Citation Nr: 1701013 Decision Date: 01/12/17 Archive Date: 01/27/17 DOCKET NO. 04-40 661 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a disability manifested by joint pain of the hands, left ankle, and hips, to include as due to an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 2. Entitlement to service connection for a disability manifested by rashes, to include as due to an undiagnosed illness or a MUCMI. 3. Entitlement to service connection for an intestinal disability, to include hemorrhoids and to include as due to an undiagnosed illness or a MUCMI. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Isaacs, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1989 to June 1992. He had service in Southwest Asia from August 1990 to April 1991. These matters are before the Board of Veterans' Appeals (Board) on appeal from an August 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claims have been remanded by the Board multiple times, most recently in November 2013. The Board indicated in the November 2013 remand that the issues of entitlement to service connection for gastroesophageal reflux disease (GERD) and a total disability rating based on individual unemployability (TDIU) had been raised and therefore were referred to the agency of original jurisdiction (AOJ). The Board notes the RO granted a TDIU in a November 2014 rating decision and denied service connection for GERD in a January 2015 rating decision. The Board notes additional evidence was received after the July 2014 supplemental statement of the case (SSOC), including VA examination reports and additional VA treatment records, as well as records from the Social Security Administration (SSA). However, the Board finds that the additional evidence is not pertinent to the claims decided herein, or is cumulative and duplicative of that already of record. Thus, a remand for an additional SSOC is not necessary for the claims. See 38 C.F.R. § 20.1304(c). FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia Theater of Operations during the Persian Gulf War. 2. The Veteran's joint pain of the hands, left ankle, and hips, which is compensably disabling, cannot be attributed to any known clinical diagnosis. 3. The Veteran's disability manifested by an ongoing rash is not a MUCMI, but is a distinct diagnosed condition; and his rash did not have its onset during service and was not caused by service. 4. The Veteran's intestinal disability, to include hemorrhoids is not a MUCMI, but is a distinct diagnosed condition; and his condition did not have its onset during service and was not caused by service. CONCLUSIONS OF LAW 1. The criteria for service connection for joint pain have been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2016). 2. The criteria for service connection for a disability manifested by rashes have not been met. 38 U.S.C.A. §§ 1110, 1131, 1117, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2016). 3. The criteria for service connection for an intestinal disability, to include hemorrhoids, have not been met. 38 U.S.C.A. §§ 1110, 1131, 1117, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be established for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability resulting from an undiagnosed illness or MUCMI that became manifest 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. 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 can be a chronic disability resulting from a MUCMI that is defined by a cluster of signs of symptoms, such as chronic fatigue syndrome and fibromyalgia. 38 C.F.R. § 3.317(a)(2)(i)(B). Analysis A. Joint Pain The Veteran asserts that he is entitled to service connection for joint pain of the hands, left ankle and hips. The Veteran's service treatment records show the Veteran received treatment during service for a left ankle sprain in February 1990 and for a back contusion in September 1990. In the April 1992 report of medical history, he reported complaints including arthritis, rheumatism, or bursitis, recurrent back pain, trick or locked knee, and foot trouble. He stated he experienced arthritis pain in his hands and back because of exposure to cold and damp weather, that he hurt his lower back in a parachute jump, and that occasionally his left knee popped out. He reported he served as a paratrooper during service with 46 jumps. The April 1992 separation examination provided normal findings. The Veteran was afforded a December 2010 VA examination in which he reported pain, stiffness and locking in the left ankle, bilateral knees and hips. The examination revealed full range of motion of the left ankle and hips, but pain was reported with motion, that increased with repetitive motion. The examiner indicated "no significant pathology of the ankle and hips." Further, the hand examination reflected that the Veteran complained of bilateral hand problems, including pain, numbness and weakness. However, no orthopedic condition was found of for the hands. Thereafter, the Board remanded this claim in April 2012 to obtain an addendum opinion from the December 2010 VA examiner. The VA examiner submitted an addendum in May 2012 in which she indicated that based on review of the Veteran's history, the Veteran did not have a disability of the hands, left ankle and left hip. She noted that his symptoms do not indicate an undiagnosed or multisystem illness. The Board determined in April 2013 that the opinions were inadequate and another VA examination was required. An examination was afforded to the Veteran in May 2013. The Veteran reported hand pain, swelling, stiffness, tingling and weakness since service. He indicated he still has complaints of pain but that he takes Tylenol and "squeezes a ball." He reported that in inclement weather, his pain flares to 8-9/10. The examiner indicated there was no rheumatologic or orthopedic diagnosis, no specific injury to the Veteran's hands, and x-rays and other tests were found negative. The examiner went on to state that the Veteran reported chronic bilateral hip pain since a hard landing he had during paratrooper training in service. The examiner noted that a December 1991 record confirms a hard landing with rib contusions; however, there was no hip pathology diagnosed at that time or presently. The Veteran reported to the examiner daily pain of 8-9/10 in the left hip and 6/10 in the right hip, with stiffness and weakness. He reported needing a cane and that he has to rest after two blocks due to the pain. The examiner noted there were insufficient objective findings on examination to establish a diagnosis for the left hip. The mild pain and weakness in the Veteran's left hip may have been subjective and did not correlate with a specific left hip diagnosis. The Board notes the examiner also indicated that there was no current left ankle injury. After review of all the evidence, including several VA examinations, the Board finds that the current joint pain the Veteran suffers from is related to his service in Southwest Asia. The Veteran has consistently reported that his joint pain began in service and the Board finds no reason to doubt the veracity of his statements regarding onset. As noted, the Veteran has been afforded multiple VA examinations on appeal. The examiners did note subjective complaints of pain; however, they failed to provide a diagnosis that would account for the Veteran's chronic pain. In making all determinations, the Board must consider the lay assertions of record. A layperson is competent to report the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran has consistently reported pain in his hands, hips and left ankle, and he is certainly competent to describe his pain symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Further, as the Veteran has consistently reported these symptoms, the Board finds him to be credible. In light of the Veteran's competent and credible reports regarding his joint pain, the Board finds that service connection is warranted as an undiagnosed illness manifested by joint pain. The Veteran has qualifying service in the Southwest Asia Theater of Operations; his hands, hips and left ankle complaints cannot by history, physical examination, or laboratory tests, be attributed to a known clinical diagnosis; and, his symptoms have persisted for more than 6 months. Further, the Board finds his symptoms are, at the very least, 10 percent disabling in the affected areas. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App 1 (2011) (providing, inter alia, that where the disability is noncompensable and the Veteran complains of pain on motion, the Veteran is entitled to at least the minimum compensable rating for the joint). After resolving reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted for disabilities manifested by joint pain of the Veteran's hands, hips and left ankle. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, entitlement to service connection for joint pain is warranted. B. Rashes The Veteran claims an ongoing genital skin rash is related to his service in Southwest Asia. The Veteran's service treatment records are negative for complaints, treatment, or diagnosis of a skin disorder. His April 1992 separation examination revealed a normal clinical evaluation. However, in an October 1996 correspondence, the Veteran reported experiencing a recurring genital rash. He reported that during his service, he had experienced an itchy inguinal area rash while in Southwest Asia. By way of history, the Veteran's claim has been remanded several times previously. The Veteran was afforded a May 2012 VA examination in which the examiner indicated the Veteran did not have a skin rash or disorder. She reported that he had a groin rash previously caused by tinea cruris, but it resolved with some residual hyperpigmentation of the groin. She indicated a thorough review of the record did not support any current skin rash or disorder and the Veteran did not have a skin condition which was indicative of an undiagnosed or multisystem illness. The claim was remanded by the Board in April 2013 for an examination. The Veteran was afforded an August 2013 VA examination in which the examiner indicated the Veteran had no current skin rash or active skin disorder. She stated, "Currently there is no evidence of an active skin condition or fungal infection, hence I cannot made a definite diagnosis of a skin condition currently." She went on to note that the Veteran has an area of hyperpigmentation of the groin, which was deemed as probably due to his reported history of tinea cruris or a fungal infection of the groin. The examiner could not connect the Veteran's skin complaints to any related disease or injury incurred in service, in part because the service treatment records were silent for complaints or treatment of an in-service skin condition. The examiner went on to state the Veteran does not have an unexplained skin disability or disease, and that his skin diagnosis was explainable. She clearly reported the condition was tinea cruris in the past, which resolved with some residual hyperpigmentation of the groin. In the November 2013 remand, the Board required an addendum opinion from the August 2013 VA examiner. The Board directed the examiner to discuss reports of intermittent rashes since 1990, as well as the presence of tinea pedis in the record. Thereafter, a June 2014 VA addendum opinion from the August 2013 VA examiner was received. The examiner extensively reviewed the record, including the December 2012 private records, and acknowledged the Veteran's long-standing complaints of rashes. However, on her two previous examinations of the Veteran in 2008 and 2013, and in a review of the record in 2014, she was unable to find evidence of recurrent, active skin rashes. She stated that any skin disorder present during the pendency of the claim (since October 1996) was not caused of permanently worsened by a service-connected disability. The post-inflammatory pigment change was noted and she found any skin disorder was not caused or permanently worsened by a service-connected disability. She provided a diagnosis for the condition, as a common resolved fungal infection of the groin and noted no evidence of a skin disorder. After review of the all the evidence set forth, the Board finds that service connection is not warranted for the Veteran's recurrent rashes. Initially, with regard to rashes being a MUCMI, the June 2014 examiner's probative opinion established the Veteran's rashes were a well characterized disease with a specific etiology. She reported that his skin diagnosis was explainable as tinea cruris and in the past it had resolved with some residual hyperpigmentation of the groin. The condition is a clear diagnosis rather than an undiagnosed illness or medically unexplained chronic multi-symptom illness, and it would not fall within the provisions of 38 C.F.R. § 3.317. Further, the Board places great probative weight on the persuasive opinion of the VA examiner from June 2014. The Board finds that the post-remand opinion is adequate to decide the issue as it is predicated on a review of the record, to include the Veteran's entire medical history. Furthermore, the opinion proffered considered all of the pertinent evidence of record and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Thus, the Board finds that the weight of the probative medical evidence of record is against a link between the Veteran's service and recurrent rashes. The Board acknowledges the Veteran's service in Southwest Asia and his contentions that his recurring rashes had their onset in service. However, while he is competent to diagnose readily observable symptoms such as a rash, he is not competent to provide opinions or statements regarding the etiology of such. See Jandreau, 492 F.3d at 1372. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinions are afforded less probative weight than the physicians' medical opinions of record. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Additionally, the Veteran's rashes were not found to have had their onset during or within a year of service, and were not caused by service. As noted, the service treatment records, including the April 1992 separation examination, were silent for complaints of a rash and the first mention of the condition was October 1996. The Board notes that the Veteran did have service in the Persian Gulf and he was exposed to environmental hazards during his service. However, the question of service connection for rashes as a result of such exposure is not subject to a presumption. Rashes have been established as a clear diagnosis rather than an undiagnosed illness or MUCMI, and it would not fall within the provisions of 38 C.F.R. § 3.317. The June 2014 opinion persuasively explained that it has conclusive pathology or at least partially understood pathology and it is also not one of the listed infectious diseases. Thus, the preponderance of the evidence is against the claim of entitlement to service connection for rashes. As the preponderance of the evidence is against the claim, the benefit-of-the doubt doctrine is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. C. Gastrointestinal Disorder/Hemorrhoids In his October 1996 correspondence, the Veteran stated he had experienced constipation and intestinal pains since service. The service treatment records include treatment in May 1990 for gastroenteritis and treatment for constipation in August 1991. In the April 1992 report of medical history, the Veteran indicated complaints of frequent indigestion as a result of eating pre-packaged field rations and that he had occasional rectal irritations. However, the April 1992 separation examination revealed a normal intestinal evaluation. In the October 1996 Persian Gulf VA examination the Veteran stated he had experienced heartburn and diarrhea while in Southwest Asia, as well as constipation. The examiner noted hemorrhoids on a rectal examination and diagnoses included heartburn and constipation. A March 2001 VA general medical examination included a diagnosis of gastroesophageal disease with onset in 1990. A March 2005 private medical record diagnosed the Veteran with irritable bowel syndrome (IBS). Thereafter, the Board remanded the claim in April 2012. The Board afforded the Veteran a May 2012 VA examination to determine the nature and etiology of all lower gastrointestinal disorders. The examiner concluded that the Veteran did not have at any point a disability manifested by lower gastrointestinal symptoms due to service. She further reported that there was no disability manifested by lower gastrointestinal symptoms due to an undiagnosed illness or a medically unexplained multi-symptom illness and further, no symptoms that collectively constitute a medically unexplained illness. The examiner's rationale centered on the Veteran's own denial of having any complaints of gastrointestinal symptoms. The examiner noted his history of hemorrhoids and occasional bright red blood spotting. However, no other IBS or other lower gastrointestinal conditions were reported. An April 2013 Board remand determined that an additional opinion was necessary to determine if the Veteran's diagnosed hemorrhoids were related to service. An April 2013 examiner diagnosed the Veteran with internal or external hemorrhoids. The examiner indicated the Veteran had a history of hemorrhoids for many years with intermittent rectal bleeding. The Veteran reported to the examiner slight discomfort but no external hemorrhoid. The Veteran reported he suffers flares 3-4 times per month. His treatment included taking continuous medication for the condition. An examination of the rectum was not provided because he reported to the examiner that no hemorrhoids were showing at that time. The examiner concluded the Veteran has hemorrhoids and the condition is less likely than not etiologically related to active service. She indicated there were no treatment records of hemorrhoids during the Veteran's military service. She did note his 1991 treatment for constipation; however, there were no hemorrhoids or rectal bleeding noted. Further the April 1992 separation examination did not mention any history of hemorrhoids or rectal bleeding. The Board finds the Veteran's current hemorrhoids are not related to service. Initially, with regard to the condition, there is a well characterized disease with a specific etiology. The May 2012 VA examiner provided a specific diagnosis and indicated there was not an undiagnosed illness or a MUCMI present. The Board finds hemorrhoids was provided as a clear diagnosis, and thus, it does not fall within the provisions of 38 C.F.R. § 3.317. With regard to etiology to service, the Board also places great probative weight on the post-remand April 2013 VA opinion. The examiner indicated the Veteran currently has a hemorrhoids diagnosis but that it is not related to his active service. An examination of the rectum area for the condition did not occur as the Veteran reported he was not currently suffering from the condition. However, based on his history, the hemorrhoids diagnosis was given and a negative nexus opinion was provided. The examiner relied on the lack of treatment records during service and also no reports of hemorrhoids or rectal bleeding in the separation examination, to conclude that the condition is not etiologically related to service. To the extent that the Veteran contends he has hemorrhoids related to service, the Board notes the Veteran is a layperson. Therefore, while the Veteran may be able to recognize hemorrhoids as being apparent, he is not qualified to provide an etiology opinion for such a complex condition. His opinions in this regard are less probative than the medical experts' opinions of record. In summary, the Board finds that, while the Veteran does currently suffer from hemorrhoids, the evidence does not show in-service onset or sufficient evidence that the condition is linked with service. Therefore, the preponderance of the evidence is against his claim, there is no doubt to be resolved, and service connection for an intestinal condition, to include hemorrhoids, is not warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for joint pain of the hands, left ankle, and hips is granted. Service connection for rashes is denied. Service connection for an intestinal condition, to include hemorrhoids, is denied. ______________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs