Citation Nr: 18146784 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 16-33 369 DATE: November 1, 2018 ORDER Whether new and material evidence has been received to reopen the claim of entitlement to service connection for erectile dysfunction is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a headache disorder is granted. Entitlement to a 10 percent rating from April 30, 2015 to December 11, 2015 for a left knee disability is granted, subject to the laws and regulations governing monetary payments. Entitlement to a compensable rating prior to April 30, 2015 for a left knee disability is denied. Entitlement to a 10 percent rating, but no higher, effective April 30, 2015 to December 11, 2015, for a left knee disability is granted. Entitlement to a rating higher than 10 percent effective December 11, 2015 for a left knee disability is denied. REMANDED Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for a headache disorder is remanded. Entitlement to service connection for a disability manifested by joint and muscle pain, to include fibromyalgia is remanded. Entitlement to service connection for an upper gastrointestinal disorder, to include gastroesophageal reflux disorder (GERD) and hiatal hernia is remanded. Entitlement to service connection for bilateral restless leg syndrome is remanded. Entitlement to service connection for rheumatoid arthritis. Entitlement to a compensable rating for plantar warts is remanded. Entitlement to an initial compensable rating for irritable bowel syndrome (IBS) is remanded. FINDINGS OF FACT 1. An August 2007 rating decision denied service connection for a headache disorder. The Veteran was notified of that decision, but he did not initiate an appeal, and new and material evidence was not received within one year of the notice of that rating decision. 2. An April 2010 rating decision denied service connection for erectile dysfunction. The Veteran was notified of that decision, but he did not initiate an appeal, and new and material evidence was not received within one year of the notice of that rating decision. 3. There is some evidence received since the August 2007 rating decision pertaining to a headache disorder and since the April 2010 rating decision concerning erectile dysfunction that when considered by itself or in connection with evidence previously assembled relates to an unestablished fact necessary to substantiate the claims, and raises a reasonable possibility of substantiating the claims. 4. Prior to April 30, 2015, the Veteran’s left knee disability was manifested by flexion to 110 degrees and full extension with no painful motion or flare-ups. 5. Beginning April 30, 2015, the left knee disability has been manifested by limitation of flexion ranging from 90 to 100 degrees with pain on motion, and normal extension. There is no indication during the appeal of left knee ankylosis; recurrent subluxation or lateral instability; dislocated, semilunar cartilage; or tibial or fibular impairment. CONCLUSIONS OF LAW 1. The evidence received since the August 2007 rating decision is new and material, and the claim of entitlement to service connection for a headache disorder is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 2. The evidence received since the April 2010 rating decision is new and material, and the claim of entitlement to service connection for erectile dysfunction is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. The criteria for a compensable rating prior to April 30, 2015 for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261 (2018). 4. The criteria for a 10 percent rating, but no higher, from April 30, 2015 to December 11, 2015 for a left knee disability have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2018). 5. The criteria for a rating in excess of 10 percent effective December 11, 2015 for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1982 to June 2007. This appeal to the Board of Veterans’ Appeals (Board) is from August 2014, December 2014, and June 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran initiated an appeal for service connection for chronic fatigue syndrome and a higher rating for a lumbar disability; the service connection claim was subsequently granted in a December 2014 rating decision and he initiated an appeal for a higher rating. In September 2015, he withdrew his appeal for higher ratings for both claims. See January 2015 NOD and September 2015 Statement in Support of Claim. Additional evidence was received since the claims were most recently adjudicated in May 2016, but since it is duplicative of records already considered the Board is free to decide the claims. New and Material Evidence In order to reopen a claim which has been denied by a final decision, the claimant must present new and material evidence. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the "credibility" of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence, and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Evidence "raises a reasonable possibility of substantiating the claim," if it would trigger VA's duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a headache disorder. The August 2007 rating decision denied service connection for a headache disorder on the basis that there were no complaints or treatment in service and no evidence of a current disability based on the VA examination. The Veteran was notified of the decision that same month, but he did not submit a notice of disagreement with the August 2007 rating decision. Furthermore, no new and material evidence was received by VA within one year of the notice of this rating decision. As such, the August 2007 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362, 136768 (Fed. Cir. 2011). Since the August 2007 rating decision, diagnoses of migraine and tension headaches have been associated with the file. See February 2010 Statement in Support of Claim. This evidence is new and material and was not previously considered in August 2007. It also raises a reasonable possibility of substantiating the claim, so the claim is reopened. See Shade, supra. 2. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for erectile dysfunction. The April 2010 rating decision denied service connection for erectile dysfunction on a direct basis and as secondary to the service-connected lumbar disability essentially because there was no evidence of the disorder in service and a VA examiner opined it was not related to the lumbar disability. The Veteran was notified of the decision that same month, but he did not submit a notice of disagreement with the April 2010 rating decision. Furthermore, no new and material evidence was received by VA within one year of the notice of this rating decision. As such, the April 2010 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362, 136768 (Fed. Cir. 2011). Since the final April 2010 rating decision, evidence concerning the onset of his erectile dysfunction was submitted. January 2014 correspondence from the Veteran’s wife states he had difficulty with erections and indicate that this problem had been present for 10 years. See January 2014 Correspondence. Her statement, therefore, indicates his erectile dysfunction began when he was still in service. The credibility of this evidence is presumed and it is considered new and material since it was not previously considered in April 2010 and suggests the disorder began when the Veteran was still in the service. Accordingly, it raises a reasonable possibility of substantiating the claim, so the claim is reopened. See Shade, 24 Vet. App. 110. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule). See generally 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.27. VA has a duty to acknowledge and to consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings,” regardless of whether a case involves an initial rating. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Staged ratings have already been assigned for the left knee disability. Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 205-06 (1995). As such, in evaluating musculoskeletal disabilities, VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca, 8 Vet. App. at 206. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, this regulation is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Court of Appeals for Veterans Claims has held that “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” See Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain may result in functional loss, but only if it limits the ability to “perform the normal working movements of the body with normal excursion, strength, speed, coordination [,or] endurance.” Id. (quoting 38 C.F.R. § 4.40). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Daye v. Nicholson, 20 Vet. App. 512 (2006). The standard of proof to be applied in decisions on claims for veterans’ benefits is set forth in 38 U.S.C. § 5107. When, after careful consideration of all the 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, 4.3 (2017). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 3. Entitlement to a compensable rating prior to December 11, 2015 and a rating greater than 10 percent beginning December 11, 2015 for a left knee disability. The Veteran contends a higher rating is warranted for his left knee disability due to chronic and often debilitating joint pain related to his rheumatoid arthritis. See January 2015 NOD. The Board notes that rheumatoid arthritis is disorder that is not yet service connected and is a claim that is addressed in the Remand below. Normal range of motion of the knee is to 140 degrees for flexion, and to 0 degrees for extension. See 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees Service connection for a left knee disability was established in an August 2007 rating decision and a noncompensable rating was assigned. The claim for a higher rating was received in March 2013 and a May 2016 statement of the case increased the rating to 10 percent, effective December 11, 2015 based on the findings in a VA examination. Although the RO granted the 10 percent rating based on the December 11, 2015 VA examination, the Board finds that the April 30, 2015 VA examination contains similar findings such that the 10 percent rating should be assigned as of this date. Neither VA examination on April 2015 and December 2015 revealed limitation of motion to a compensable degree, as flexion was limited to 90 degrees in April and to 100 degrees in December; full extension was demonstrated on both exams. There were no changes after repeated use over time or following repetitive use testing. However, the Veteran was shown to have painful motion. Painful motion is an important factor of disability, and it is the intention of the Rating Schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 CF.R. § 4.59. Thus, resolving reasonable doubt in his favor, the Board finds that a 10 percent rating is assignable from April 30, 2015 to December 11, 2015. However, a higher rating is not warranted. As noted, VA examinations in 2015 showed there was no limitation of motion to a compensable level and there is no evidence to suggest the disability has worsened since December 2015. In fact, a September 2015 treatment record indicates there was full range of motion. See December 2015 CAPRI records. A June 2015 treatment record indicated there was some limited knee extension with pain but no measurements were taken, but the December 2015 VA examination showed that left knee extension was full. See December 2015 CAPRI records. The 2015 VA examinations show the Veteran reported flare-ups twice a week that for the most part coincide with the frequency of functional impairment, the duration of which lasted two to four hours. He also reported wearing a brace twice a week and using a cane twice a week during flare-ups. The December 2015 examiner indicated that additional factors that contributed to the left knee disability were disturbance of locomotion, interference with sitting and standing, and pain with prolonged standing, siting, and walking up stairs. The Veteran also reported that he sometimes had pain in non-weightbearing when lying down. When these factors that contribute to functional impairment are considered along with the limitation of motion, they are not of sufficient frequency, duration, and severity to more closely approximate the criteria for a rating greater than 10 percent. Although the Veteran identified pain as the main reason for increasing the rating, the Board notes that while pain is an important factor, the rating criteria are not designed to offer varying levels of compensation based on escalating levels of pain alone; rather, it is the functional loss due to pain and adequate pathology that affect the level of disability beyond range of motion. See DeLuca, supra; Johnston v. Brown, 10 Vet. App. 80, 85 (1997); Mitchell v. Shinseki, 15 Vet. App. 32 (2011). Here, the functional loss due to these other factors was not sufficient to assign a higher rating. A compensable rating prior to April 30, 2015 is also not warranted. On April 2014 VA examination, the Veteran reported that since his last VA examination he had a gradual increase in left knee stiffness and cramping that has been noticeable since 2011. Range of motion testing revealed flexion to 110 degrees and extension to zero degrees; there was no objective evidence of painful motion. After repetitive use testing there was no change in range of motion or flare-ups. There was also no evidence of functional loss or impairment. See June 2014 VA Examination. In the absence of motion limited to a compensable degree, painful motion, flare-ups, or functional impairment or loss, a compensable rating is not assignable. Since there is no evidence of ankylosis on VA examinations or in treatment records, Diagnostic Code 5256 does not apply. Diagnostic Codes 5258 and 5259 (symptomatic dislocation or removal of semilunar cartilage), Diagnostic Code 5262 (impairment of tibia and fibula), and Diagnostic Code 5263 (genu recurvatum) are also not applicable since those disabilities are also not shown on examination. See 38 C.F.R. § 4.71a. The Board is aware the Veteran reported having some intermittent knee buckling on the April 2014 VA examination, but a preponderance of the evidence is against assigning a separate compensable rating under Diagnostic Code 5257 because he has not reported this complaint since and all VA examiners found no evidence of left knee subluxation, instability or weakness. See 38 C.F.R. § 4.71a. REASONS FOR REMAND Regarding all the issues being remanded below, ongoing VA treatment records since December 2015 should be obtained and associated with the file. 1. Entitlement to service connection for erectile dysfunction is remanded. The Veteran contends that his erectile dysfunction is directly related to service and secondary to chronic fatigue syndrome, PTSD, and low back disability, which includes medication taken for these disabilities. See March 2013 Fully Developed Claim and January 2015 NOD. Although service treatment records do not address erectile dysfunction, the Veteran’s wife indicated the problem started when he was in service and she is competent to say so. A medical opinion, therefore, is needed to address service connection on a direct basis. Additional opinions are also needed for secondary service connection. Although a September 2009 opinion did not link erectile dysfunction to a back disability, the only diagnosis considered at that time was scoliosis. See September 2009 VA Examination. However, since the service-connected low back disability includes lumbosacral strain, degenerative arthritis, and intervertebral disc syndrome these must also be considered. Finally, none of the opinions address whether medications for the service-connected disabilities have caused or aggravated the Veteran’s erectile dysfunction. 2. Entitlement to service connection for a headache disorder is remanded. Although past rating decisions have stated there are no complaints or treatment for headaches in service, the Board found several treatment records that note his complaints of headaches and while many have been associated with other symptoms and diagnoses, not all have been. In particular, tension headaches are noted in April 1990 and headache complaints are noted after the Veteran’s 2006 deployment to Iraq. He also reported being exposed to blasts. See July 2007 STR – Medical. Post service treatment records also show the Veteran has diagnoses of tension headaches and migraines. See February 2014 Statement in Support of Claim. Given that the Veteran served in the Persian Gulf, consideration must also be given to whether he has headaches not explained by migraines or tension headaches that may qualify as part of an undiagnosed illness. For these reasons, a VA examination and additional opinions are needed. 3. Entitlement to service connection for rheumatoid arthritis is remanded. The Veteran was diagnosed with having rheumatoid arthritis in November 2014 based on positive RF and CCP findings. Service treatment records note complaints concerning the left knee, low back, and left ankle, and service connection was later established for low back and left knee disabilities. While many of the complaints appear to coincide directly with an injury to a specific body part it is unclear if any of the complaints could overlap or be attributed to other causes, such as rheumatoid arthritis. Notably, post service treatment records have been unclear on whether the rheumatoid arthritis involves any active disease process or if the seropositivity is related to any real disease. Therefore, an examination is needed to confirm the diagnosis and obtain an opinion to determine if any of the joint complaints in service could also be attributed to rheumatoid arthritis. 4. Entitlement to service connection for fibromyalgia is remanded. Additional development is needed due to conflicting evidence concerning the diagnosis of fibromyalgia. The December 2014 VA unfavorable opinion states there is no formal diagnosis in service treatment records or post service records and that the Veteran’s joint pain has been recently diagnosed as rheumatoid arthritis. See December 2014 VAPRI records. However, VA treatment records indicate rheumatology has diagnosed both fibromyalgia and rheumatoid arthritis and has indicated not all the Veteran’s complaints are explained by rheumatoid arthritis. See December 2015 CAPRI records. Given the Veteran’s service in Southwest Asia and the possibility of an undiagnosed illness manifested by joint or muscle pain and the possible diagnosis of fibromyalgia, an examination is needed to clarify the diagnoses and the etiologies. 5. Entitlement to service connection for an upper gastrointestinal disorder, to include GERD and hiatal hernia, is remanded. The Veteran’s GERD was first diagnosed in September 2007, within three months of his separation from service. At the time, he reported having burning chest pain lying down and feeling acid and food in his mouth and throat. A July 2014 esophagram revealed a small hiatal hernia with GERD. See December 2015 CAPRI records. Notably, service treatment records also note complaints of chest pain and even though other symptoms were not reported it is unclear if his in-service complaints were related to GERD. See January 2014 Correspondence. The December 2014 VA examiner offered an unfavorable opinion, but did not explain the rationale, so it is inadequate. Instead, the clinician only stated that although GERD was not related to the Veteran’s time in Gulf War, he was diagnosed within one year of leaving service. See December 2015 CAPRI records. Consequently, another opinion is needed. 6. Entitlement to service connection for a bilateral restless leg disorder is remanded. Restless leg syndrome was first suspected in June 2009 and later diagnosed in June 2012. See December 2015 CAPRI records. A December 2014 unfavorable opinion was based on restless leg syndrome not being diagnosed until 2012; the examiner did not discuss why it could not have had its onset during service particularly since it was suspected two years after separation from service. See December 2014 CAPRI records. Furthermore, the impression in a June 2012 treatment record indicates the Veteran had it for seven years, which suggests an onset during service and a January 2007 medical examination and history report prior to separation from service shows the Veteran reported “shakiness” in his body. See June 2009 STR – Medical. The Board also notes that the June 2009 record that first suggested the diagnosis also stated that antidepressants could aggravate the disorder. Even though it added that bupropion, the antidepressant the Veteran takes for depression, has the least adverse effect on restless leg syndrome, the record does not answer the question of whether it has in fact aggravated the Veteran’s disorder. Based on the above, opinions for direct and secondary service connection are needed. 7. Entitlement to a compensable rating for plantar warts is remanded. The Veteran’s bilateral plantar warts have been assigned a noncompensable rating under Diagnostic Code 7802, which pertains to burn scars or scars due to other causes, not of the head, face, or neck that are superficial and nonlinear. See 38 C.F.R. § 4.118. In April 2014, he had a VA skin examination that found no evidence of scars and the examiner indicated that the warts had resolved. See June 2014 VA Examination. However, January 2014 correspondence from the Veteran’s wife states he complains of foot pain due to his warts, which are present on the sides and bottom of his feet. She helps him shave down the warts, but he still has pain. Since the plantar warts are not shown to have produced scars, but rather produce foot symptoms not contemplated in the criteria for skin disabilities, he should be afforded a VA examination that also includes evaluating the warts as a foot disability. 8. Entitlement to an initial compensable rating for IBS is remanded. The Veteran was afforded a VA examination in April 2015. The Veteran reported having intermittent and alternating diarrhea and constipation with few normal bowel movements; he did not have episodes of bowel disturbance with abdominal distress or exacerbations. Five months later, in September 2015, in addition to reporting alternating diarrhea and constipation, he reported having frequent abdominal cramping. See December 2015 CAPRI records. Since he did not have abdominal distress during the examination and then later reported abdominal cramping, the record indicates there may have been a worsening in his disability. Accordingly, an examination is needed for current findings. The matters are REMANDED for the following action: 1. Before scheduling the Veteran for any VA examinations, associate with the claims file all VA treatment records since December 2015. 2. Arrange for an appropriate clinician to review the Veteran’s claims file to determine the likely etiology of his erectile dysfunction. Based on a review of the record that includes medical and lay evidence, the clinician must address the following: a) Opine whether the Veteran’s erectile dysfunction at least as likely as not (50 percent or greater probability) had its onset during service or is otherwise related to service. In considering lay evidence, the Veteran’s wife is competent to report when she noticed the Veteran’s erectile dysfunction began. b) Opine whether it is at least as likely as not that the Veteran’s erectile dysfunction was caused by his service-connected lumbar disability, PTSD, or chronic fatigue syndrome to include the medications prescribed for each. c) Opine whether it at least as likely as not that the Veteran’s erectile dysfunction was aggravated by his service-connected lumbar disability, PTSD, or chronic fatigue syndrome to include the medications prescribed for each. • If the disability was aggravated by a service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. d) Provide a complete rationale that supports the opinion. The clinician should comment on the relevance of the September 2007 treatment record that first diagnosed the disorder and indicates an onset in December 2006. 3. Schedule a VA examination to determine etiology of the Veteran’s headache disorders. Make the claims file available for the clinician to review. The history and findings concerning the headaches should be reported in full. Based on the examination and review of the claims file, the clinician should must respond to the following: a) Regarding each disorder diagnosed (i.e., tension headaches and migraines) opine whether it at least as likely as not (50 percent or greater probability) that both had their onset during service or are otherwise related to service and the complaints and exposure to blasts noted therein. b) If the above opinions are negative, then opine whether the Veteran has any headaches apart from migraines and tension that are signs or symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness. c) Provide a complete rationale that supports the opinions. 4. Schedule a VA examination for to determine the nature and etiology of the Veteran’s rheumatoid arthritis. The claims file must be made available to the clinician for review. Any indicate evaluations, studies, or tests should be conducted. Based on the examination and review of the claims file, the clinician must address the following: a) Opine whether the Veteran’s rheumatoid arthritis at least as likely as not (50 percent or greater probability) had its onset during service, manifested in the first post-service year, or is otherwise related to service to include complaints of joints pain. b) Provide a complete rationale that supports the opinions. 5. Schedule a VA examination to determine the nature and etiology of the Veteran’s fibromyalgia. The claims file must be made available to the clinician for review. Any indicate evaluations, studies, or tests should be conducted. Based on the examination and review of the claims file, the clinician must address the following: a) State whether the Veteran has a diagnosis of fibromyalgia. b) If any symptoms of his claimed fibromyalgia condition have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. c) Provide a complete rationale that supports the opinion. 6. Schedule a VA examination to determine the nature and etiology of the Veteran’s GERD/hiatal hernia. The claims file must be made available to the clinician for review. Any indicate evaluations, studies, or tests should be conducted. Based on the examination and review of the claims file, the clinician must address the following: Opine whether the GERD/hiatal hernia at least as likely as not (50 percent or greater probability) had its onset during service. The examiner should note GERD was diagnosed in September 2007, shortly after his separation from service. 7. Schedule a VA examination to determine the nature and etiology of the Veteran’s restless leg syndrome. The claims file must be made available to the clinician for review. Any indicate evaluations, studies, or tests should be conducted. Based on the examination and review of the claims file, the clinician must address the following: a) Opine whether the Veteran’s restless leg syndrome at least as likely as not (50 percent or greater probability) had its onset during service to include the reports of “shakiness” reported in January 2007. b) Opine whether it at least as likely as not that the Veteran’s restless leg syndrome was caused by the antidepressant medication prescribed for his service-connected PTSD. c) Opine whether it at least as likely as not that the Veteran’s restless leg syndrome was aggravated by the antidepressant medication prescribed for his service-connected PTSD. • If the disability was aggravated by a service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. d) Provide a complete rationale that supports the opinions. 8. Schedule VA foot and skin examinations to determine the severity of the Veteran’s bilateral plantar warts. Any indicated tests or studies should be conducted and all complaints and pertinent findings reported in full. The examination should encompass evaluations of his warts as skin and foot disabilities. 9. Schedule a VA examination to determine the severity of the Veteran’s IBS. All pertinent symptomatology and findings must be reported in detail. Any diagnostic tests deemed necessary must be conducted. The examiner must record all pertinent medical complaints, symptoms, and clinical findings, in detail. Based on the examination and the Veteran’s complaints, the clinician should specifically indicate if there has been any change in the disability since the last VA examination. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Bredehorst