet the medical criteria for a finding of a medically unexplained chronic multisymptom illness such as fibromyalgia or chronic fatigue syndrome, and he is not otherwise shown to have a disability manifested by muscle pain that is etiologically linked to his service or to service-connected disability. 6. The Veteran is not shown to have objective or independently verifiable signs of a disability manifested by fatigue; he is not shown to meet the medical criteria for a finding of a medically unexplained chronic multisymptom illness such as chronic fatigue syndrome of fibromyalgia, and he is not otherwise shown to have a disability manifested by fatigue that is etiologically linked to his service or to service-connected disability. CONCLUSIONS OF LAW 1. Service connection for hepatitis C is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2016). 2. Service connection for GERD, to include as due to an undiagnosed illness or as secondary to IBS, is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317 (2016). 3. Service connection for left shoulder disability / joint pain, to include as due to an undiagnosed illness, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1117, 1118, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2016). 4. Service connection for disability manifested by muscle pain, to include as due to an undiagnosed illness or as secondary to hepatitis C, is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317 (2016). 5. Service connection for disability manifested by fatigue, to include as due to an undiagnosed illness or as secondary to hepatitis C, is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The RO's actions substantially complied with the remand instructions pursuant to the Board's February 2015 remand; the reports of the directed VA examination completed in April 2016 are adequate for the purposes of appellate review, as discussed below. Stegall v. West, 11 Vet. App. 268, 271 (1998). Analysis The Veteran claims entitlement to service connection for hepatitis C, GERD, left shoulder / joint pain, and disabilities manifested by muscle pain and fatigue. The Veteran claims, in part, that these disabilities are due to unsanitary conditions and pertinent chemical exposures during Gulf War service. The Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. The Board preliminarily notes that the Veteran's exposure to unsanitary conditions and certain toxic chemicals during his Persian Gulf service is accepted for the purposes of this decision. The Board observes that the claims-file contains copies of letters (including dated in December 2000 and September 2005) from the Department of Defense (DoD) to the Veteran identifying toxic exposures associated with his specific service locations. A key question for each of the issues in this case is whether any of the claimed disabilities are shown to be etiologically linked to the events or conditions of the Veteran's active duty service. Alongside consideration of the undiagnosed illness theory in the pertinent claims, the Board has also considered whether service connection for any claimed disability may be warranted on a direct basis. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that it was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a claimed disability, there must be evidence of: (1) a current disability; (2) of incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be established for a chronic disability resulting from an undiagnosed illness that became manifested either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Service connection may also be established for a Persian Gulf Veteran who exhibits objective indications of "qualifying chronic disability," a chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines warrants a presumption of service connection. 38 U.S.C.A. § 1117. An "undiagnosed illness" is one that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a present disability for which service connection is sought, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). Lay evidence can also be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. April 2016 VA Examination Report - Undiagnosed Illness Pertinent to several of the issues individually addressed below, the April 2016 VA examination report's "Gulf War General" Disability Benefits Questionnaire (DBQ) indicates that the Veteran reported symptoms/disabilities pertaining the following categories: "Esophageal Disorder (GERD and Hiatal Hernia)," "Liver Conditions, including hepatitis and cirrhosis," "Shoulder and Arm," and "Fibromyalgia." A separate DBQ was completed for each of these areas of concern, in addition to a DBQ addressing concerns of Chronic Fatigue Syndrome. The "Gulf War General" DBQ states the VA examiner's finding that "No," there is not "any diagnosed illnesses for which no etiology was established," and the VA examiner identified no "[a]dditional signs and/or symptoms that may represent an 'undiagnosed illness' or 'diagnosed medically unexplained chronic multisymptom illness'" for this Veteran. The VA examiner found that "No," the Veteran did not "report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections." Each of the subject-specific DBQs in the April 2016 VA examination report shows that the Veteran was examined and the claims-file was reviewed to inform the VA examiner's findings. Service Connection for Hepatitis C The Veteran contends that he has hepatitis C due to his active duty service; specifically he contends that he was infected with hepatitis C during Gulf War service in locations with unsanitary conditions. The Board first notes that the evidence of record establishes that the Veteran has been medically diagnosed with hepatitis C, including as confirmed in an April 2016 VA examination report. As the current diagnosis of the claimed disability is established, the Board moves to consideration of whether the Veteran's hepatitis C is etiologically linked to his active duty military service. The Veteran's service treatment records contain no suggestion of any diagnosis, symptomatology, or pertinent active duty service event associated with incurrence of hepatitis C. The Veteran's February 1976 separation examination report from his first period of service includes a medical history questionnaire showing that the Veteran reported he was in "Good" health and responded "Don't Know" when asked if he had ever had "Jaundice or hepatitis," and answered "No" when asked if he had ever had liver problems. The Board observes that the Veteran denied any history of venereal disease at that time. A complete clinical examination revealed no pertinent abnormalities, including a notation of normal findings for the evaluation of the abdomen and viscera. The February 1976 medical history questionnaire shows that the Veteran denied experiencing any other pertinent symptomatology as of that time. The Board notes that the February 1976 examination findings are substantially identical to September 1975 service examination results, to the extent pertinent to this claim. The Board notes that the Veteran does not contend that he had any pertinent diagnoses, treatment, or symptoms of hepatitis C during this (or any) period of active duty service. February 1980 and February 1984 periodic service examination reports, during reserve service, show that clinical examinations of the Veteran revealed no pertinent abnormalities in any respect, including notations of normal findings for the evaluation of the abdomen and viscera. A May 1988 periodic service examination report (during reserve service) shows no pertinent abnormalities suggestive of hepatitis C; the report specifically notes a clinically normal abdomen and viscera evaluation. Only left shoulder and lower extremity abnormalities were noted. The associated May 1988 medical history questionnaire shows that the Veteran reported that he was "in good health and on no medication," in addition to showing that the Veteran denied having ever had "jaundice or hepatitis." The May 1988 medical history questionnaire did note the Veteran's report of a history of venereal disease by this time, and noted "VD - several years ago...." There appears to be no documentation of any entrance examination report for the Veteran's second period of active duty service (September 1990 to May 1991). An April 1991 service separation examination report (for release from active duty) for this period shows no pertinent abnormalities suggestive of hepatitis C; the report specifically notes a clinically normal abdomen and viscera evaluation. The associated medical history questionnaire shows that the Veteran stated "I am in good health" and "not on any medication." The Veteran specifically denied any history of "Jaundice or hepatitis." The Board observes that the Veteran did report a history of venereal disease, and explained "No STD x 12 yrs (no symptoms x 12 yrs.)." The Board notes that the Veteran does not contend that he had any pertinent diagnoses, treatment, or symptoms of hepatitis C during this (or any) period of active duty service. Following the conclusion of the Veteran's second (final) period of active duty service, a June 1993 periodic service examination report (from reserve service) shows that clinical examination again revealed no pertinent clinical abnormalities, including a notation of normal findings for the evaluation of the abdomen and viscera. The associated medical history questionnaire shows that the Veteran certified that he was "in good health and on no medication." The Veteran specifically denied any history of "Jaundice or hepatitis." The Board observes that the Veteran did again report a history of venereal disease. A July 1996 service examination report (from reserve service) shows that clinical examination again revealed no pertinent clinical abnormalities, including a notation of normal findings for the evaluation of the abdomen and viscera. The associated medical history questionnaire shows that the Veteran again specifically denied any history of "Jaundice or hepatitis." The Veteran did again report a history of venereal disease. A September 2002 VA treatment report shows that the Veteran denied any history of hepatitis at the time, but medical evaluation and notation of the Veteran endorsing one or more risk factors for hepatitis led to laboratory testing (that eventually confirmed a diagnosis of hepatitis C). Additional medical treatment reports contained in the claims-file show ongoing evaluation and treatment for hepatitis C. The Veteran filed a claim seeking to establish entitlement to service connection for hepatitis C in September 2003. In his filing of the claim, he indicated that his first abnormal liver study was in September 2002, and he was otherwise unsure (he was unable to identify a date) for when his hepatitis C infection may have actually begun. In December 2003, the Veteran submitted a written statement asserting that "I ... have done research on my self and the women in my life. The medical history do not provide information about being infected with Hepatiti[s] C. I never had a blood transfusion or used intravenous drugs." The Veteran concludes that "I have to believe I was infected while serving in the Gulf War, or any other time while in the service." A February 2004 VA examination report confirmed that the Veteran was diagnosed with hepatitis C; no analysis of etiology was made at that time. In April 2006, the Veteran submitted an article collected from an internet website discussing VA's findings regarding the heightened rate of hepatitis C infections amongst U.S. veterans, noting "'One in 10 US Veterans are infected with HCV', a rate 5 times greater than the 1.8% infection rate of the general population." In April 2006, the Veteran also submitted a sworn affidavit presenting his testimony that "I never shared any needles and/or had a blood transfusion. I have also contacted all of my sexual partners, and none of them have been diagnosed with Hepatitis C." The Veteran discussed that "I have read several reports stating that Hepatitis C is a common disease affecting military veterans," and argues that "[i]t is a reasonable assumption that I could have been exposed to Hepatitis C while stationed in Saudi Arabia under unsanitary conditions." The Veteran concludes that "I can not prove that I was infected with Hepatitis C while serving in the military, but any other explanation is not plausible." The Veteran has repeatedly directed attention, including in a January 2009 written statement, to the fact that "veterans are at great risk" for hepatitis C infections. The Veteran's December 2008 claim for service connection for hepatitis identified the "Date disability occurred" as a date in November 2002. The Veteran's April 2016 VA examination report's "Hepatitis, Cirrhosis and other Liver Conditions" DBQ presents the VA examiner's finding that the Veteran has a diagnosis of "Hepatitis C" dating back to September 2002. The report discusses the Veteran's 2002 diagnosis and subsequent treatments for hepatitis C, and that the "Veteran thinks he had a blood transfusion in 1982, following MVA with internal bleeding (Springhill Memorial Hospital, Mobile AL); however there is no supporting medical record documentation...." The report also notes that the Veteran "denies high sexual risk exposure, or any other Hep C risk factors." (The Veteran has not requested VA assistance in attempting to obtain records from the 1982 hospitalization, and the Board accepts the Veteran's own description of receiving a blood transfusion during that hospitalization for the purposes of the analysis in this case.) The associated medical opinion (available in Virtual VA) explains that the Veteran's "asymptomatic Hep C" presents a "disability pattern ... that meets TL10-01 criteria for a disease with a clear and specific etiology and diagnosis." Additionally, "[i]t is not caused by or related to AD military service," "[i]t is less likely than not caused by or related to GW environmental exposures, including unsanitary conditions during service." To support the conclusion that the Veteran's hepatitis C did not begin during service, the opinion presents a rationale citing the absence of any indication of hepatitis C manifestations during service or proximately following service; the VA examiner notes that the Veteran's hepatitis C was diagnosed in "2002 ... (11 years post-service)." The VA examiner explains that "HCV is a blood borne viral infection, it is not transmitted by unsanitary conditions. The VA examiner concludes that the Veteran's hepatitis C "is most likely acquired by historic report of blood transfusion during 1982 MVA hospitalization...." The VA examiner's opinion also indicated having completed an "'UpToDate' Literature review" in preparing the medical opinion, specifically addressing "Epidemiology & Risk factors of Hepatitis C, and noting that "[m]ost patients infected with HCV in the United States and Europe acquired the disease through intravenous drug use or blood transfusion, the latter of which has become rare since routine testing of the blood supply for HCV was begun in 1990." Other medical reports of record make additional references to assessment and treatment of the Veteran's hepatitis C. However, none of these reports present informational significantly contradicting the detailed findings in the evidence discussed above. In June 2016, the Veteran's representative submitted a brief arguing that the April 2016 VA medical opinion is inadequate because the "examiner failed to support her conclusion that Veteran's diagnosed hepatitis C was not incurred coincident to service." The June 2016 brief argues: "[The] examiner concluded that Veteran's hepatitis C was contracted through a blood transfusion in 1982.... The lack of any bloodwork done during Veteran's second period of service does not allow for the conclusion that Veteran's hepatitis C was contracted in 1982 through a blood transfusion." The brief further argues that "no evidence was presented that Veteran had already contracted hepatitis C at the time of his reentry into service in September of 1990. Therefore, the April 29, 2016 C&P examiner did not provide an opinion VA can rely upon." However, the Board finds the medical opinion presented in the April 2016 VA examination report to be adequate, probative, and persuasive evidence in this case. The Veteran's representative is correct in noting that there is no contemporaneous blood testing demonstrating the presence of hepatitis C prior to the Veteran's period of active duty service beginning in September 1990. However, it is important to note that there is also no contemporaneous evidence demonstrating the presence of hepatitis C during the Veteran's active duty service or at any time at all prior to September 2002. Given that the Veteran's hepatitis C infection is first clearly shown to have existed more than 11 years after the Veteran's separation from service, the question of whether the hepatitis C is related to service requires a medical opinion to consider the applicable medical principles (including the pertinent risk factors for hepatitis C infection) and the Veteran's specific history to determine the probability that the Veteran's hepatitis C is linked to his active duty service. The April 2016 VA medical opinion was prepared by a competent medical doctor informed by interview of the Veteran and review of the claims-file, and relies upon the Veteran's own description of a recollection of undergoing a blood transfusion in 1982 following serious injuries in a motor vehicle accident. Although the Veteran had previously denied ever undergoing a blood transfusion, the Board finds no reason to doubt the Veteran's own statement to the April 2016 VA examiner that he recalls undergoing a blood transfusion following the 1982 accident, and this account appears consistent with the descriptions of the severity of the accident as described throughout the evidentiary record. The Veteran has not identified experiencing any other medically recognized risk factors for hepatitis C infection. The Veteran's suggestion that Gulf War exposures including chemicals and generally unsanitary conditions during service may have caused his hepatitis C is expressly addressed by April 2016 VA examiner, who identifies such exposures as unrelated to the likely etiology of the Veteran's hepatitis C infection, noting that hepatitis C "is not transmitted by unsanitary conditions." The Board finds it reasonable and persuasive for the VA examiner to conclude that the single medically recognized significant risk factor for hepatitis C, identified by the Veteran's own account, is the most likely cause of the Veteran's hepatitis C infection. Accordingly, the Board finds the VA examiner's conclusion that the Veteran's hepatitis C was not incurred during active duty service, but more likely incurred in the blood transfusion following the 1982 motor vehicle accident, is a probative medical opinion reasonably supported by the evidence of record and the examiner's analytical rationale. As there is no contrary medical opinion of record (there is no medical opinion of record asserting that the Veteran's hepatitis C is etiologically linked to his active duty military service), the Board finds the pertinent medical opinion presented in the April 2016 VA examination report to be persuasive. The Board has considered the Veteran's statements directing the Board's attention to the fact that Veterans experience a higher rate of hepatitis C infections than do the general population. The Board recognizes the information presented by the Veteran in this regard and naturally understands his concern that his service may have increased his risk for infection. However, the information regarding the rate of hepatitis C infection in the veteran community does not present a basis for concluding that the Veteran's specific case of hepatitis C was incurred as a result of the particular events of his active duty military service. The medical evidence specifically addressing this case, featuring the uncontradicted April 2016 VA medical opinion, indicates that the Veteran's hepatitis C was most likely contracted during a 1982 blood transfusion that the Veteran recalls taking place following a serious motor vehicle accident, and thus it is unlikely that the hepatitis C was incurred during periods of service during which no significant medically recognized risk factors for hepatitis C have been identified. As the evidence in this case indicates that the Veteran's hepatitis C was most likely caused by a blood transfusion in 1982, the Board has considered the Veteran's second period of active duty service (from September 1990 to May 1991) with careful consideration of the significance of any pre-existing hepatitis C infection/disease. For the Veteran's second period of active duty service, there is no entrance examination report, and therefore, the presumption of soundness is not for application. See Smith v. Shinseki, 24 Vet. App. 40 (2010). In Smith, the Court explained that the presumption of soundness requires that there be an examination prior to entry into the period of service on which the claim is based, and that in the absence of such an examination, there is no basis from which to determine whether the claimant was in sound condition upon entry into that period of service on which the claim is based. The Board finds the evidence of record shows that any hepatitis C infection that the Veteran may have had during the second period of active duty service was the result of the blood transfusion that took place prior to that service. Notably, the Veteran has not specifically contended that he experienced any medically recognized risk factor for hepatitis C infection during active duty service to suggest an in-service cause for those residuals (aside from the theory of infection from generally unsanitary conditions, rejected by the competent medical evidence featuring the April 2016 VA medical opinion). The Veteran has repeatedly described his 1982 hospitalization for serious injuries (including in a May 1988 reserve service examination report prior to the second period of service) and the Veteran told the April 2016 VA examiner that he recalled receiving a blood transfusion during that 1982 hospitalization; the Veteran has never reported that any such medically recognized risk factor for hepatitis C occurred during active duty service. As the presumption of soundness does not apply, the Board must consider whether the evidence establishes that aggravation of the Veteran's hepatitis C infection occurred during the second period of active duty service. 38 U.S.C.A. § 1153 contains a presumption of aggravation when it is shown that a pre-existing disorder underwent an increase in disability during service. The presumption of aggravation does not arise if the pre-existing disorder did not undergo an increase in severity in service. In this case, there is no suggestion whatsoever of any increase in any hepatitis C symptomatology during service. The April 1991 service separation examination report for this period shows that the Veteran was clinically normal in all respects, and the associated medical history questionnaire shows that the Veteran certified that he was in good health and specifically denied having ever experienced hepatitis or jaundice. Following the period of service, a June 1993 periodic service examination report shows that the Veteran was again found to be clinically normal in all pertinent respects and again denied having ever experienced hepatitis or jaundice. Accordingly, the Board finds that there was no increase in severity of a pre-existing hepatitis C infection during the Veteran's second period of active duty service; there can be no increase in severity that results in a complete absence of symptoms and clinical signs. The Board also notes that the absence of any suggestion of a manifestation of hepatitis C during active duty service would prevent the presumption of soundness from attaching even in the event the Veteran's liver health were found to have been sound at an entrance medical examination. Before the presumption of soundness is for application in a service connection case, there must be evidence that a disease or injury that was not noted upon Veteran's entry to service manifested or was incurred in service. 38 U.S.C.A. § 1111. Gilbert v. Shinseki, 26 Vet.App. 48, 53 (2012). The April 2016 VA medical opinion is also uncontradicted in its conclusions explaining that the Veteran's hepatitis C is neither a manifestation of an undiagnosed illness nor a diagnosed medically unexplained chronic multisymptom illness. The April 2016 VA examination report's "Hepatitis, Cirrhosis and other Liver Conditions" section clearly explains that the Veteran's hepatitis C represents a disease "with a clear and specific etiology and diagnosis," with no objective signs of symptomatology to attribute to undiagnosed illness. Furthermore, the "Gulf War General" section (as discussed above) makes clear that the Veteran's disability manifestations include no additional signs and/or symptoms that may otherwise represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." Accordingly, service connection for this disability cannot be granted through application of the special provisions of 38 C.F.R. § 3.317. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not allow for a grant of the appeal in this matter. 38 U.S.C.A. § 5107(b). Service Connection for GERD, to include as due to IBS The Veteran contends that he has GERD, to include as being due to undiagnosed illness associated with his Gulf War service. He asserts that this disability may also be secondary to his service-connected IBS. The Board first notes that the evidence of record establishes that the Veteran has been medically diagnosed with GERD, including as confirmed in an April 2016 VA examination report. As the current diagnosis of the claimed disability is established, the Board moves to consideration of whether the Veteran's GERD is etiologically linked to his active duty military service. The Veteran's service treatment records contain no suggestion of any diagnosis, symptomatology, or pertinent active duty service event associated with incurrence of GERD or hiatal hernia. The Veteran's February 1976 separation examination report from his first period of service includes a medical history questionnaire showing that the Veteran reported he was in "Good" health and responded "No" when asked if he had ever had pain or pressure in chest, frequent indigestion, or stomach problems. A complete clinical examination at that time revealed no pertinent abnormalities; the report specifically notes a clinically normal evaluation of the mouth and throat, as well as the abdomen and viscera. The February 1976 medical history questionnaire shows that the Veteran denied experiencing any other pertinent symptomatology as of that time. The Board notes that the February 1976 examination findings are substantially identical to September 1975 service examination results, to the extent pertinent to this claim. The Board notes that the Veteran does not contend that he had any pertinent diagnoses, treatment, or symptoms of GERD or hiatal hernia during this (or any) period of active duty service. February 1980 and February 1984 periodic service examination reports, during reserve service, show that clinical examinations of the Veteran revealed no pertinent abnormalities in any respect; the reports specifically note a clinically normal evaluation of the mouth and throat, as well as the abdomen and viscera. A May 1988 periodic service examination report (during reserve service) shows no pertinent abnormalities suggestive of GERD or hiatal hernia; the report specifically notes a clinically normal mouth, throat, abdomen, and viscera. Only left shoulder and lower extremity abnormalities were noted. The associated May 1988 medical history questionnaire shows that the Veteran reported that he was "in good health and on no medication," in addition to showing that the Veteran denied having ever had throat problems, pain or pressure in chest, chronic cough, frequent indigestion, or stomach problems. There appears to be no documentation of any entrance examination report for the Veteran's second period of active duty service (September 1990 to May 1991). An April 1991 service separation examination report (for release from active duty) for this period shows no pertinent abnormalities suggestive of GERD or hiatal hernia; the report specifically notes a clinically normal evaluation of the mouth and throat, as well as the abdomen and viscera. The associated medical history questionnaire shows that the Veteran stated "I am in good health" and "not on any medication." The Veteran specifically denied any history of throat problems, pain or pressure in chest, chronic cough, frequent indigestion, or stomach problems. The Board again notes that the Veteran does not contend that he had any pertinent diagnoses, treatment, or symptoms of GERD or hiatal hernia during this (or any) period of active duty service. Following the conclusion of the Veteran's second (final) period of active duty service, a June 1993 periodic service examination report (from reserve service) shows that clinical examination again revealed no pertinent clinical abnormalities, including a notation of normal findings for the evaluation of the mouth and throat, as well as the abdomen and viscera. The associated medical history questionnaire shows that the Veteran certified that he was "in good health and on no medication." The Veteran specifically denied any history of throat problems, frequent indigestion, or stomach problems. The Board notes that the Veteran did report a history of experiencing pain or pressure in chest, and chronic cough. The endorsement of a history of these symptoms in June 1993 after denying any history of these symptoms at the April 1991 pre-separation examination suggests that such symptomatology (to whatever extent it may or may not be indicative of any GERD or hiatal hernia) had its onset after the Veteran's period of active duty service. A July 1996 service examination report (from reserve service) shows that clinical examination again revealed no pertinent clinical abnormalities, including a notation of normal findings for the evaluation of the mouth and throat, as well as the abdomen and viscera. The associated medical history questionnaire shows that the Veteran specifically denied any history of chronic cough, frequent indigestion, or stomach problems. The Board notes that the Veteran did report a history of ear, nose or throat problems in addition experiencing pain or pressure in chest. The endorsement of a history of chronic cough in July 1996, after denying any history of chronic cough at the April 1991 pre-separation examination and the June 1993 reserve service examination, suggests that such symptomatology (to whatever extent it may or may not be indicative of any GERD or hiatal hernia) had its onset after the Veteran's period of active duty service. A September 2002 VA treatment report shows that the Veteran reported a past medical history of episodic epigastric pain, with treatment for acid reflux concerns beginning "2 months ago with improvement." The assessment was "epigastric pain - stable." Subsequent medical records, including VA and private treatment reports, confirm that the Veteran has had ongoing treatment for acid reflux symptomatology / GERD. The Veteran filed a claim seeking to establish entitlement to service connection for GERD (claimed at the time in terms of abdominal and epigastric pain) in September 2003. In the filing of the claim, the Veteran reported that the disability began in September 2002. A February 2004 VA examination report confirmed that the Veteran was diagnosed with GERD; no analysis of etiology was made at that time. The Veteran's January 2009 claim for service connection included his statement that "I am not sure when this disability began. For a long time I thought I was just having a[n] upset stomach and heartburn, but it just kept getting worse." The Veteran recalled that "[t]o the best knowledge 04/18/1995 was the first time I went to a doctor. I was not treated until 02/28/2001." The Veteran explained: "I believe my ... acid reflux and heartburn are manifestations of my undiagnosed illness." A June 2009 VA gastroenterology consultation report shows that the Veteran reported that he had "had GERD symptoms for the last 10 yrs." This suggests onset of the GERD symptomatology in approximately 1999. A November 2009 VA examination report presents a diagnosis of "GERD with medication therapy," without clear etiological analysis. The Veteran's April 2016 VA examination report's "Esophageal Conditions" DBQ presents the VA examiner's finding that the Veteran has been diagnosed with GERD and hiatal hernia, with the Veteran's reported history indicating GERD since "1999-2000." The associated medical opinion (available in Virtual VA) explains that the Veteran's "heartburn & reflux" presents a "disability pattern ... that meets TL10-01 criteria for a disease with a clear and specific etiology and diagnosis." Additionally, "[i]t is not caused by or related to AD military service," "[i]t is not caused by or related to GW environmental exposures (such as low level exposure to chemical warfare agents released during demolition operations in March 1991 near Khamisiyah, Iraq or any administered preventative agents including the Veteran's cited 'Pyridostigmine-Bromide pills" and Anthrax Botulinum vaccination)." Additionally, "[i]t is not caused by, related to or aggravated beyond its natural progression by SC IBS." To support the conclusion that the Veteran's GERD did not begin during service, the opinion presents a rationale citing the absence of any indication of GERD manifestations during service or proximately following service; the VA examiner notes that the Veteran's GERD/hiatal hernia was diagnosed in approximately "2000-2002 (9-10 years post-service)," and "is common in the general population." To support the conclusion that the Veteran's GERD / hiatal hernia is not caused or aggravated by his IBS, the opinion presents a rationale explaining, from the authoring physician's expertise, that "[t]here is no clinical correlation-nexus between [GERD/hiatal hernia] and IBS (the one does not cause the other, or vice-versa.) IBS affects the lower GI tract (intestines) and [GERD/hiatal hernia] affects the upper GI tract (gastroesophagus)." The VA examiner's opinion also indicated having completed an "'UpToDate' Literature review" in preparing the medical opinion. The Board finds that the April 2016 VA examination report's presentation of these expert medical opinions is adequate and probative evidence addressing the medical questions central to the service connection claim for GERD. The opinions are presented by a medical doctor competent to provide the analysis, and is informed by examination and interview of the Veteran together with review of the claims-file. The opinions are presented with a persuasive analytical rationale citing medical principles and the specific factual history of this case. The Veteran's own account of his medical history indicates that his GERD symptoms did not appear until several years following his final period of active duty service, and the April 2016 VA medical opinion specifically addresses the Veteran's contentions that the post-service onset of GERD may be etiologically related to in-service exposures during Gulf War service. The opinion acknowledges the exposures in question, but reference to the pertinent medical literature and the frequency of GERD in the general population supports the VA examiner's conclusion that the Veteran's post-service onset of GERD is not medically attributable to his active duty military service. With regard to the Veteran's theory that his GERD has been caused or aggravated by his service-connected IBS, the April 2016 VA medical opinion makes clear that IBS does not cause nor aggravate GERD. The opinion adequately explains that the two diagnostic entities involve distinct systems with no pertinent medical relationship to support a theory of causation or aggravation linking the two. As there are no contrary medical opinions of record (there is no medical opinion of record asserting that the Veteran's GERD is etiologically linked to his active duty military service, and there is no medical opinion of record asserting that the Veteran's GERD is caused or aggravated by his IBS), the Board finds the pertinent medical opinions presented in the April 2016 VA examination report to be persuasive. The preponderance of the evidence is therefore against finding that the Veteran's GERD is etiologically linked to service, and the preponderance of the evidence is against finding that the Veteran's GERD is etiologically linked (through causation or aggravation) to service-connected IBS. Accordingly, the claim for service connection for GERD cannot be granted on these direct or secondary bases. The April 2016 VA medical opinion is also uncontradicted in its conclusions explaining that the Veteran's GERD symptomatology is neither a manifestation of an undiagnosed illness nor a diagnosed medically unexplained chronic multisymptom illness. The April 2016 VA examination report's Esophageal Conditions section clearly explains that the Veteran's diagnosed GERD and hiatal hernia represent a disease "with a clear and specific etiology and diagnosis," with no objective signs of symptomatology to attribute to undiagnosed illness. Furthermore, the "Gulf War General" section (as discussed above) makes clear that the Veteran's disability manifestations include no additional signs and/or symptoms that may otherwise represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." Accordingly, service connection for this disability cannot be granted through application of the special provisions of 38 C.F.R. § 3.317. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not allow for a grant of the appeal in this matter. 38 U.S.C.A. § 5107(b). Service Connection for Left Shoulder Pain, also claimed as Joint Pain due to Undiagnosed Illness The Veteran contends that he has a left shoulder disability due to his active duty military service, to include as being due to undiagnosed illness. The Board first notes that the evidence of record establishes that the Veteran has been medically diagnosed with left shoulder disabilities, including as confirmed in an April 2016 VA examination report. As the existence of the claimed disability is established, the Board moves to consideration of whether the Veteran's left shoulder disabilities are etiologically linked to his active duty military service. The Veteran's service treatment records from his first period of active duty service (June 1975 to February 1976) contain no suggestion of any diagnosis, symptomatology, or pertinent active duty service event associated with incurrence of a left shoulder disability or any generalized joint pain pathology. The Veteran's February 1976 separation examination report from his first period of service includes a medical history questionnaire showing that the Veteran reported he was in "Good" health and responded "No" when asked if he had ever had "Swollen or painful joints," "Cramps in your legs," "Broken bones," "Arthritis, Rheumatism, or Bursitis," "Bone, joint or other deformity," "Painful or 'trick' shoulder or elbow," "Recurrent back pain," "'Trick' or locked knee," or "Foot trouble." A complete clinical examination at that time revealed no pertinent abnormalities, including with regard to the neck, upper extremities, feet, lower extremities, spine, and other musculoskeletal features. The February 1976 medical history questionnaire shows that the Veteran denied experiencing any other pertinent symptomatology as of that time. The Board notes that the February 1976 examination findings are substantially identical to September 1975 service examination results, to the extent pertinent to this claim. The Board notes that the Veteran does not contend that he had any pertinent diagnoses, treatment, or symptoms of left shoulder disability or generalized joint pain during this first period of active duty service. February 1980 and February 1984 periodic service examination reports, during reserve service, show that clinical examinations of the Veteran revealed no pertinent abnormalities in any respect; the reports specifically show that clinical examination at that time revealed clinically normal neck, upper extremities, feet, lower extremities, spine, and other musculoskeletal features. A May 1988 periodic service examination report (from reserve service) shows that the examiner noted left shoulder and left tibia abnormalities, but the left shoulder retained normal strength and full range of motion. The Veteran reported that he had been hospitalized in 1982 for injuries following a motor vehicle accident involving a broken or dislocated shoulder, pelvis, and knee; the Veteran described "[n]o current problems except for some pain in L leg when working." The May 1988 examination otherwise confirmed normal findings for the neck, feet, spine, and other musculoskeletal features (excluding upper and lower extremities, as explained). The associated May 1988 medical history questionnaire shows that the Veteran reported that he was "in good health and on no medication," in addition to showing that the Veteran denied having ever had "Swollen or painful joints," "Arthritis, Rheumatism, or Bursitis," "Bone, joint or other deformity," "Painful or 'trick' shoulder or elbow," "Recurrent back pain," "'Trick' or locked knee," or "Foot trouble." The Veteran did endorse having experienced "Cramps in your legs" and "Broken bones" consistent with the explained history of 1982 injuries and residual lower extremity symptoms. There appears to be no documentation of any entrance examination report for the Veteran's second period of active duty service (September 1990 to May 1991). An April 1991 service separation examination report (for release from active duty) for this period shows no pertinent abnormalities suggestive of left shoulder or generalized joint symptoms; the report specifically notes a clinically normal evaluation of the neck, upper extremities, feet, lower extremities, spine, and other musculoskeletal features. The associated medical history questionnaire shows that the Veteran stated "I am in good health" and "not on any medication." He specifically denied any history of "Swollen or painful joints," "Cramps in your legs," "Arthritis, Rheumatism, or Bursitis," "Bone, joint or other deformity," "Painful or 'trick' shoulder or elbow," "Recurrent back pain," "'Trick' or locked knee," or "Foot trouble." The Veteran did endorse of a history of "Broken bones," consistent with the account of the 1982 injuries from motor vehicle accident (identified in this report as occurring in 1980, but elsewhere repeatedly indicated as occurring in 1982). Following the conclusion of the Veteran's second (final) period of active duty service, a June 1993 periodic service examination report (from reserve service) shows that examination revealed no pertinent clinical abnormalities, including a notation of normal findings for the evaluation of the neck, upper extremities, feet, lower extremities, spine, and other musculoskeletal features. The associated medical history questionnaire shows that the Veteran certified that he was "in good health and on no medication." The Veteran specifically denied any history of "Swollen or painful joints," "Arthritis, Rheumatism, or Bursitis," "Bone, joint or other deformity," "Painful or 'trick' shoulder or elbow," "Recurrent back pain," "'Trick' or locked knee," or "Foot trouble." The Veteran endorsed a history of "Cramps in your legs," consistent with prior accounts of residual left leg symptoms from injuries associated with a 1982 motor vehicle accident. A July 1996 service examination report (from reserve service) shows that clinical examination again revealed no pertinent clinical abnormalities, including a notation of normal findings for the evaluation of the neck, upper extremities, feet, lower extremities, spine, and other musculoskeletal features. The associated medical history questionnaire shows that the Veteran specifically denied any history of "Swollen or painful joints," "Arthritis, Rheumatism, or Bursitis," "Bone, joint or other deformity," "Painful or 'trick' shoulder or elbow," "Recurrent back pain," "'Trick' or locked knee," or "Foot trouble." The Veteran endorsed a history of "Cramps in your legs," consistent with accounts of residual left leg symptoms from injuries associated with a 1982 motor vehicle accident. A September 2002 VA treatment report shows that the Veteran reported a past medical history including "periodic l[eft] shoulder pain since MVA 19 yrs ago which resulted in l[eft] shoulder dislocation and l[eft] lower extrem[ity] compound f[racture]." The report describes that the occasional pain radiates down the left arm, and also notes the Veteran's belief that the left shoulder / arm symptoms may be related to his service in the Gulf War due to "exposure." The medical assessment was "l[eft] shoulder and arm pain" with reference to "h[istory] of [motor vehicle accident] with dislocated l[eft] shoulder and f[ractured] l[eft] leg." The assessment contains no suggestion of a medically recognized link between the symptoms and the Veteran's military service, to include Gulf War exposures. The Veteran filed a claim seeking to establish entitlement to service connection for joint pain, featuring the shoulder symptoms, in September 2003. In the filing of the claim, the Veteran reported that he began experiencing the disability in September 2002. Subsequent medical records, including VA and private treatment reports, confirm that the Veteran has had ongoing treatment for complaints associated with left shoulder pain. VA treatment reports from 2003, beginning in June 2003, indicate that the Veteran complained of left sided paresthesias and tingling during interferon treatment; an August 2003 MRI of the shoulder revealed normal findings. A July 2003 report shows that the treating physician "felt that the tingling was due to a chronic problem of his left shoulder," and did "not think that this is a central [nervous system] problem." An August 2003 VA medical report shows that the Veteran deferred further treatment as he felt that taking Zantac relieved his left shoulder pain. A February 2004 VA examination report confirmed that the Veteran was diagnosed with "muscle aches of unclear etiology." This report does not otherwise discuss any generalized muscle aches, but rather discusses the details of the Veteran's left shoulder complaints of "aches and tingles," with reference to having "dislocated his left shoulder in a motor vehicle accident about 18 years ago." The diagnostic findings for the left shoulder were "[l]eft shoulder with normal x-ray and no acute functional loss of range of motion due to pain," with further notation of "muscle aches of unclear etiology." In March 2005, the Veteran submitted a statement describing: "I have been suffering with joint and muscles pain for a long time." The Veteran recalled that during his Gulf War service "we were giv[en] the Pyridstigmine-Bromide pills to take for protection from nerve gas," and he asserted that "[t]his pill causes chronic fatigue." Furthermore, he cites his recollection of being given "the Anthrax-Botulinum vaccination." The Veteran's January 2009 claim for service connection explained: "I believe my joint pain, muscle pain ... [and other symptoms] are manifestations of my undiagnosed illness." A November 2009 VA examination report presents a diagnostic finding of ""No objective finding to support a diagnosis for residual functional limitation left shoulder status post MVA." A May 2012 VA orthopedic consultation report shows that the Veteran stated "he has had intermittent pain in the left shoulder for the past 10 years." He also reported that his "right shoulder has been painful for the past 3 months and it is now more painful that the left shoulder." The Veteran denied any neck pain or radicular symptoms. After examination and interview, the medical impression was "[p]robable intermittent anterior impingement, both shoulders," and continuing treatment with cortisone injections was recommended. The Veteran's April 2016 VA examination report's "Shoulder and Arm Conditions" DBQ presents the VA examiner's finding that the Veteran has been diagnosed with left shoulder/joint pain due to left shoulder impingement syndrome (diagnosed in May 2012), left rotator cuff tendonitis (diagnosed in 2003), and left glenohumeral joint dislocation (diagnosed through the Veteran's account of his history, associated with the 1982 motor vehicle accident injuries). The report notes that the "Veteran reports onset of Left Shoulder problems, following a 1982 Civilian MVA .... '.... My left shoulder was dislocated out of joint, they put it back in place. Ever since then, I have had problems with my shoulder.'" The VA examiner notes that the Veteran's account was consistent with the account recorded in past medical records, particularly the September 2002 VA initial intake report. The associated medical opinion (available in Virtual VA) explains that the Veteran's "chronic intermittent left shoulder discomfort" presents a "disability pattern ... that meets TL10-01 criteria for a disease with a clear and specific etiology and diagnosis." Additionally, "[i]t is not caused by or related to AD military service," "[i]t is not caused by or related to GW environmental exposures." To support the conclusion that the Veteran's left shoulder disability did not begin during service, the opinion presents a rationale citing the absence of any indication of active left shoulder disability in the February 1976 separation examination and the April 1991 preseparation examination, and the absence of indications of an active left shoulder disability manifestations proximately following either service period. The VA examiner finds that the left shoulder disability was acquired outside of either period of active duty service: "It is acquired [from] ... Left Shoulder dislocation/reduction, following 1982 MVA" and "Diagnosed by 2003 MRI Left Shoulder." The VA examiner also concluded that "[t]here is insufficient evidence to warrant or confirm a diagnosis of acute or chronic Arthralgia, Myalgia, Fibromyalgia, Chronic Fatigue Syndrome (claimed as joint pain, muscle pain and fatigue) or its residuals...." The VA examiner explained that the Veteran's symptomatology "[d]oes not meet VA criteria for Chronic Fatigue syndrome or Fibromyalgia." Other medical reports of record make additional references to assessment and treatment of the Veteran's left shoulder complaints. However, none of these reports present informational significantly contradicting the detailed findings in the evidence discussed above. The Board finds that the April 2016 VA examination report's presentation of these expert medical opinions is adequate and probative evidence addressing the medical questions central to the service connection claim for left shoulder disability or generalized joint pain. The uncontradicted opinions are presented by a medical doctor competent to provide the analysis, and is informed by examination and interview of the Veteran together with review of the claims-file. The opinions are presented with a persuasive analytical rationale citing medical principles and the specific factual history of this case. The opinion cites the Veteran's own accounts of his medical history that repeatedly point to the 1982 motor vehicle accident featuring a dislocation of his left shoulder as the origin of any recurring left shoulder symptoms (with some suggestions that significant manifestations of symptomatology did not emerge until several years after his second period of active duty service). The opinion also cites the absence of indications of left shoulder injury or disability manifestations during active duty service or proximately following active duty service. The April 2016 VA medical opinion specifically identifies the most likely etiology of the left shoulder disability as the dislocation and reduction of the joint in the 1982 motor vehicle accident, outside of any period of active duty service. The April 2016 VA medical opinion also specifically addressed the Veteran's contention that his left shoulder disability may be attributable to particular exposures during his Gulf War service; the medical opinion clearly and competently concludes that such exposures are not the etiology of the Veteran's left shoulder disability. The Board notes that the author of the April 2016 VA examination report's author specifically demonstrated awareness and consideration of the Veteran's "low level exposure to chemical warfare agents released during demolition operations in March 1991 near Khamisiyah, Iraq," and "administered preventative agents including the Veteran's cited 'Pyridostigmine-Bromide pills" and Anthrax Botulinum vaccination," in one section of the overall report. The April 2016 VA examiner also provided the uncontradicted competent medical assessment that the Veteran's symptom complaints do not otherwise support a diagnosis involving generalized joint pain such as arthralgia, myalgia, fibromyalgia, or chronic fatigue syndrome. No diagnosed disability manifesting in generalized joint pain has been noted in the evidence of record. Service connection for a diagnosable disability manifested by generalized joint pain is not warranted without a competent medical diagnosis of such. In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As there is no contrary medical opinion of record (there is no medical opinion of record asserting that the Veteran has a left shoulder or generalized joint diagnosis that is etiologically linked to his active duty military service), the Board finds the pertinent medical opinion presented in the April 2016 VA examination report to be persuasive. The preponderance of the evidence is therefore against finding that the Veteran has a left shoulder or generalized joint disability that is etiologically linked to service. Accordingly, the claim for service connection for left shoulder or generalized joint disability is not warranted on this direct causation basis. As the evidence in this case indicates that the Veteran's chronic left shoulder pathology was caused by an injury in 1982, the Board has considered the Veteran's second period of active duty service (from September 1990 to May 1991) with careful consideration of the significance of the pre-existing left shoulder disability. For the Veteran's second period of active duty service, there is no entrance examination report, and therefore, the presumption of soundness is not for application. See Smith v. Shinseki, 24 Vet. App. 40 (2010). In Smith, the Court explained that the presumption of soundness requires that there be an examination prior to entry into the period of service on which the claim is based, and that in the absence of such an examination, there is no basis from which to determine whether the claimant was in sound condition upon entry into that period of service on which the claim is based. However, the Board finds the evidence of record shows that any residuals of a left shoulder dislocation and reduction the Veteran may have had during the second period of active duty service were the result of the left shoulder dislocation and reduction that took place prior to that service. Notably, the Veteran has not specifically contended that he suffered any other left shoulder injury to suggest an in-service cause for those residuals (aside from the theory of left shoulder pain being due to Gulf War exposures, rejected by the competent medical evidence featuring the April 2016 VA medical opinion). Also, the report of a reserve service examination in May 1988, prior to the second period of active duty service, documents the Veteran's own account of the significant 1982 left shoulder injury. As the presumption of soundness does not apply, the Board must consider whether the evidence establishes that aggravation of the Veteran's left shoulder disability occurred during the second period of active duty service. 38 U.S.C.A. § 1153 contains a presumption of aggravation when it is shown that a pre-existing disorder underwent an increase in disability during service. The presumption of aggravation does not arise if the pre-existing disorder did not undergo an increase in severity in service. In this case, there is no suggestion whatsoever of any increase in any left shoulder symptomatology during service. The April 1991 service separation examination report for this period shows that the Veteran was clinically normal in all respects, and the associated medical history questionnaire shows that the Veteran certified that he was in good health and denied experiencing shoulder problems. Following the period of service, a June 1993 periodic service examination report shows that the Veteran was again found to be clinically normal with respect to the left shoulder and again denied experiencing left shoulder problems. Accordingly, the Board finds that there was no increase in pre-existing left shoulder disability during the Veteran's second period of active duty service; there can be no increase in severity that results in a complete absence of symptoms and clinical signs. The Board also notes that the absence of any suggestion of a manifestation of left shoulder disability during active duty service would prevent the presumption of soundness from attaching even in the event the Veteran's left shoulder were found to have been sound at an entrance medical examination. Before the presumption of soundness is for application in a service connection case, there must be evidence that a disease or injury that was not noted upon Veteran's entry to service manifested or was incurred in service. 38 U.S.C.A. § 1111. Gilbert v. Shinseki, 26 Vet.App. 48, 53 (2012). The April 2016 VA medical opinion is also uncontradicted in its conclusions explaining that the Veteran's left shoulder or generalized joint complaints is neither a manifestation of an undiagnosed illness nor a diagnosed medically unexplained chronic multisymptom illness. The April 2016 VA examination report's Shoulder and Arm Conditions section clearly explains that the Veteran's residuals of left shoulder dislocation and reduction represent a disease "with a clear and specific etiology and diagnosis," with no objective signs of symptomatology to attribute to undiagnosed illness. Furthermore, the "Gulf War General" section (as discussed above) makes clear that the Veteran's disability manifestations include no additional signs and/or symptoms that may otherwise represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." Accordingly, service connection for this disability cannot be granted through application of the special provisions of 38 C.F.R. § 3.317. (There is otherwise no evidence in this case establishing the medical existence of a disability manifested by generalized joint pain.) The preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not allow for a grant of the appeal in this matter. 38 U.S.C.A. § 5107(b). Service Connection for Undiagnosed Illness Manifested By Muscle Pain and Undiagnosed Illness Manifested By Fatigue The Veteran contends that he suffers from a disability manifested by muscle pain and by fatigue due to environmental hazards he encountered during his active duty service in Iraq. He also contends that his reported muscle pain and fatigue symptoms amount to an undiagnosed illness. Finally, the Veteran's claims include the theory that a disability manifested by muscle pain and/or fatigue may be secondary to his hepatitis C (for which he is also seeking to establish service-connection, in a claim addressed above.) An essential question at the core of these claims is whether the Veteran has objective signs of pertinent muscle pain and/or fatigue symptomatology that cannot be attributed to a known medical diagnosis or, alternatively, whether the Veteran may have a medically unexplained chronic multisymptom illness such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome that is defined by a cluster of signs and symptoms. (The Veteran has already established service connection for irritable bowel syndrome). The Board finds that the evidence in this case shows that the Veteran does not objective signs of such a disability, and the Board's discussion of these issues will focus upon that finding. The Veteran was afforded a thorough VA examination to address these questions in April 2016, and the report of that examination (discussed below) presents the most significant evidence addressing these matters. A February 2004 VA examination report indicates that the Veteran was diagnosed with "muscle aches of unclear etiology." This report does not otherwise discuss any generalized muscle aches, but rather discusses the details of the Veteran's left shoulder / left arm complaints of "aches and tingles," with reference to having "dislocated his left shoulder in a motor vehicle accident about 18 years ago." The report does not clearly indicate that the Veteran had any objective signs of generalized muscle pain beyond the specified complaints concerning the left shoulder. In March 2005, the Veteran submitted a statement describing: "I have been suffering with joint and muscles pain for a long time," and "[t]here are times when I do feel fatigue." The Veteran recalled that during his Gulf War service "we were giv[en] the Pyridstigmine-Bromide pills to take for protection from nerve gas," and he asserted that "[t]his pill causes chronic fatigue." Furthermore, he cites his recollection of being given "the Anthrax-Botulinum vaccination." The Veteran's January 2009 claim for service connection explained: "I believe my joint pain, muscle pain, fatigue ... [and other symptoms] are manifestations of my undiagnosed illness." The Veteran's April 2016 VA examination report's "Chronic Fatigue Syndrome" DBQ presents the VA examiner's conclusion that the Veteran does not now have a valid diagnosis of chronic fatigue syndrome and that he has never had a valid diagnosis of chronic fatigue syndrome. The report notes that the Veteran "denies having any joint pain or muscle pain (other than left shoulder pain/impingement syndrome => see DBQ Shoulder conditions.)" Additionally, the "Veteran denies having any other arthralgia/myalgia symptoms, and denies ever being diagnosed, managed, or treated for CFS." The report notes that the "Veteran reports mild intermittent, episodic fatigue (unrelated to CFS) which he directly correlates with his GERD PPO medications: 'I think it is due to side effects from my stomach medications." Furthermore, the report indicates that the "Veteran is currently asymptomatic, he is on new GI Medication...." The April 2016 VA examiner remarks that "[t]here are no associated CFS symptoms. In-service and post-service medical records are silent for CFS," and notes that the "Veteran works as a full-time Machine operator x 20 years; his mild intermittent fatigue does not affect his work, productivity or regular lifestyle. No sick time lost from work." The VA examiner noted that the Veteran "adheres to a regular exercise-walking routine 4 days a week x 2 miles, which he is used to, to maintain his overall health." The report describes: "Generally, veteran feels well, and is in good spirits." The VA examiner indicated that "No," the Veteran has not "had any findings, signs and symptoms attributable to chronic fatigue syndrome." The VA examiner reported that "VA lab work is generally unremarkable with normal CBC, iron levels, electrolytes, renal labs, normal glucose, normal TSH." The VA examiner concluded: "There is insufficient evidence to warrant or confirm a diagnosis of Chronic Fatigue Syndrome (claimed as joint pain, muscle pain and fatigue) or its residuals." The VA examiner clarified that "no condition is diagnosed," and the Veteran "[d]oes not meet VA criteria for Chronic Fatigue syndrome." The VA examiner also explained that the "[s]ubjective complaint of left shoulder joint pain is part & parcel of Left Shoulder Impingement syndrome...." The associated medical opinion (available in Virtual VA) reasserts that "[t]here is insufficient evidence to warrant or confirm a diagnosis of acute of chronic Arthralgia, Myalgia, Fibromyalgia, Chronic Fatigue Syndrome (claimed as joint pain, muscle pain and fatigue) or its residuals," and that the Veteran "[d]oes not meet VA criteria for Chronic Fatigue syndrome or Fibromyalgia." The Veteran's April 2016 VA examination report's "Fibromyalgia" DBQ presents the VA examiner's conclusion that "No," the Veteran has not "ever been diagnosed with fibromyalgia." The report notes that the Veteran "denies ever being diagnosed, managed or treated for Rheumatologic conditions, including Fibromyalgia." The VA examination report makes reference to the Veteran's medical history regarding joint symptoms. (This Board decision has previously provided a thorough discussion of the Veteran's history of particular joint pain symptoms in the section of the decision addressing the issue of entitlement to service connection for left shoulder disability / joint pain.) The VA examiner finds that "[t]here is insufficient evidence to warrant or confirm a diagnosis of acute or chronic Arthralgia, Myalgia, Fibromyalgia (claimed as joint plain, muscle pain and fatigue) or its residuals," and that the Veteran "[d]oes not meet VA criteria for Fibromyalgia." The VA examiner also reiterates that the "[s]ubjective complaint of left shoulder joint pain is part & parcel of Left Shoulder Impingement syndrome...." The Board finds that the April 2016 VA examination report presents medical findings and opinions that are highly probative; they are presented by a medical doctor competent to provide them, informed by interview and examination of the Veteran together with review of the claims-file, and presented with sufficient explanation of rationale, citing the Veteran's own statements, documented medical history, and the expert author's knowledge of medical principles. As the April 2016 VA examination report's opinions are not contradicted by any of the other evidence of record, the Board finds them to be persuasive. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328 (1997). Congress has specifically limited entitlement to service connection for disease or injury to cases where such in-service events have resulted in a current disability. See 38 U.S.C.A. §§ 1110, 1131. Thus, without "competent evidence of current disability," there can be no award of service connection. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). The requirement of having a current disability is met "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran's description of muscle pain to the April 2016 VA examiner was limited to the left shoulder and attributed to the diagnosed left shoulder disabilities, for which service connection has been denied in a separate section of this Board decision. The Veteran's description of mild intermittent episodic fatigue was attributed, even by the Veteran's own impression, to a side effect of a past medication for GERD that has resolved with a change to a new medication. The VA examiner found that there was no diagnosis to be made concerning fatigue. Based on a careful review of the evidence, the Board finds that service connection is not warranted for a disability manifested by general muscle pain nor for a disability manifested by fatigue on the basis of any diagnosis; the competent medical evidence establishes no diagnosed disability manifested by such symptoms at any point during the pendency of this claim (aside from any extent to which the Veteran's left shoulder diagnoses, addressed in a separate section above, may be seen to overlap with the muscle pain issue). Further, the preponderance of the evidence is against a finding that the Veteran has symptoms that cannot be attributed to a known diagnosis; to the contrary, the evidence (featuring the thorough April 2016 VA examination report) is clear that there is simply no current disability or pathology (diagnosed or undiagnosed / explained or unexplained) manifesting in medically significant general muscle pain or fatigue. Moreover, § 3.317 contains a requirement of chronicity, and the record is devoid of documentation of any chronic general muscle pain or fatigue. Service connection cannot be granted on a presumptive basis as due to an undiagnosed illness. Furthermore, as the competent medical evidence (featuring the uncontradicted April 2016 VA examination report) indicates that the Veteran does not meet the medical criteria to support a finding/diagnosis of chronic fatigue syndrome or fibromyalgia. Also, the Veteran's claim of entitlement to service-connection for the claimed disabilities manifested by muscle pain and by fatigue as secondary to nonservice-connected hepatitis C is barred as a matter of law. 38 C.F.R. § 3.310(a); Sabonis v. Brown, 6 Vet.App. 426 (1994). As discussed elsewhere in this Board decision, the Board has determined that service connection is not warranted for hepatitis C. As the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt rule does not apply and the claims must be denied. 38 U.S.C.A § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hepatitis C is denied. Entitlement to service connection for GERD, claimed as due to an undiagnosed illness, to include as secondary to IBS, is denied. Entitlement to service connection for left shoulder pain, also claimed as joint pain due to undiagnosed illness, is denied. Entitlement to service connection for undiagnosed illness manifested by muscle pain is denied. Entitlement to service connection for an undiagnosed illness manifested by fatigue is denied. ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs