Citation Nr: 1756053 Decision Date: 12/05/17 Archive Date: 12/15/17 DOCKET NO. 10-02 398 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a sinus disorder, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 2. Entitlement to service connection for headaches, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 3. Entitlement to service connection for chronic fatigue, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 4. Entitlement to service connection for a left knee disability, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 5. Entitlement to service connection for a right knee disability, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD A. Parrish, Associate Counsel INTRODUCTION The Veteran had active service from March 6, 2000, to May 7, 2004, to include service in Iraq. The Veteran also had a second period of active service from May 8, 2004, to May 8, 2006, in which he was discharged under conditions other than honorable. In a final October 2007 administrative decision, it was held that the character of his second period of active service was a bar to payment of VA benefits for that period of active service. These matters are before the Board of Veterans' Appeals (Board) from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran thereafter moved and jurisdiction over the appeal was transferred to the RO in Waco, Texas. The issue of entitlement to a TDIU is on appeal from rating decisions of the VA RO in Waco, Texas. The Board observes that the Veteran requested a hearing before a Veterans Law Judge in connection with his appeal. He was informed in March 2014 correspondence that his requested hearing had been scheduled for April 2014; however, he failed to report for such hearing. Therefore, his request for a Board hearing is considered withdrawn. 38 C.F.R. §§ 20.702(d), 20.704(d) (2017). In July 2014 and February 2017, the Board remanded these matters for additional development. FINDINGS OF FACTS 1. There is no competent evidence showing that the Veteran has ever been diagnosed with sinusitis. 2. The Veteran's allergic rhinitis did not have its onset in service and is not otherwise related to service, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 3. There is no competent evidence showing that the Veteran has ever been diagnosed with a headache disorder. 4. The Veteran's headaches did not have onset in service and are not otherwise related to service, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 5. There is no competent evidence showing that the Veteran has ever been diagnosed with chronic fatigue syndrome. 6. The Veteran's left knee patellofemoral pain syndrome did not have onset in service and is not otherwise related to service, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 7. The Veteran's right knee patellofemoral pain syndrome did not have onset in service and is not otherwise related to service, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. 8. The Veteran's service-connected disabilities do not preclude him from securing and following any substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for sinusitis or for allergic rhinitis, to include as due to an undiagnosed illness or other qualifying chronic disability, have not been met. 38 U.S.C. §§ 1110, 1113, 1117, 1118, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.317 (2017). 2. The criteria for service connection for headaches, to include as due to an undiagnosed illness or other qualifying chronic disability, have not been met. 38 U.S.C. §§ 1110, 1113, 1117, 1118, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.317 (2017). 3. The criteria for service connection for chronic fatigue, to include as due to an undiagnosed illness or other qualifying chronic disability, have not been met. 38 U.S.C. §§ 1110, 1113, 1117, 1118, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.317 (2017). 4. The criteria for service connection for a left knee disability, to include as due to an undiagnosed illness or other qualifying chronic disability, have not been met. 38 U.S.C. §§ 1110, 1113, 1117, 1118, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.317 (2017). 5. The criteria for service connection for a right knee disability, to include as due to an undiagnosed illness or other qualifying chronic disability, have not been met. 38 U.S.C. §§ 1110, 1113, 1117, 1118, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.317 (2017). 6. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2017). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303 (2017). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2017). Additionally, pursuant to 38 U.S.C. § 1117, a Persian Gulf Veteran with a qualifying chronic disability that manifests to a degree of 10 percent or more before December 31, 2021, may be entitled to compensation. See 38 U.S.C. § 1117 (2012); 38 C.F.R. § 3.317 (a)(1) (2017). See also 81 Fed. Reg. 71,382 (October 17, 2016) (rule extending the date by which a disability must manifest to a degree of 10 percent or more pursuant to 38 C.F.R. § 3.317). There are three avenues for finding that a chronic disability may qualify for presumptive service connection pursuant to 38 U.S.C. § 1117. Qualifying chronic disabilities include those that result from (1) an undiagnosed illness, (2) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders, or (3) any diagnosed illness that the Secretary determines in regulations . . . warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2)(A), (B), (C); 38 C.F.R. § 3.317(a)(2)(i)(B). A medically unexplained chronic multi-symptom illness is "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." 38 C.F.R. § 3.317(a)(2)(ii). Disabilities that have existed for 6 months or more and disabilities that that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). A qualifying chronic disability shall be rated using the criteria from part 4 of the chapter for a disease or injury which the functions affected, anatomical localization, or symptomology are similar. 38 C.F.R. § 3.317(a)(4). Along with the three examples of a medically unexplained chronic multi-symptom illness provided by § 1117(a)(2)(B), the law provides a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multi-symptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. See 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). The first requirement for any service connection claim, however, is evidence of a disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Initially, the Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to each claim. Factual Background The Veteran seeks service connection for a sinus disorder, headaches, chronic fatigue, a left knee disability and a right knee disability. The Veteran's February 2000 enlistment report of medical history and concurrent medical examination do not report complaints or issue with any of the aforementioned systems. A March 2003 service treatment record (STRs) indicated the Veteran presented with fatigue, hot flashes, and sweating. He stated that he believed his symptoms were related to a vaccine he received days prior. His examination was normal and he was advised to return to duty and follow-up as needed. In a November 2004 post-deployment health assessment, the Veteran reported he developed chronic cough, runny nose, headaches, and weakness. He denied having swollen, stiff or painful joints. He reported his health as being very good and denied that any medical problems developed during his deployment. A December 2004 private medical report showed the Veteran had been involved in a motorcycle accident in which he lost consciousness. His major compliant was facial and head pain, along with bilateral hand and wrist pain. A CT of the Veteran's face indicated his paranasal sinuses were normally aerated with the exception of a very small polypoid foci in the maxillary sinuses. A February 2005 STR separation report of medical examination showed the Veteran had abrasions on this bilateral knees due to a motorcycle accident. He also was found to have post-concussive syndrome due to his motorcycle accident. No issues regarding the Veteran's sinuses or nose was found or reported. Abrasions to his bilateral knees were found secondary to his motorcycle accidents. In his concurrent report of medical history, the Veteran denied sinusitis, chronic fever or frequent colds, chronic cough, bronchitis, or any breathing problems. He also denied ear, nose, or throat trouble. He denied knee trouble, locking, giving out, or pain. He denied frequent or severe headaches. A March 2005 STR reported the Veteran was healthy and had no limitations on his duty. A May 2005 STR indicated the Veteran was involved in a motorcycle accident. He reported that both of his knees hurt. Upon examination, he reported tenderness of his right knee with pain at 8 out of 10 on the pain scale. He had tenderness of the patella of both knees and edema of both knees. In a concurrent report of medical history, the Veteran indicated he had nosebleeds which lasted 5 minutes. A November 2007 VA Medical Center (VAMC) primary care intake note stated the Veteran was there for a new patient visit. He did not report any complaints. In December 2007, the Veteran underwent a VA examination. The Veteran identified groin pain, bilateral pes planus, and back pain as his problems to be evaluated. He did not report sinus pain and his nose, sinuses, mouth and throat were generally clear to examination. He did not report headaches. The Veteran also did not report fatigue or any complaint regarding his knees. Upon examination, his knees were noted to have good motion. He was not noted to use braces of any sort. A May 2012 VAMC primary care clinic note indicated the Veteran reported a history of left knee pain after jumping 1 week prior during a pickup basketball game. He experienced subsequent knee buckling. He reported his pain was not relieved by medication. A June 2012 VAMC MRI of the Veteran's left knee showed bone contusion at the lateral tibial plateau and few areas of full-thickness chondral fissuring at the lateral tibial plateau. An X-ray was noted to be unremarkable, with no degenerative changes noted. A May 2013 VA Gulf War General Medical examination found the Veteran did not have a diagnosed illness for which no etiology was established or additional signs and/or symptoms that may have represented an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." In February 2014, a VAMC clinical history of the Veteran indicated that the Veteran had numerous motorcycle accidents, with the most recent being 2006. A CT of the Veteran's head had normal findings, with visible portions of the paranasal sinuses and mastoid air cells found to be clear. In April 2014, a VAMC general consult note showed the Veteran to have right and left knee flexion and extension at full strength which was nonpainful. A May 2015 VA examination regarding sinusitis indicated the Veteran had been diagnosed with allergic rhinitis in 2015. The Veteran reported that he had onset of sinus symptoms in his late teen years, which increased during his deployment in 2001 and increased in symptoms while in Iraq. He reported that his symptoms intensified due to his inability to take his over the counter (OTC) medications. He reported an increase in his symptoms since his return to Texas. He reported nasal congestion, rhinorrhea, sneezing and watery eyes. He stated that his OTC medications were not effective. He denied taking antibiotics for allergy symptoms and he did not report a history of allergy symptoms. The Veteran estimated he missed 2 days of work in the last 12 months, due to allergy symptoms, having to re-schedule his clients in his barber work. Upon examination the Veteran was found to have rhinitis, but did not have a 50 percent obstruction of the nasal passages, complete obstruction of nasal passages, hypertrophy of the nasal turbinates, nasal polyps, or any granulomatuous conditions. His nasal mucosa was pink and moist, with no bulbar or palpebral conjunctival redness. There was no palpable sinus tenderness found. The Veteran's tonsils were present and normal appearing. There was no palpable cervical adenopathy found. The examiner noted that the Veteran's nasal symptoms were a disease with a clear and specific etiology and diagnosis of allergic perennial rhinitis. The examiner stated that the disability pattern or diagnosed disease was not likely related to a specific exposure event experienced by the Veteran during service in Southwest Asia, as the evidence found indicated onset of allergy symptoms prior to entering military service, with variable intensity of symptoms occurring with environmental change, which was anticipated as a natural course of events for allergic rhinitis. The examiner further stated that there was no evidence to support unusual aggravation of the disease as related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Ultimately, the examiner opined that the Veteran's allergic rhinitis was less likely than not caused by or was otherwise related to the Veteran's period of active service from March 2000 to May 7, 2004, to include his service in Southwest Asia. A May 2015 VA examination regarding the Veteran's headaches found that the Veteran had headaches by history in 2015, though his examination on that date was normal. He reported that he had not been diagnosed with migraine headaches and he could not recall when his last headache had occurred. His prior headaches had occurred in a hot environment during physical training, along with nosebleeds. He reported that he did not seek treatment for his headaches, but had self-treated. Upon examination, he did not have headache pain, non-headache symptoms associated with headaches, prostrating attacks of migraine/non-migraine headache pain, or other physical findings, complications, conditions, signs and/or symptoms of headaches. The examiner also found that the Veteran's headaches were not described as migrainous. The examiner stated that the Veteran's reported prior headaches were more likely than not related to his qualifying period of active service, as the current clinical examination findings were most consistent with a diagnosis of normal findings on exam, with history of chronic headaches secondary to environmental heat exposure, which had since resolved. The examiner stated that the evidence supported the fact that the Veteran was exposed to hot environmental temperatures during military service and that his headaches had also been associated with several motorcycle accidents, which had also resolved since the last motorcycle accident. A May 2015 VA examination regarding CFS found that the Veteran had not ever been diagnosed with CFS. The Veteran reported a gradual onset of fatigue about 2002 during his first deployment to Afghanistan. He attributed the onset to receiving multiple vaccines prior to his deployment. Overall, he stated the fatigue was about the same currently. He described a lack of energy for daily activities, in spite of amount of rest. He reported feeling "tired and sluggish." He denied receiving any treatment for the chronic fatigue. He reported treating his stress and pain with marijuana. He reported that his typical sleep pattern was going to bed about 2200 and getting up at 0600, with difficulty falling asleep and staying asleep, which he attributed to stress/anxiety. He denied taking daytime naps and estimated missing either study time or work in the last 12 months, 2 days a week due to generalized fatigue. Upon examination, the Veteran was found to have evidence of chronic anxiety and depression with chronic sleep disturbances, as well as evidence of mild anemia, all of which contributed to overall generalized chronic fatigue. His symptoms attributable to CFS were sleep disturbance, which were nearly constant. The symptoms did not restrict routine daily activities as compared to the Veteran's pre-illness levels or result in periods of incapacitation. The examiner stated that the clinical examination finding were most consistent with a diagnosis of chronic mental health conditions with sleep disturbance, with secondary chronic fatigue. The examiner found no evidence of chronic fatigue syndrome. The examiner further stated that the Veteran's disability pattern was a disease with a clear and specific etiology and diagnosis: chronic mental health conditions with sleep disturbance, with secondary chronic fatigue, and opined that it was not likely that chronic fatigue was related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner opined that the Veteran's chronic fatigue was not likely caused by, has continued since, or was otherwise related to his period of active service from March 2000 through May 7, 2004, which included a tour of duty in Southwest Asia and included a March 2003 complaint of fatigue symptoms following a vaccine injection, documented in the STRs. A May 2015 VA examination regarding the Veteran's bilateral knees found that the Veteran had bilateral patellofemoral pain syndrome, diagnosed in 2015. The Veteran reported gradual onset of bilateral knee pain beginning in 2006, which he attributed to excessive physical training and hiking with carrying heavy artillery and gear. He denied any direct trauma to the knees. He stated both knees were now worse, requiring knee braces before he worked out or ran/played. He reported self-treatment with OTC medication. The Veteran had a history of multiple motorcycle accidents, with last accident about 2009. He denied recalling injuring the knees during any motorcycle accident. He reported his left knee pain was greater than his right knee pain, which was intermittent and occurred about 4 times a week, lasting 2 days. He stated that the average pain rating was 6 out of 10 for both knees. He reported the pain increased with body weight lifting, running, and playing basketball. He reported his pain decreased with resting and wearing knee braces. He denied taking any pain medication for the knees. He had left knee mild swelling weekly with strenuous activity and workouts. He denied knee popping/clicking or giving out. He did not report flare-ups of pain or having functional loss or impairment. Upon examination, his right and left knee had flexion to 135 degrees and extension to 0 degrees. His range of motion was found to be normal for his age and bony habitus. The range of motion did not contribute to functional loss. No pain was noted upon examination and there was no evidence of pain upon weight-bearing. He was able to perform repetitive testing with at least three repetitions without any additional functional loss or range of motion. Pain significantly limited his functional ability with repeated use over a period of time in both the right and left knee. Muscle strength testing of both knees was normal. No ankylosis of the right or left knee or joint instability was found. Degenerative arthritis was not found in either knee. The examiner found that the Veteran's disability pattern was a disease with a clear and specific etiology and diagnosis: a history consistent with bilateral patellofemoral syndrome. The examiner stated that it was not likely that bilateral patellofemoral syndrome was related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Further, the examiner found that there was no evidence of evaluation or treatment for bilateral knee injuries while in SWA region or during military service. The examiner opined that the Veteran's bilateral patellofemoral pain syndrome was not caused by or otherwise related to his period of active service from March 2000 to May 7, 2004, to include his service in Southwest Asia. In July 2015, a VAMC ambulatory care history and physical indicated the Veteran had a negative history for increased frequency headaches and negative for nasal discharge. In April 2017, a VA examination regarding the Veteran's knees found him to have bilateral patellofemoral pain syndrome, which the Veteran reported caused dull pain in the anterior aspect and infrapatellar region of his knees. He pain was worse with running long distance, running or walking, bending in a crouched position as in when he rode his motorcycle, and when arising from a seated position after a prolonged period of sitting. He also reported intermittent swelling. Alleviating factors were reported to be rest. He stated that he managed the condition with rest and intermittent use of knee strap "for runner's knee." He did not take pain medications or use assistive ambulatory devices. He reported flare-ups only when he was in active pain, and described them as dull pain which lasted 20 to 30 minutes or until he rested. He reported functional loss as not being able to run or walk for long periods of time over 30 minutes, lift weight over 200 lbs, or ride his motorcycle. Upon examination, his right and left knee had flexion to 135 degrees and extension to 0 degrees. Pain on flexion was noted in both knees, but did not contribute to functional loss. There was no evidence of pain upon weight-bearing in either knee. There was objective evidence of crepitus in both knees. There was objective evidence of localized tenderness or pain on palpation of the left knee, but no such objective evidence in the right knee. The left knee had mild tenderness to palpation of the anterior patella. He was able to perform repetitive testing with at least three repetitions without any additional functional loss or range of motion. Muscle strength testing of both knees was normal. No ankylosis of the right or left knee or joint instability was found. Degenerative arthritis was not found in either knee. The examiner found that the Veteran's knee condition might impair his ability to perform occupational tasks that required repetitive kneeling, squatting, or prolonged standing and walking, but that it did not preclude sedentary activities. The examiner stated that the Veteran's bilateral patellofemoral pain syndrome less likely than not had its onset directly during the Veteran's qualifying period of service (i.e., March 6, 2000, to May 7, 2004) and was less likely than not related to any event or injury during his qualifying period of service. The examiner further stated that the Veteran's bilateral knee condition was not an undiagnosed illness, and was not a part of a diagnosable chronic multi-symptom illness of unknown etiology. The Veteran's bilateral knee condition was not found by the examiner to result from exposure to environmental hazards due to service in SWA, as patellofemoral pain syndrome is caused by repetitive contact between the femur and the patella that is due to mal-tracking of the patella. The examiner noted that the Veteran reported that his knee pain had been ongoing since active duty service. The examiner stated, however, that the weight of evidence did not support continuity of or chronicity of knee pain in service. The examiner's review of the Veteran's file provided documentation of complaint bilateral knee pain in May 2005 after falling off a motorcycle and in December 2004 after a motorcycle accident. The examiner further noted that there was insufficient evidence that the condition incurred during those periods became chronic as evidenced by his military separation medical history in which the Veteran denied "knee trouble." Moreover, the examiner noted that the 2007 VA examination documented a normal range of motion to both knees. The examiner also found that the June 2012 VAMC primary care note that stated that the Veteran complained of knee pain while jumping during basketball game and subsequent knee buckling was exemplary of injury and overuse reported after active duty service that was more likely than not the etiology of the Veteran's diagnosed knee problem. In May 2017 the Veteran had a comprehensive VA examination regarding his claimed conditions. In that examination, regarding CFS, the examiner found that the Veteran did not have and had not been diagnosed with CFS, and did not have or had been found to have any findings, signs and symptoms attributable to chronic fatigue syndrome. Similarly, the examiner found that the Veteran did not have and had not been diagnosed with a headache condition. Additionally, the VA examination regarding the Veteran's sinuses found that the Veteran had allergic rhinitis. The Veteran reported constant nasal congestion and itchy, runny nosed with headache, which he pointed to his sinuses. He was found to have a greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis, but not a complete obstruction of either nasal passage. He was also found to have permanent hypertrophy of the nasal turbinates. No nasal polyps or granulomatous conditions were found. He reported taking OTC medications as needed. The examiner stated that the Veteran reported congestion with pain in his paranasal sinuses. The examiner's review of the STRs and post-service medical records did not reveal treatment for that condition. Thus, the examiner stated that it was less likely than not that the Veteran's allergic rhinitis was related to service. The examiner found that the Veteran did not have a diagnosis of headaches. Thus, the examiner opined that it was less likely than not that the Veteran had chronic headaches or sinusitis related to service. The examiner noted that CT scans of the Veteran's head in 2004 and 2014 were normal. Ultimately, the May 2017 examiner stated that the Veteran's physical examination and diagnostic studies did not reveal any "undiagnosed illnesses" or "diagnosed medically unexplained chronic multisymptom illnesses." The Veteran was not found to have any established illnesses with findings that could not be attributed to a known, clearly defined diagnosis. The examiner specifically stated that he knew of no credible medical authority, peer reviewed study, or directive that had established a link between Southwest Asia service and the Veteran's claimed conditions. In light of the above, the Board finds that service connection for a sinus disorder, headaches, chronic fatigue, a left knee disability, and a right knee disability, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317, is not warranted. Direct service connection necessitates a finding that the Veteran's disorders are related to an injury or disease incurred in service. The evidence of record does not support such a finding regarding the disorders claimed by the Veteran. In regards to the Veteran's contended sinusitis claim, the Board finds that there is no evidence of record which would establish that the Veteran has or has ever been diagnosed with sinusitis. The Veteran's STRs are void of treatment for or complaint of symptoms associated with his sinuses within the Veteran's qualifying period of service (March 6, 2000, to May 7, 2004). In fact, there is no evidence of record which establishes the Veteran sought treatment for any sinus related complaints. Though he did report cough and runny nose in his 2004 post-deployment physical, he also indicated in that same report that he was in good health and did not develop any medical problems while deployed in 2004. He denied sinusitis and related nasal symptomology in his 2005 separation report of medical history and the concurrent examination did not find any symptomology regarding the Veteran's nose or sinuses. The Veteran also did not indicate he had any sinus symptoms in his November 2007 VAMC record or in his December 2007 VA examination. Indeed, the Veteran has not identified any medical treatment for sinusitis and none can be found in the medical evidence of record. Thus, the claim for service connection for sinusitis must be denied because the first essential element for the grant of service connection, competent evidence of the disability for which service connection is sought, is not met. In regards to the Veteran's diagnosed allergic rhinitis, the medical opinions of record all stated that the Veteran's diagnosis was less likely than not related to service. From the medical evidence of record, the first diagnosis of allergic rhinitis was made in the Veteran's May 2015 VA examination - over nine years after his qualifying period of active duty service. The passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Again, though the Veteran did have complaint of runny nose during his 2004 deployment, there is no evidence of record which would support a finding that those complaints persisted. He denied such symptomology in his 2005 separation examination and report of medical history. In his 2007 VA treatment, to include his 2007 VA examination, he did not indicate that he was suffering from any rhinitis complaints and no such symptoms were found upon examination. Additionally, both the May 2015 and May 2017 VA examiners determined that the Veteran's condition was unrelated to his qualifying period of active service. Thus, the medical evidence of record does not establish that the Veteran had been diagnosed with allergic rhinitis until many years after his discharge from service, and that his disorder was unrelated to his period of active service. Similarly, in regards to the Veteran's claimed headaches, the evidence of record does not support a finding that the Veteran was diagnosed with a headache disorder. His first reports of headaches were in his November 2004 post deployment health assessment, where he also denied any medical problems that developed during his deployment. He next complained of headaches after a December 2004 motorcycle accident that occurred outside of his qualifying period of active service - i.e. after May 7, 2004. He denied suffering from headaches in his 2005 separation report of medical history. The Veteran's medical records of evidence also do not support a finding that the Veteran was treating for headaches. In his May 2015 VA examination the Veteran reported headaches by history and could not recall when his last headache had occurred. He also reported that he did not seek treatment for his headaches. Though the examiner found that the headaches the Veteran had reported by history were likely related to the heat to which the Veteran was exposed during service, the examiner also found that the Veteran did not have a diagnosed headache disorder and that what headaches he did have had since resolved. An additional VA examination in May 2017 also found that the Veteran was not suffering from a headache disorder and opined that it was less likely than not that the Veteran had chronic headaches related to service. Thus, the medical evidence of record does not establish that the Veteran had been suffering with a headache disorder, to include attributing such a disorder to service. Similarly, there is no evidence of record that establishes that the Veteran is currently experiencing headaches which are attributable to service. Though the May 2015 examiner found that the Veteran had headaches which were attributable to his active service, that examiner also found that the Veteran's headaches had resolved and that the Veteran was not currently suffering from headaches. As such, the Board finds that the Veteran's headaches did not have onset within the Veteran's qualifying period of active service and is unrelated to that service. There is also no such evidence of record which would support a finding that the Veteran suffered from chronic fatigue syndrome or a chronic fatigue disorder. His complaints of fatigue after a March 2003 vaccination were a one-time complaint while in-service and do not document continued treatment for such a disorder. There are no other medical records of evidence which find the Veteran suffering from chronic fatigue. At his November 2007 VAMC intake examination, the Veteran reported no health complaints. At his May 2015 VA examination, the Veteran's reports of fatigue were associated with his mental health diagnosis and not related to his period of qualifying active service. Thus, the claim for service connection for chronic fatigue must be denied because the first essential element for the grant of service connection, competent evidence of the disability for which service connection is sought, is not met. The Veteran has been diagnosed with bilateral patellofemoral pain syndrome. His first complaint of knee pain contained in the evidence of record is a February 2005 STR which documented the Veteran had been involved in a motorcycle accident and injured his knees. The Board notes that this motorcycle accident, and another motorcycle accident in May 2005, occurred outside of the period of the Veteran's qualifying active duty service. Thus, injury to his knees during these accidents does not constitute a link for direct service connection. The Veteran also denied knee pain or symptomology in his 2005 separation examination and report of medical history and, in his May 2015 VA examination stated that his knee pain began in 2006 - two years after his qualifying period of service had ended. Furthermore, VAMC records from May 2012 showed the Veteran to have suffered an injury to his left knee after a basketball game, wherein the Veteran claim his knee subsequently buckled. Examinations performed on the Veteran's knees in 2007, 2015, and 2017 did find any evidence of arthritis. The Veteran's VA examinations in 2015 and 2017 indicated that the Veteran's bilateral knee disorder was less likely than not related to his service as he had no complaints of knee pain or treatment during his qualifying period of active service. The May 2017 examiner noted that the Veteran had full range of motion in the 2007 VA examination and had denied knee pain in his separation examination. Further, the 2017 examiner opined that the Veteran's bilateral patellofemoral pain syndrome was more likely due to the Veteran's history of injury and overuse after his active duty service. As such, the Board finds that the Veteran's diagnosed bilateral patellofemoral pain syndrome did not have onset within the Veteran's qualifying period of active service and is unrelated to that service. Presumptive service-connection via 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 is also not established in regards to the Veteran's claimed disorders, including bilateral patellofemoral pain syndrome. Though the Veteran did have active duty service in the Southwest Asia Theater of operations during the Persian Gulf War, none of his claimed disorders - allergic rhinitis, headaches, chronic fatigue, and bilateral patellofemoral pain syndrome - are included on the list conditions afforded presumptive service connection. Furthermore, as the VA examiners explained, the Veteran's disorders are all known clinical conditions and are neither undiagnosed illnesses nor manifestations of medically unexplained chronic multisymptom illnesses. 38 C.F.R. § 3.317(a)(1)(i)-(ii). Additionally, the examiners did not find evidence that the Veteran's disorders were aggravated beyond their normal progression by the Veteran's service, including his service in Southwest Asia. Accordingly, the Board finds that service connection for the Veteran's disorders cannot be granted under the presumptive provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The Board finds the May 2015, April 2017, and May 2017 VA examiners' medical opinions adequate and highly probative both as to the Veteran's subjective reports and the resulting objective findings. The examiners possess the necessary education, training, and expertise to provide the requested opinions. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Specifically, the examiners interviewed the Veteran, reviewed his claims file, and conducted a physical examination. Moreover, the examiners had the requisite medical expertise and had sufficient facts and data on which to base their conclusions. As such, the Board accords the May 2015, April 2017, and May 2017 VA examination opinions great probative weight. Significantly, neither the Veteran nor his representative has presented or identified any contrary medical opinion that supports the claims for service connection. The Board also notes that VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board has considered the Veteran's lay statements and does not dispute his self-reported symptomology. Although the Veteran is competent to describe observable symptoms of pain, he not competent to opine as to the diagnosis or etiology of his claimed disorders, as he has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, his lay opinions that his claimed disorders were caused by active service do not constitute competent medical evidence and lack probative value. In sum, the claims file does not contain competent and credible evidence that the Veteran's claimed conditions - sinusitis, allergic rhinitis, headaches, chronic fatigue, or bilateral patellofemoral pain syndrome - are related to service. Accordingly, as the preponderance of the evidence is against the claims for service connection, the benefit-of-the-doubt rule is not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU As an initial matter, a July 2014 Board decision found that the claim for a TDIU was raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The Veteran subsequently reported that his service-connected lower back disorder, to include radiculopathy and IVDS, prevents him from securing and following any substantially gainful employment. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15 (2017). A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet those percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment due to service-connected disability. 38 C.F.R. § 4.16(b). "Substantially gainful employment" is that employment, "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). The Veteran is service connected for piriformis myofascial pain syndrome of the left lower extremity (previously diagnosed as left lower extremity radiculopathy) and intervertebral disc syndrome (previously rated as lumbosacral strain), bilateral pes planus, tinnitus, and seborrheic dermatitis (claimed as a dry skin condition). From May 9, 2006, to December 16, 2012, the Veteran has a combined evaluation of 40 percent. At a 40 percent combined evaluation, the Veteran's service-connected disabilities do not render him eligible for a TDIU under the schedular percentage requirements contemplated by VA regulation. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Thus, the schedular criteria have not been satisfied. As of December 17, 2012, the Veteran has a combined evaluation of 60 percent. Similarly, at a 60 percent combined evaluation, the Veteran's service-connected disabilities still do not render him eligible for a TDIU under the schedular percentage requirements contemplated by VA regulation. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Thus, the schedular criteria have not been satisfied. However, consideration of TDIU pursuant to 38 C.F.R. § 4.16 (b) must be considered. The question then becomes whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment, work which is more than marginal, that permits the individual to earn a living wage consistent with education and occupational experience. Moore v. Derwinski, 1 Vet. App. 356 (1991). For an appellant to prevail on a claim for a total compensation rating based on individual unemployability, the record must show some factor which takes the case outside the norm. The sole fact that a claimant is unemployed, is employed only part-time, or has difficulty obtaining employment, is not enough. A rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the appellant is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In a December 2007 VA examination, the examiner found that the Veteran's lower back symptomology affected his activities of daily living in that it was uncomfortable for prolonged standing or prolonged sitting. The Veteran needed to move at least every 30 or 40 minutes. At the end of the day, after standing, it was painful for him bend forward and hold a forward bent position for any prolonged period of time. The Veteran reported that he had not lost any days of work due to his lower back. He also reported that he wore arch supports for his pes planus and had pain after prolonged standing. In a March 2009 VA examination regarding his tinnitus, the Veteran was found to have normal hearing, but reported tinnitus, which was attributed to his service. The Veteran reported the ringing in his ears that occurred daily with periods lasting seconds per episode. No functional limitations were noted. A concurrent examination of the Veteran's spine found no limitation on standing and walking on the tiptoes or heels. However, the Veteran reported functional impairment due to pain on prolonged standing, walking or bending. In a February 2011 VA examination of his lumbar spine, the examiner noted the Veteran's lumbar spine disorder caused problems with lifting and carrying and had decreased strength and pain. He was limited in bending, lifting, twisting, and standing for greater than 5 to 10 minutes. The Veteran reported that he was unemployed for the past 2 to 5 years due to pain in his back and legs. In a January 2012 VA examination, the examiner noted that the Veteran's dry skin condition did not impact the Veteran's ability to work. In December 2012, a VA examination noted that the Veteran's lower back condition impacted the Veteran's ability to work as he had difficulty with prolonged standing. In a December 2015 VA examination of his peripheral nerves, the examiner did not find that there was any functional impairment due to the Veteran's left lower extremity radiculopathy or his lower back disorder. Though, the Veteran did report that he had to stop cutting hair full-time due to his back pain. The examiner found that the Veteran's lumbar spine service connected diagnosis had resolved and that the Veteran did not have objective evidence to support a peripheral nerve diagnosis at that time. In a February 2016 VA examination, the Veteran's history and exam was found to be consistent with piriformis myofascial pain syndrome. In a March 2017 VA examination, the Veteran's lower back condition was found to limit his ability to perform repetitive heavy lifting, pushing or pulling. The Veteran described his functional loss as decreased flexibility. The Veteran stated that he last worked in 2015 as a barber, but had to stop due to his lower back problems. In a May 2017 VA examination regarding the Veteran's dry skin, the examiner found that there was no functional impairment associated with the Veteran's condition. Considering the foregoing, the evidence of record does not reveal factors outside the norm resulting in unemployability. The Veteran has not shown that his service-connected myofascial pain syndrome of the left lower extremity, intervertebral disc syndrome, bilateral pes planus, tinnitus, and seborrheic dermatitis have significantly hindered his ability to maintain some form of gainful employment. While the objective evidence shows that the Veteran low back disability would interfere with his ability to function in certain occupational environments, the evidence also demonstrated that with limitations he could still obtain and follow substantially gainful employment. Overall, the Board finds that the evidence does not support a finding that the Veteran's service-connected disabilities cause a significantly diminished level of functioning to the point where the Veteran is unable to work. The Board also notes that there is no evidence of record wherein the Veteran was found to be unable to obtain or retain substantially gainful employment due to his service-connected disabilities. The Board emphasizes that the rating schedule is intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. To the extent the service-connected disabilities affect the Veteran's employment, the assigned schedular ratings for the disabilities compensate the Veteran for such impairment. Therefore, as the Veteran has not provided any competent and credible evidence that his service-connected disabilities, either singly or combined, prevent him from securing or following any substantially gainful employment, the Board finds that referral for extraschedular consideration is not appropriate. The Board finds that the preponderance of the evidence is against the claim for a TDIU and the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a sinus disorder, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is denied. Service connection for allergic rhinitis, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is denied. Service connection for headaches, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is denied Service connection for chronic fatigue, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is denied. Service connection for a left knee disability, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is denied. Service connection for a right knee disability, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is denied. Entitlement to a TDIU is denied. ____________________________________________ Lesley A. Rein Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs