Citation Nr: 18143185 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 15-05 787 DATE: October 18, 2018 ORDER The petition to reopen the claim of entitlement to service connection for a gynecological disorder resulting in hysterectomy is granted. Entitlement to service connection for fibromyalgia is granted. Entitlement to service connection for degenerative joint disease and degenerative disc disease of the back is granted. Entitlement to service connection for bilateral foot disabilities diagnosed as Morton’s neuroma, hallux valgus, and bilateral bunions, status post bunionectomy, is granted. Entitlement to service connection for temporomandibular joint disorder (TMJ) is granted. Entitlement to service connection for a gynecological disorder resulting in hysterectomy is denied. FINDINGS OF FACT 1. The Veteran’s claim of entitlement to service connection for a gynecological disorder resulting in hysterectomy was denied by a May 2009 RO rating decision; the Veteran did not appeal the denial of this claim (the issue was excluded from the limited scope of the Veteran’s notice of disagreement), and VA did not receive new and material evidence on the matter within one year following the rating decision. 2. Evidence submitted since the May 2009 RO rating decision pertaining to the issue of entitlement to service connection for gynecological disorder resulting in hysterectomy includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 3. The Veteran has been diagnosed with fibromyalgia and had a period of active duty service in Southwest Asia during the Gulf War. 4. Resolving reasonable doubt in the Veteran’s favor, her degenerative joint disease and degenerative disc disease of the back are at least as likely as not etiologically related to one or more in-service strains, stresses, or injuries. 5. Resolving reasonable doubt in the Veteran’s favor, her bilateral foot disabilities diagnosed as Morton’s neuroma, hallux valgus, and bilateral bunions, status post bunionectomy, are at least as likely as not etiologically related to one or more in-service strains, stresses, or injuries. 6. Resolving reasonable doubt in the Veteran’s favor, her TMJ is at least as likely as not etiologically related to one or more in-service strains, stresses, or injuries. 7. The Veteran was not medically examined when accepted and enrolled for her first period of active duty service from January 1991 to July 1991, prior to her hysterectomy in October 1992; the most probative competent evidence of record shows that the Veteran’s gynecological disorder resulting in hysterectomy pre-existed her active duty military service and was not aggravated during her active duty military service. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for a gynecological disorder resulting in hysterectomy have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 2. The criteria for service connection for fibromyalgia due to Gulf War service have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.317. 3. The criteria for service connection for degenerative joint disease and degenerative disc disease of the back have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for bilateral foot disabilities diagnosed as Morton’s neuroma, hallux valgus, and bilateral bunions, status post bunionectomy, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for service connection for TMJ have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 6. The criteria for service connection for gynecological disorder resulting in hysterectomy have not been met. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.306. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1991 to July 1991, from October 2000 to September 2002, and from November 2002 to April 2003. This matter is before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to service connection for fibromyalgia and entitlement to service connection for a gynecological disorder resulting in hysterectomy (including the petition to reopen this claim) are before the Board on appeal from a May 2013 RO rating decision. The remaining issues on appeal are each before the Board on appeal from a May 2009 RO rating decision. The Veteran testified before the undersigned at a Travel Board hearing in April 2018. Following the May 2009 decision, the Veteran filed a notice of disagreement initiating an appeal on a limited set of the issues addressed in the May 2009 decision. Following an October 2009 request from the RO to clarify the limited scope of the appeal, the Veteran submitted a statement in December 2009 reiterating the limited scope of the appeal. Thus, the issues addressed by the May 2009 RO rating decision but excluded from the limited scope of the Veteran’s notice of disagreement did not enter appellate status and are not before the Board at this time. Among the issues excluded from the scope of the appeal of the May 2009 rating decision was the denial of service connection for gynecological disorder resulting in hysterectomy, and that issue is not currently in appellate status from that May 2009 adjudication. Following the Veteran’s subsequent initiation of an appeal of the May 2013 RO rating decision (including the issue of the Veteran’s petition to reopen the previously denied claim of entitlement to service connection for gynecological disorder resulting is hysterectomy), the RO issued a statement of the case in December 2014 addressing a set of 11 issues in appellate status from the two different notices of disagreement on the two different RO rating decisions of May 2009 and May 2013. Following the issuance of the statement of the case, the Veteran submitted a VA Form 9 in February 2015 that expressly limited the appeal to the issues addressed in this Board decision at this time. None of the other issues addressed in the statement of the case or the RO rating decisions are currently in appellate status. 1. The petition to reopen the claim of entitlement to service connection for a gynecological disorder resulting in hysterectomy is granted. As to the matter of whether new and material evidence has been received to reopen the claim of entitlement to service connection for a gynecological disorder resulting in hysterectomy, the Board is required to consider the question of whether new and material evidence has been received to reopen the claim, without regard to the RO’s determination, in order to establish the Board’s jurisdiction to address the underlying claim and to adjudicate it on a de novo basis. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). A May 2009 RO rating decision denied the Veteran’s claim of entitlement to service connection for a gynecological disorder resulting in hysterectomy. No new and material evidence was submitted within a year following the May 2009 denial of the claim. 38 C.F.R. § 3.156(b). The Veteran filed a notice of disagreement initiating an appeal on a limited set of the issues addressed in the May 2009 decision, but excluded the gynecological disorder issue from the appeal. Following an October 2009 request from the RO to clarify the limited scope of the appeal, the Veteran submitted a statement in December 2009 reiterating the limited scope of the appeal. The May 2009 RO denial of service connection for a gynecological disorder resulting in hysterectomy is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104(a), 20.302. The Veteran petitioned to reopen the claim in December 2011. The prior final decision denying service connection for a gynecological disorder resulting in hysterectomy was based upon the RO’s finding that the Veteran’s pre-existing gynecological disorder was not shown to have been aggravated during active duty service. The Board finds that new and material evidence has been presented sufficient to reopen this claim. During the Veteran’s April 2018 Board hearing, the merits of the claim of entitlement to service connection for a gynecological disorder were discussed. The Veteran’s testimony included her recollection of being “normal,” and medically cleared as gynecologically healthy at the time of her entrance to active duty in January 1991; the Veteran also testified with details regarding her recollections that “[w]hen I returned home from deployment” she experienced the return of “severe dysmenorrhea again, [and] incredible pain upon onset of menses.” To the extent necessary to meet the low threshold to reopen a claim, these statements reasonably tend to indicate that the Veteran’s pre-existing gynecological disorder may have increased in severity during the 1991 period of active duty service. The Board finds that new and material evidence has been submitted on the issue of entitlement to service connection for a gynecological disorder resulting in hysterectomy, following the prior final denial of that claim. Accordingly, the Board has reopened the claim of entitlement to service connection for a gynecological disorder resulting in hysterectomy for consideration on the merits at this time. Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. To substantiate a claim of service connection, there must be evidence of: (1) a current disability; (2) a disease, injury, or event in service; and (3) a nexus or causal relationship between the claimed disability and the disease, injury, or event in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (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). Service connection is also warranted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). 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 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. § 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. § 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. § 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). The Board also notes that signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, enumerated examples presented in 38 C.F.R. § 3.317(b). Among the presented examples potentially notable in this case are menstrual disorders, muscle pain, and joint pain. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness in such claims. Id. In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of a veteran’s service as shown by a veteran’s service record, the official history of each organization in which a veteran served, a veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is 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). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. 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 deemed appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. 2. Entitlement to service connection for fibromyalgia is granted. The Veteran’s set of Defense Department Forms 214 (DD 214s) reflects that the Veteran received the Southwest Asia Service Medal, served “IN SUPPORT OF OPERATION DESERT SHIELD/STORM 910122-910616/SAUDI ARABIA” and received the “KUWAIT LIBERATION MEDAL (KINGDOM OF SAUDI ARABIA).” With consideration of these records and other evidence, the Board is satisfied that the Veteran qualifies as a Persian Gulf Veteran for the purposes of pertinent presumptions of service connection for fibromyalgia. The Veteran has submitted several consistent lay statements indicating that she has experienced widespread pain since she was deployed to Southwest Asia. For instance, during her April 2018 Board hearing she testified that in 2001 a doctor at Walter Reed Army Medical Center told her that she had “all the earmarks [sic] of fibromyalgia,” but that she was able to mitigate the symptomatology for years with a heavy exercise routine until her civilian career made the routine unsustainable and her symptoms became more severe in 2008. The Veteran described that in 2011 she sought medical treatment and was diagnosed with fibromyalgia; she described continuing problems including widespread pain including joint pain and headaches. The Veteran has explained that she has been unable to obtain documentation of the 2001 medical impression of fibromyalgia at Walter Reed. However, the Veteran has submitted documentation of multiple treating physicians diagnosing her with fibromyalgia. The Veteran has submitted medical records showing treatment for diagnosed fibromyalgia by a rheumatologist named Dr. Barger. A September 2012 report, for example, documents the rheumatologist’s medical assessment of “Mild fibromyalgia (729.1); 12/18 tender points.” Additionally, an August 2011 letter from the Veteran’s “primary care physician” at the time, named Dr. Redard, explains that “In January 2011 I diagnosed [the Veteran] with fibromyalgia.” The Board notes that a set of VA examination reports prepared in August 2012 provides a negative medical opinion regarding the Veteran’s claim of entitlement to service connection for fibromyalgia. The August 2012 VA examination reports include a medical opinion from a nurse practitioner that states: “The veteran’s multiple joint pains appear to be normal for this age patient who is actively stretching to her tolerance with yoga. The joint pains found on exam do not represent an undiagnosed illness but are found to be within normal range / commonly found for a person of this age and activity level.” However, other sections of the August 2012 VA examination report set contain somewhat contradictory remarks and indications from the same authoring VA nurse practitioner. This VA examiner marked “Yes” to indicate that the Veteran had “diagnosed illnesses for which no etiology was established” and specifically identifying “Diagnosis #1: fibromyalgia.” The VA examiner marked “Yes” to indicate that the Veteran has “signs and/or symptoms” associated with the Veteran’s “report[] [of] missing 30% of work due to s/s that she attributes to ‘fibromyalgia.’” The VA examiner then remarked: “Veteran with multiple joint pain of unclear etiology. Pain is chronic and has been undiagnosed in the past…. [I]t is unclear why she has pain in multiple joints.” The VA examiner discussed “[p]otential etiologies” for the Veteran’s pain, including “trauma from falls” that was not well established or “lyme disease.” The report contains a later update that indicates that testing failed to establish a diagnosis of lyme disease. The Board notes that the VA examination report appears to indicate that the Veteran’s level of symptomatology is consistent with some manner of medical pathology, as the VA examiner considered traumas and lyme disease to be possible etiologies for consideration, which does not appear to be reconciled with the eventual medical opinion that the Veteran’s complaints are simply “normal” for her age. While it may be possible to reconcile the VA examiner’s final medical opinion with the prior indications that the Veteran has widespread pain symptoms of unclear etiology and a past diagnosis of fibromyalgia, the Board finds that the August 2012 medical opinion of the VA nurse practitioner as presented is of somewhat diminished persuasive value in comparison with the multiple medical assessments from the Veteran’s treating rheumatologist and the Veteran’s primary care physician that unequivocally state that the Veteran has been diagnosed (by both doctors) with fibromyalgia. The Board finds that the evidence is at least in equipoise as to whether the Veteran has a current fibromyalgia diagnosis. The negative opinion did not explain why the Veteran’s symptoms failed to meet the clinical criteria for a fibromyalgia diagnosis, and the positive opinions concluded that the Veteran’s symptoms were sufficient for a diagnosis. Therefore, the Board finds that the Veteran has a current fibromyalgia diagnosis and, based upon medical and lay evidence of record, that the condition has existed for more than six months. Accordingly, there is a presumption of a nexus between the Veteran’s current fibromyalgia and her Gulf War service. Medical evidence of record does not demonstrate affirmative evidence of an alternative etiology for the disability that would rebut the presumption of service connection. See 38 C.F.R. 3.317(a)(7). The Board notes that although some of the Veteran’s painful symptomatology of specific anatomical locations have other diagnoses and etiologies, the greater breadth of the Veteran’s widespread pain complaints are not entirely explained by any clearly identified alternative diagnosis and etiology. Therefore, the Board finds that the criteria for entitlement to service connection for fibromyalgia on a presumptive basis have been met. 3. Entitlement to service connection for degenerative joint disease and degenerative disc disease of the back is granted. 4. Entitlement to service connection for bilateral foot disabilities diagnosed as Morton’s neuroma, hallux valgus, and bilateral bunions, status post bunionectomy, is granted. 5. Entitlement to service connection for temporomandibular joint disorder (TMJ) is granted. The Veteran contends that she suffers from disabilities of the back, the feet, and the jaw/TMJ that are causally related in-service strains and injuries associated with the physical nature of her duties during active duty service, including as explained in some detail in her April 2018 hearing testimony. The Board finds the Veteran’s description of the nature of her duties to be essentially credible and generally consistent with the indications of her service records. The Board concludes that the Veteran has current diagnoses of degenerative joint disease and degenerative disc disease, as indicated in evidence including an August 2012 VA examination report. The Board concludes that the Veteran has current diagnoses of the feet featuring Morton’s neuroma, hallux valgus, and bilateral bunions status post bunionectomy, as indicated in evidence including the August 2012 VA examination report. The Board also concludes that the Veteran has a current diagnosis of TMJ disorder, as indicated in evidence including the August 2012 VA examination report and a May 2014 VA examination report. For the purposes of this analysis, the Board considers each of the Veteran’s foot disabilities to involve both feet bilaterally. The Board notes that while the August 2012 VA examination report marks a box to indicate that the Veteran has Morton’s neuroma of the right foot only, other evidence of record suggests bilateral involvement and the August 2012 medical opinion from the VA examiner appears to acknowledge “Bilateral foot neuroma” as etiologically linked to active duty service. The Board finds that the diagnosed disabilities of the back, the feet, and the TMJ are each related to events of her military service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). With regard to the back disability, a May 2018 letter from the Veteran’s current private treating physician, Dr. Lee, discusses the Veteran’s “incidents during her service where she has fallen” and her “significant labor with her duties” in relation to her “lumbar degenerative disc disease.” Dr. Lee opines that it is “more likely than not, that her years of service during Operation Desert Storm may have contributed to her lumbar degenerative disease.” Dr. Lee’s statement was received by VA in June 2018 and was accompanied at that time by another statement, undated, from the Veteran’s treating chiropractor, Dr. Bell. Dr. Bell’s statement includes the medical opinion: “It is probable (more than 50%) that the natural progression of [the Veteran]’s condition of arthritis in the lumbar spine [w]as aggravated beyond the natural progression of the disease due to the work conditions encountered during her participation in deployment to the Kingdom of Saudi Arabia as part of Operation Desert Shield / Storm ….” With consideration of the entire record, the Board finds that these private medical opinions together reasonably support a finding that the Veteran’s current back disability is causally attributable to her military service. While Dr. Lee’s phrasing indicates that the Veteran’s active duty service “contributed to” the back disability, and Dr. Bell indicates that active duty service “aggravated” the disability, the Board finds no clear indication of a back disability that predated the Veteran’s first period of active duty service, and the Board observes that her February 1990 annual reserve duty medical examination report indicates that her back was clinically normal with no suggestion of disability or pertinent symptomatology at that time prior to her January 1991 entrance to active duty service. Accordingly, the Board finds that these two medical opinions, both indicating that the Veteran’s back was likely damaged by her active duty military service in a manner notably contributing to her current back disabilities, reasonably indicate that the Veteran’s back disabilities are causally attributable to her active duty service in this case. The Board finds that these medical opinions are not persuasively contradicted by any other evidence of record, and thus the medical opinions are persuasive. A September 2009 medical opinion from a treating private chiropractor, Dr. Walker, states: “From her history, I have determined that her lower back... conditions are related to having to move, lift and carry equipment including the standard field equipment plus a field radio.” The opinion concludes by asserting that the Veteran “is suffering the late effects of injuries and conditions acquired during her military service. All areas of complaint, including her... lower spine..., are related to some form of injury or stress placed on her body while serving our country in Desert Storm One. I see no reason to deny her claim....” The Board finds that this September 2009 medical opinion tends to support the claim and does not provide evidence weighing against the claim. With regard to the Veteran’s foot disabilities, the Board notes that a July 2000 letter from a private medical provider notes that the Veteran was diagnosed with “hallux valgus of her right foot” at that time, and explained that “[t]he development of the joint deformity and the early arthritic changes are from prolonged standing and activity….” Additionally, the July 2000 letter discusses that the Veteran was at that time “currently being treated for symptoms consistent with bilateral forefoot neuromas,” and explains that “[t]his develops due to constant mechanical irritation or trauma to the forefoot…. Usually, certain activities, such as prolonged standing and walking, can provoke chronic inflammation of the intermetatarsal nerve.” Notably, this letter was authored during the Veteran’s period of active service from October 2000 to September 2002. The Board notes that the Veteran’s service treatment records include a February 1991 report during her earlier period of active duty service showing that the Veteran sought treatment for “complaints of swelling and discoloration of right foot,” describing that “it is painful upon movement and has difficulty wearing boots.” The Veteran had problems associated with this that led to imbalance, hard steps, and “bruising of foot.” Some right foot swelling was observed and documented. The August 2012 VA examination report includes a somewhat internally inconsistent medical opinion that is generally supportive of the Veteran’s claim of entitlement to service connection disabilities of the bilateral feet. The VA examiner stated: “The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness.” The examiner then went on to explain a rationale stating: “It is ALALAN [at least as likely as not] that the veteran’s bilateral foot condition was aggravated beyond it[]s natural progression during the approximately 2 years of active duty due to the increased impact associated with required physical training and the performance of military duty[].” Additionally, with regard specifically to the neuroma diagnosis, the same VA examination report went on to state that “[t]he single acute injury documented preceded by about 7 years the development/ documentation of neuroma and is not seen as sufficient to have resulted in and of itself in a neuroma. A neuroma is caused by prolonged and chronic abrasion / pressure due to the intrinsic of the feet.” The report then also states that the “[b]ilateral foot neuromas noted prior to 2 year service and due to service requirements / impact likely aggravated beyond natural progression.” The Board finds that the medical evidence of record supports finding that the Veteran’s bilateral foot disabilities are proximately attributable, at least in significant part, to the type of stress the Veteran’s feet experienced during her active duty service. The VA medical opinion is clear such disabilities were at least aggravated by the Veteran’s active duty service. The Board further finds that the equivocal and inconsistent August 2012 VA medical opinions reasonably support finding that the bilateral foot disabilities can be causally attributed to service, rather than deemed service-connected on the more limited basis of aggravation. The Board notes that the evidence of record does not establish that any current claimed foot disability existed prior to the Veteran’s earliest period of active duty service. With consideration of the entire record, the Board finds that these medical opinions together reasonably support a finding that the Veteran’s current foot disabilities are causally attributable to her military service. Despite some of the language suggesting that the disabilities may have been aggravated rather than caused during active duty service, the Board finds no clear indication of a foot disability that predated the Veteran’s first period of active duty service, and the Board observes that her February 1990 annual reserve duty medical examination report indicates that her feet were clinically normal with no suggestion of disability or pertinent symptomatology at that time prior to her January 1991 entrance to active duty service. Accordingly, the Board finds that these medical opinions, indicating that the Veteran’s feet were likely damaged by her active duty military service in a manner notably contributing to her current foot disabilities, reasonably indicate that the Veteran’s foot disabilities are causally attributable to her active duty service in this case. The Board finds that these medical opinions are not persuasively contradicted by any other evidence of record, and thus the medical opinions are persuasive in this regard. A June 2009 letter from another private provider, a podiatrist named Dr. Del Zotto, discusses the Veteran’s pertinent foot diagnoses (including structural diagnoses as well as her neuroma pain) in the context of the Veteran’s description of “a history of injury/trauma” in her “first tour of duty during the first Gulf War,” “the physical and mechanical demand on her lower extremities and feet regarding her assignments during this period of time, being quite extensive,” and also “discussion of her shoe gear/military boots that were required.” Dr. Del Zotto opines: “Considering all of these [foot disability] conditions are very commonly induced and/or accelerated from the significant mechanical demand on the limbs and feet as well as a history of a traumatic event, I can say with reasonable probability this did occur.” The Board finds that this June 2009 medical opinion tends to support the claim and does not provide evidence weighing against the claim. A September 2009 medical opinion from a treating private chiropractor, Dr. Walker, discusses the Veteran’s foot disabilities including neuromas and misalignments of both feet. Dr. Walker opined that findings were “consistent with chronic micro-traumas like those found in people who are on their feet for long hours, frequently have to move moderate to heavy [loads] and who are required to wear steel-toed boots while doing so.” The opinion concludes by asserting that the Veteran “is suffering the late effects of injuries and conditions acquired during her military service. All areas of complaint, including her... feet..., are related to some form of injury or stress placed on her body while serving our country in Desert Storm One. I see no reason to deny her claim....” The Board finds that this September 2009 medical opinion tends to support the claim and does not provide evidence weighing against the claim. The Board notes that entitlement to service connection based upon in-service causation of a disability does not require that military service be the single and only cause of a disability. Some of the VA medical opinion’s apparent reluctance to unequivocally attribute causation (rather than aggravation) of the foot disabilities to active duty service involves the observation that in-service injury may not have been “sufficient” to cause chronic disability, and that inherent structural predisposition and other factors were also likely involved. The Board finds that the medical evidence of record persuasively indicates that the Veteran’s foot disabilities are all of a nature that is causally attributable to the type of stress on the feet that the Veteran is reasonably shown to have experienced during her active duty service, with consideration of her lay testimony and contemporaneous service records. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the evidence of record sufficiently indicates that the Veteran’s foot disabilities are causally linked to her military service. With regard to the Veteran’s TMJ, the September 2009 medical opinion of Dr. Walker discusses the Veteran’s report of “ongoing complaints of TMJ syndrome since being in the military.” Dr. Walker explains that the Veteran’s “TMJ [syndrome] is related to a condition called bruxing (grinding of the teeth) which is common amongst peoples placed in stressful situations....” Dr. Walker concludes: “It [is] my opinion that [the Veteran] is suffering the late effects of injuries and conditions acquired during her military service. All areas of complaint, including her... TMJ..., are related to some form on injury or stress placed on her body while serving our country in Desert Storm One. I see no reason to deny her claim of injury to any of the above noted areas.” A June 2014 VA examination report presents a negative nexus opinion with regard to the alleged link between the Veteran’s TMJ and her active duty military service. However, the June 2014 VA medical opinion is somewhat inadequate. The June 2014 VA examiner frames the question as concerning “aggravation of a pre-existing condition with regard to the active duty period in Saudi Arabia in 1991 and by her active duty service October 2000 to April 2003,” but supports this framing of the analysis with flawed reasoning. The VA examiner states: “Records indicate that Veteran had oral surgery for TMJ [disorder] in 1996, outside the period of active duty and thus, pre-existing condition is established.” However, the demonstration of TMJ disorder in 1996 does not establish that the disability pre-existed the Veteran’s 1991 period of active duty service, and the Veteran specifically contends that her TMJ is causally linked to her 1991 period of active duty service (including as explained in her April 2018 Board hearing testimony). As the June 2014 VA medical opinion does not address the Veteran’s actual contention of a causal link between the TMJ syndrome and her active duty service in 1991, it does not significantly contradict the September 2009 private medical opinion that supports finding a causal link between the TMJ syndrome and the Veteran’s active duty service deployment in 1991 (via stress-related bruxing). An August 2012 VA examination report addressing the TMJ issue does not opine upon the likelihood of the claimed link between the Veteran’s TMJ and her service, but does opine: “with her recent diagnosis of fibromyalgia, her TMD [TMJ disorder] has exacerbated in my opinion.” Significantly, this appears to strongly suggest a medical impression that the Veteran’s newly service-connected fibromyalgia has aggravated the Veteran’s TMJ syndrome, supporting an alternative theory of entitlement to service connection for TMJ syndrome as a disability secondary to the service-connected fibromyalgia pathology. In light of all the evidence of record, viewed in the light most favorable to the Veteran’s claim and with resolution of reasonable doubt in the Veteran’s favor, the Board finds that the evidence of record sufficiently indicates that the Veteran’s TMJ syndrome is causally linked to her active duty military service. In summary, resolving reasonable doubt in the Veteran’s favor, the Board finds that service connection may be granted for the Veteran’s degenerative joint disease and degenerative disc disease of the back; for her Morton’s neuroma, hallux valgus, and bunions status post bunionectomy, of the bilateral feet; and for her TMJ syndrome. 6. Entitlement to service connection for a gynecological disorder resulting in hysterectomy is denied. Evidence of record, including the Veteran’s own testimony (including during the April 2018 Board hearing) indicates that the Veteran had a gynecological condition diagnosed as fibroids and endometriosis prior to her entrance to active duty military service. Notably, the Veteran’s service treatment records for her pertinent period of active duty service from January 1991 to July 1991 contain no suggestion of any symptom manifestations of a gynecological disorder. The Veteran explained during her April 2018 Board hearing, is that “between 1988 and 1990 …” she was “diagnosed with endometriosis and fibroid tumors … ” and received medical treatment including having “had 18 fibroid tumors removed from [her] uterus….” The Veteran asserted: “By the time I was deployed, I had healed from surgery, I was clear. As far as [my doctor] was concerned medically, I was normal, ready to get pregnant, go to Gulf War.” The Veteran explained: “I’m not denying that I had female issues before I went. My argument is that the work I did … was so physically strenuous that it severely aggravated the condition. When I returned home from deployment I started to have severe dysmenorrhea again, incredible pain upon onset of menses,” and that this progression led to the October 1992 surgery. Consistent with the Veteran’s testimony and other evidence of record regarding the details of the gynecological disorder pre-existing her 1991 period of active duty service, her contemporaneous service treatment records include reports from June, July, and August 1989 detailing the described treatment for diagnosed “[m]ultiple symptomatic leiomyomata uteri and endometriosis.” A pre-existing disorder will be considered to have been aggravated by active military service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306 (a), (b). Aggravation of a pre-existing condition may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). A Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the “correct standard for rebutting the presumption of soundness under Section 1111 requires the government to show by clear and unmistakable evidence both (emphasis added) that (1) the Veteran’s disability existed prior to service and (2) that the pre-existing disability was not aggravated during service.” The Federal Circuit noted that the lack of aggravation could be shown by establishing there was no increase in disability or that any increase in disability was due to the natural progress of the pre-existing condition. See Wagner v. Principi, 370 F. 3d 1089, 1096-97 (Fed. Cir. 2004). The Board notes that the Veteran had multiple distinct periods of active duty military service; however, there is no official entrance medical examination report for any pertinent period of service in this case. The presumption of soundness only attaches when a veteran is “examined” in connection with acceptance and enrollment to active duty service. Accordingly, the presumption of soundness does not attach to any pertinent period of service in this case. The only benefit that can be awarded for the Veteran’s claimed gynecological disorder is service connection on the basis of aggravation of the pre-existing gynecological disorder, by application of 38 U.S.C. § 1153, and 38 C.F.R. § 3.306. Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). The question of whether there has been an increase in disability during service must be answered in the affirmative before presumption of aggravation attaches, so that presumption is unaffected by the rule on service connection for increase in disability during service. Verdon v. Brown, 8 Vet. App. 529 (1996); see also Falzone v. Brown, 8 Vet. App. 398, 402 (1995). The Veteran’s service treatment records do not present any clear medical indication of an increase in the severity of her gynecological disorder during the period of active duty military service from January 1991 to July 1991. The Board notes that the Veteran’s service treatment records include documentation of an October 1991 annual medical examination report, and this report shows no pertinent abnormalities with regard to the Veteran’s gynecological health. The accompanying October 1991 medical history questionnaire shows that the Veteran presented no indication of any pertinent gynecological symptomatology during the 1991 period of service. Neither the service treatment records nor any other evidence indicates any pertinent gynecological symptomatology or abnormality during the Veteran’s active duty service in 1991. Notably, the Veteran’s explanation of her contentions during her April 2018 Board hearing did not specifically indicate any in-service symptomatic emergence of her gynecological disorder. Rather, she described that she was healthy prior to her deployment and that she began to experience pertinent problems “[w]hen I returned home from deployment….” The October 1991 annual examination report with medical history questionnaire is significant, as it was prepared three months after the conclusion of her pertinent period of active duty service, and it documents that the Veteran was clinically normal in all pertinent respects with no diagnoses or symptom complaints associated with gynecological concerns at that time. The Board finds that the evidence does not indicate that the Veteran had onset of any increased severity of gynecological disorder during the pertinent period of active duty service from January 1991 to July 1991. As the evidence indicates that the symptomatic re-emergence of the gynecological disorder occurred more than three months after the conclusion of the pertinent period of active service, that re-emergence does not indicate in-service worsening or aggravation of the pathology on its face. The Board finds that finding in-service aggravation of the gynecological disorder in this case would require support from independent medical evidence. An August 2012 VA medical opinion presents a competent medical opinion from a medical professional, informed by review of the pertinent contents of the claims-file, addressing the pertinent medical questions at issue with regard to the Veteran’s claim for service connection for the gynecological disorder. The VA examiner found that the gynecological disorder “clearly and unmistakably existed prior to service,” and furthermore found that the gynecological disorder was “clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness.” The VA examiner explained that the “Vet developed … chronic pelvic pain in late 1980’s, and was diagnosed with fibroids and endometriosis. Underwent open myomectomy in 1989, while she was in reserve.” The VA examiner then notes that the Veteran “was in Saudi Arab[i]a in 1991,” during her pertinent period of active duty service, and that the Veteran “[u]ltimately underwent hysterectomy with bilateral salpingo-oophorectomy in 10/1992 while she was in reserve....” The VA examiner explains that this history “is more likely the natural progression of her pre military diagnosed fibroids and endometriosis and not a worsening as a result of any in-service injury, event or illness.” The Board finds that the August 2012 VA medical opinion is competent probative evidence indicating that the Veteran’s gynecological disorder was not aggravated during her active duty service. The opinion is authored by a medical professional competent to provide it, and it is probative because it is based upon a rationale informed by review of the correct factual and medical history including review of the VA claims-file. Furthermore, the August 2012 VA medical opinion is persuasive in light of the fact that there is no contrary competent medical opinion of record. The presumption of soundness does not attach in this case in which the Veteran was not medically examined in connection with her January 1991 entrance to the pertinent period of active duty service. The Veteran is shown to have had pertinent gynecological pathology prior to her entrance to military service. The evidence of record does not indicate that the pre-existing gynecological disorder increased in severity during service. In the absence of a shown increase of severity during active duty service, there is no presumption of in-service aggravation of the gynecological disorder. The competent medical evidence of record does not otherwise support finding permanent aggravation of the gynecological disorder during service, nor does any evidence indicate the onset of any new gynecological pathology (beyond the pre-existing gynecological diagnoses) during active duty service. The August 2012 VA medical opinion specifically considers the key fact of the Veteran’s argument that she underwent a “hysterectomy with bilateral salpingo-oophorectomy” in October 1992, fifteen months after the conclusion of her active duty service with deployment to Saudi Arabia. The Veteran argues that the progression of her gynecological disorder from asymptomatic in 1991 to a level of severity requiring hysterectomy with bilateral salpingo-oophorectomy in October 1992 must reflect that her 1991 active duty featuring deployment to Saudi Arabia permanently aggravated the gynecological pathology. However, the August 2012 VA medical opinion from a competent medical professional draws a contrary conclusion, and the Veteran has not presented any independent medical evidence indicating in-service aggravation to support her claim. Therefore, there is no valid basis for an award of service connection for the Veteran’s gynecological disorder based upon the pertinent cited period of active duty military service in this case. To the extent that some of the Veteran’s contentions suggest that she may seek entitlement to service connection for gynecological disorder on the basis of a theory of undiagnosed illness or chronic multisymptom illness associated with her service in the Persian Gulf War, the claim cannot be granted on such a basis. The Veteran’s gynecological disorder has been clearly attributed by competent medical evidence to a pathology with specific diagnoses that pre-existed the Veteran’s service in the Persian Gulf. There is no basis for attributing the Veteran’s diagnosed gynecological disorder to an undiagnosed illness or to a chronic multisymptom illness associated with her service in the Persian Gulf War. The competent medical evidence of record, featuring the August 2012 VA medical opinion, clearly and unequivocally attributes the Veteran’s October 1992 hysterectomy with bilateral salpingo-oophorectomy to her pathology featuring fibroids and endometriosis diagnosed prior to her 1991 active duty service with deployment to the Persian Gulf. The evidence of record does not include any medical indication that her gynecological disorder on appeal is attributable to an undiagnosed illness or chronic multisymptom illness. Accordingly, service connection cannot be established for the gynecological disorder on the basis of a theory of undiagnosed illness or chronic multisymptom illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Accordingly, the Board finds that service connection for the Veteran’s gynecological disorder is not warranted. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt standard of proof does not permit a grant of this appeal. 38 U.S.C. § 5107(b). M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Barone, Counsel