Citation Nr: 18150341
Decision Date: 11/15/18	Archive Date: 11/14/18

DOCKET NO. 15-10 206
DATE:	November 15, 2018
ORDER
Entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities is dismissed.
Entitlement to special monthly pension based upon the need for regular aid and attendance is dismissed.
REMANDED
Entitlement to service connection for bilateral hearing loss is remanded.
Entitlement to service connection for tinnitus is remanded.
Entitlement to service connection for left shin splints is remanded.
Entitlement to service connection for right shin splints is remanded.
Entitlement to service connection for left shoulder disorder (claimed as shoulder problems and joint pain) is remanded.
Entitlement to service connection for right shoulder disorder (claimed as shoulder problems and joint pain) is remanded.
Entitlement to service connection for frostbite of the feet is remanded.
Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded.
Entitlement to service connection for traumatic brain injury (TBI) (also claimed as short-term memory loss, concussions, problem focusing and balance off) is remanded.
Entitlement to service connection for headaches, to include as secondary to a TBI, is remanded.
Entitlement to service connection for left wrist disorder (claimed as wrist pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for right wrist disorder (claimed as wrist pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a left hip disorder (claimed as hip pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a right hip disorder (claimed as hip pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a left ankle disorder (claimed as ankle pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a right ankle disorder (claimed as ankle pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a left knee disorder (claimed as knee pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a right knee disorder (claimed as knee pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a left elbow disorder (claimed as elbow pain and joint pain), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for right elbow disorder (claimed as elbow pain and joint pain), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a left little finger disorder (claimed as left pinky finger injury) is remanded.
Entitlement to service connection for a right little finger disorder (claimed as right pinky finger) is remanded.
Entitlement to service connection for bilateral plantar fasciitis (claimed as feet problems), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for hallux valgus with degenerative joint disease of the first metatarsophalangeal joint, left foot, to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for hallux valgus with degenerative joint disease of the first metatarsophalangeal joint, right foot, to include as due to undiagnosed illness, is remanded.
Entitlement to service connection for lumbar spine disorder (claimed as back pain), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a cervical spine disorder, to include as due to undiagnosed illness, is remanded.
Entitlement to service connection for erectile dysfunction, to include as secondary to an acquired psychiatric disorder or as due to an undiagnosed illness, is remanded.
Entitlement to service connection for sleep apnea, to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a skin disorder (claimed as dry skin on both arms, back of neck and small of back with itching), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a sinus disorder (claimed as sinus problems), to include as due to an undiagnosed illness, is remanded.
Entitlement to service connection for a disability manifested by hair loss as due to an undiagnosed illness is remanded.
Entitlement to service connection for a disability manifested by stomach pain as due to an undiagnosed illness is remanded.
Entitlement to service connection for a disability manifested by groin problems and pain as due to an undiagnosed illness is remanded.
Entitlement to service connection for a right eye disorder (claimed as weakness and pink eye), to include as due to an undiagnosed illness, is denied.
Entitlement to a compensable disability rating for service-connected pseudofolliculitis barbae is remanded.
Entitlement to a compensable disability rating for service-connected dermatophytosis is remanded.
Entitlement to non-service-connected disability pension is remanded.
FINDING OF FACT
Prior to promulgation of a decision by the Board, on the record during the March 2018 Board hearing, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew the appeals as to the issues of entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities and special monthly pension based on the need for regular aid and attendance.
CONCLUSIONS OF LAW
1. The Veteran’s claim for entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities is dismissed for lack of a justiciable issue.  38 U.S.C. §§ 511(a), 7104, 7105, 7108; 38 C.F.R. § 20.101.
2. The Veteran’s claim for entitlement to special monthly pension is dismissed for lack of a justiciable issue.  38 U.S.C. §§ 511(a), 7104, 7105, 7108; 38 C.F.R. § 20.101.
REASONS AND BASES FOR FINDING AND CONCLUSIONS
The Veteran served with the United States Air Force Reserves from July 2000 to March 2011.  During such time, he served an initial period of active duty for training (ACDUTRA) from September 2000 to December 2000 with periods of annual and weekend trainings.  He also had honorable active military service from August 2004 to August 2005 during which he served in Southwest Asia from September 2004 to March 2005 in support of Operation Noble Eagle/Enduring Freedom.  
The Veteran appeared and testified at a Travel Board hearing held at the RO before the undersigned Veterans Law Judge in March 2018.  A transcript of this hearing is associated with the claims file.  
Entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities and special monthly pension based on the need for regular aid and attendance
During the March 2018 Board hearing, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew the issues of entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities and special monthly pension based on the need for regular aid and attendance.  The undersigned clearly identified the withdrawn issues and that the withdrawal of those issues was discussed with the Veteran and his attorney prior to the hearing.  The undersigned then listed the remaining issues on appeal.  Although the Veteran did not expressly affirm he was requesting a withdrawal of those issues, his attorney confirmed the issues on appeal by listing them in his opening statement, which did not include the two issues withdrawn.  See Hearing Transcript, pp. 2-4.  The Veteran’s full understanding of the consequences is shown by the fact that, prior to the hearing, the consequences of withdrawal of these claims was fully discussed by the undersigned and the Veteran’s attorney.  See Acree v. O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018).
The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed.  38 U.S.C. § 7105.  An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision.  38 C.F.R. § 20.204.  Withdrawal may be made by the appellant or by his or her authorized representative.  38 C.F.R. § 20.204.  In the present case, the Veteran, through his authorized representative, has withdrawn the appeal as to the claims of entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities and special monthly pension based on the need for regular aid and attendance.  Hence, there remain no allegations of errors of fact or law for appellate consideration as to those claims.  Accordingly, the Board does not have jurisdiction to review those issues on appeal, and they are dismissed.


REASONS FOR REMAND
1. Entitlement to service connection for bilateral hearing loss and tinnitus.
The Veteran contends he lost his hearing due to a roadside bomb while in Iraq.  See November 25, 2013 Correspondence.  At the March 2018 Board hearing, the Veteran elaborated that he was exposed to loud noise while in Iraq for seven months from firing weapons a lot at close range.  He reported he fired a few hundred rounds each day without hearing protection.  He associated his hearing loss and tinnitus to this military noise exposure.  He denied any post-service noise exposure.  In addition, his attorney argued that the Veteran’s claims for service connection for hearing loss and tinnitus should be remanded for a new VA examination because the December 2013 VA examination was inadequate.  
The Board acknowledges the contention by the Veteran’s attorney’s that the VA examination is inadequate because the examiner stated that the Veteran could not be tested and his argument that the Veteran should be retested.  However, the examiner’s explanation for why he reported “could not be tested” was that “hearing loss could not be established due to the inconsistencies of the Veteran-volunteered responses after instruction and retest” for the hearing loss portion of the examination and that “tinnitus could not be established due to inconsistencies in the Veteran-volunteered responses during the appointment” on the tinnitus portion of the examination.  
The Board agrees that remand is warranted for a new VA examination, given the Veteran is competent to report he has current difficulties with his hearing and tinnitus.  However, the Board advises the Veteran that it is his responsibility to cooperate with VA in the development of his claim, including the examination process.  See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992).  That includes being fully honest and forthright with the VA examiner in his responses to the questions asked so that a complete examination can be obtained, including responding appropriately to audiometric testing.  The Veteran’s failure to do so could have a negative impact on the outcome of his claims.  
2. Entitlement to service connection for left and right shin splints is remanded.
The Veteran contends he has bilateral shin splints that had their onset during Basic Training at Lackland Air Force Base, San Antonio, Texas, from running during physical training.  He says he felt a burning sensation in both shins for which he sought treatment and an X-ray shows a fracture in his shin.  He complains of still feeling burning daily.  See November 25, 2013 Correspondence.  At the March 2013 Board hearing, the Veteran further elaborated that, in service, he had to run with a ruck sack every day and he had a burning sensation down his legs.  He sought treatment for this in service and would get ice for it every day.  He reported this was a continuous problem that has not gone away.
The Veteran indicated that his bilateral shin splints began in basic training during his initial period of ACDUTR A with the Air Force Reserve from September 2000 to December 2000.  He reports he received treatment for such condition, including X-rays.  However, a review of the claims file does not find that his service treatment records contain any records of such treatment, as well as other treatment the Veteran reports.  The only available treatment note showing complaints of shin splints is from January 2009.  In addition, at the December 2013 VA examination, the examiner remarked that the Veteran showed him a September 2006 physical profile due to shin splints which is not part of the available records.  
Given the Veteran’s reports of treatment during his initial period of ACDUTRA, as well as the evidence of shin splints during the latter part of his Reserve service, the Board finds that further efforts are needed to locate any available treatment records.  This should include asking the Veteran to provide any records he may have.  The Board acknowledges that he previously indicated he did not have his service records, but he clearly has some now.  
On VA examination in December 2013, the Veteran reported a history of hairline fractures to the bilateral shins in 2003 due to strenuous running and exercise and was on profile for no running.  Current symptoms consist of bilateral lower leg pain with prolonged walking.  On physical examination, there was diffuse tenderness to palpation of the bilateral anterior tibial regions.  The assessment was bilateral shin splint pain.
In rendering a medical nexus opinion, the VA examiner only opined that shin splints are a disease with a clear and specific etiology and diagnosis and, therefore, it is less likely than not that the Veteran’s shin splints are related to any environmental exposure he may have had in the Gulf War Region.  However, the Veteran has never contended that his shin splints were due to an undiagnosed illness resulting from his service in Iraq from September 2004 to March 2005.  His contention has clearly been that they had their onset during his initial period of ACDUTRA.  The VA examiner did not address that contention in rendering his medical opinion.  Thus, remand is necessary to obtain such an opinion.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  
3. Entitlement to service connection for left and right shoulder disorders (claimed as shoulder problems and joint pain) is remanded.
The Veteran contends that, during basic training during his initial period of ACDUTRA, he was doing physical training and while doing exercises, such as pushups or pullups, he heard a pop in his left shoulder.  Overcorrection for his left shoulder caused his right shoulder to pop.  The doctor popped them both back in, and he was placed on profile of no physical training for two weeks.  
The Veteran’s service enlistment examination reports from June 2000 are silent for any report of a history of shoulder problems or findings of current shoulder abnormalities.  In September 2000, a Consultation Sheet indicates the Veteran was being referred for an orthopedic consultation due to complaints of pops, pains and dislocation of the left shoulder.  He reported a history of numerous bilateral dislocations with a history of rehabilitation more than six months before but did not inform MEPS.  He was noted to have decreased range of motion with guarding.  He was to be evaluated for duty disposition recommendation.  However, on orthopedic consultation, the Veteran reported only left shoulder pain for one day waking up from sleep with it and being able to do physical training that morning.  He denied pain, weakness or loss of motion that day.  He only reported a history of burners and stingers playing football in 1993.  The assessment was a normal shoulder.  When seen on follow up the next day and confronted with the discrepancies between the reported histories, it was noted the Veteran acted confused and said he was misinterpreting his symptoms as dislocations but he was not able to state what Ortho said it was.  However, it was reiterated that Ortho said he had a normal shoulder.  The remainder of the Veteran’s service treatment records are silent for any shoulder conditions.
The January 2013 VA Primary Care treatment note shows the Veteran complained of feeling like his right shoulder “pops” out of place following injury while doing pushups, low crawls, etc.  Objectively, there was tenderness to palpation over both shoulders anteriorly with decreased abduction bilaterally.  The assessment was bilateral shoulder pain.  In June 2013, he was noted to have discomfort on abduction of the shoulders and was assessed to have shoulder arthralgia.  In July 2013, X-rays of the bilateral shoulders showed joint space narrowing with mild degenerative joint disease in the acromioclavicular joint, but otherwise no significant degenerative joint disease was seen. 
On VA examination in December 2013, the Veteran was diagnosed to have bilateral mild degenerative joint disease of the acromioclavicular joint.  The Veteran reported onset of his bilateral shoulder pain while in basic training.  He again related that, while doing exercises, such as pushups and chin ups, he heard his left shoulder popping.  He went to sick call where he was told X-rays should he had torn cartilage on the left and subluxation of the right.  He was given an ace wrap and pain medication with a profile for no pushups and no running.  He stated he only had one week left in basic training.  Once he got to technical school, he went back to the doctor for continuous shoulder pain and was told that he could either have surgery on the left shoulder or manage it with pain medication.  He chose the latter.  He also stated that he shoots left-handed and injured his left shoulder in Iraq while shooting a rifle in 2004-2005.  Once he returned back from Iraq, he was referred to physical therapy.  He reported he has been doing physical therapy and pain medicine to date.  He reported he was on profile for no running, no pushups or sit-ups for his entire military career.  In terms of the right shoulder, he reported he was doing sit-ups in basic training in 2000 and came up too fast and the right shoulder popped out of place.  He went to sick call and was prescribed ice compression and pain medication.  Now his shoulder pops out of place with overhead movement and lifting over 15-20 pounds.  
In general, “every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination.”  38 U.S.C. § 1111, see also 38 C.F.R. § 3.304(b).  However, for appellants who are already veterans based upon a period of active duty but the claim is based on a separate period of ACDUTRA, such as in the present case, “[t]he statute requires that there be an examination prior to entry into the period of service on which the claim is based – here, the period of active duty for training.”  Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). The presumption of soundness condition “attaches only where there has been an induction examination in which the later-complained-of disability was not detected.”  Crowe v. Brown, 7 Vet. App. 238, 245 (1994).  In the present case, because of the June 2000 enlistment examination along with the September 2000 recertification, the presumption of soundness would be for application for the Veteran’s initial period of ACDUTRA from September 2000 to December 2000 for any conditions not noted on that examination.  
The Board further notes that the Court of Appeals for Veterans Claims (Court) has held on multiple occasions that lay statements by a veteran concerning a preexisting condition, alone, are not sufficient to rebut the presumption of soundness.  See e.g., Gahman v. West, 13 Vet. App. 148, 150 (1999); Crowe v. Brown, 7 Vet. App. 238 (1995); Leshore v. Brown, 8 Vet. App. 406 (1995).  Thus, the Veteran’s statements in the service treatment records of pre-service football injuries to his bilateral shoulders in 1993 or dislocations of his bilateral shoulders with rehab prior to service without more evidence is, therefore, of no consequence and cannot rebut the presumption of soundness or otherwise be used against his claim for service connection.
In rendering a medical nexus opinion, the VA examiner only opined that the Veteran’s degenerative joint disease of the bilateral shoulders is a disease with a clear and specific etiology and diagnosis.  In addition, the examiner stated that shoulder subluxation and burners and stingers were pre-existing prior to the Veteran’s deployment to the Gulf region as he was evidently evaluated by an orthopedic specialist while in basic training for bilateral shoulder dislocation and noted to have a history of burners and stingers which he sustained while playing football in 1993.  Therefore, he opined it is less likely than not that the Veteran’s bilateral shoulder degenerative joint disease is related to any specific exposure event experienced by the Veteran during his service in Southwest Asia.  However, the Veteran has never contended that his bilateral shoulder problems were due to an undiagnosed illness resulting from his service in Iraq from September 2004 to March 2005.  His contention has clearly been that his bilateral shoulder problems had their onset during his initial period of ACDUTRA, although he related he had an injury to his left shoulder in Iraq while shooting a rifle (notably in his November 2013 correspondence, he also reported he injured his right shoulder in an accident).  The VA examiner did not address these contentions of direct service connection in rendering his medical opinion.  Thus, remand is necessary to obtain such an opinion.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  
4. Entitlement to service connection for frostbite of the feet is remanded.
The Veteran contends that his frostbite was incurred while doing his technical training at Fort Leonard Wood, Missouri, during his initial period of ACDUTRA during his Reserve service from September 2000 to December 2000.  He reports going to sick call and it being determined he had frostbite.  However, a review of the claims file does not find that his service treatment records contain any record of such treatment, as well as other treatment he reports.  Thus, it appears his service treatment records are incomplete.
Although the Veteran was afforded a VA examination in December 2013, that examination did not evaluate his claim of frostbite of the feet.  The Board cannot make a fully-informed decision on this issue because no VA examiner has opined whether the Veteran has residuals of frostbite that may be related to the Veteran’s contentions of sustaining cold weather injuries during his initial period of ACDUTRA from September 2000 to December 2000.
5. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded.
The Veteran was afforded VA examination in December 2013.  However, the VA examiner did not render a mental health diagnosis at that time, finding the Veteran’s presentation precluded doing so as he failed to cooperate with the examination process as his self-reported social, educational, military and occupational histories were markedly inconsistent with the rest of the record.  Essentially, the examiner found that the Veteran was not forthright with him regarding his educational, occupational and military history and that this made it impossible for the examiner to assess accurately the Veteran’s occupational and social functioning.  Moreover, the examiner stated that the Veteran did not reliably report a single symptom consistent with PTSD as the symptoms he did report were either so vague or could be related to other conditions.  
Moreover, although the Veteran’s VA treatment records show a diagnosis of PTSD and major depressive disorder (MDD), the examiner found that the diagnosis of PTSD is based upon the Veteran’s inaccurate report that he was in combat service in Iraq.  Unfortunately, the Veteran’s service records do not show he is a combat veteran.  His military occupational specialty (MOS) was Vehicle Operations Helper, which is a non-combat MOS.  Furthermore, his DD Form 214 for this period of service does not show any combat awards or medals were issued.  Even more significantly, on the Veteran’s February 2005 Post-Deployment Health Assessment, it is blank where it would indicate a Combat Specialty, indicating he was not in combat during his deployment.  
However, not all of the Veteran’s reported stressors are related to engaging in direct combat with the enemy.  In a November 2013 statement, the Veteran reported stressors from his time in Iraq, including from when a truck behind him during a convoy hit an IED and exploded when his truck had previously driven over it without harm and from having insufficient security on convoys and having Iraqis following them but managing to get away.  He also reported that, while on active duty at Charleston, South Carolina, he lost a very close friend due to an alcohol-related accident whom he thinks of daily and that his work was very stressful as bomb threats made him fearful for his life.  However, at the March 2018 Board hearing, the Veteran reported it was while he was on active duty at Langley Air Force Base, Virginia, that he had a stressful work environment because his schedule changed weekly and he had no sleep.
Moreover, at a September 2013 VA mental health initial evaluation, the Veteran reported the following stressors: (1) During a convoy in Iraq, the truck in which the Veteran was in ran over an IED but it did not detonate until the third truck after his went over it.  A soldier from that vehicle lost his leg and the left side of his torso was severely injured, but he did not die.  (2) The first attack he experienced upon arriving in Iraq occurred 30 minutes after he landed when he and his soldiers were attacked by small arms fire.  (3) While stationed in the United States, a friend left a party they had attended while drunk and died soon after in a car accident.  He drove to the accident site and saw his friend dead.  (4) While stationed in the United States, his friend got into a motorcycle accident (his bike went off road).  He turned around to find out what happened and he witnessed his friend going through the process of dying.  
With the above taken into consideration, the Board notes that the Veteran has more recently submitted treatment records from his private primary care physician (from March through August 2017) and a private mental health care provider from April 2018 indicating treatment for anxiety, depression and PTSD.  Significantly, an April 2018 Clinical Progress Summary from the Veteran’s private mental health care provider indicates treatment of the Veteran since June 2017 on a monthly basis and provides that the Veteran has a diagnosis of PTSD under the DSM-5 as a result of being directly impacted by military traumatic exposure to a war-zone/combat environment while serving in the USAF in Iraq.  Based on these records, it appears that the Veteran may have a diagnosis of PTSD due to stressors that are related to his fear of hostile military or terrorist activity.  However, more information is needed to allow the Board to make a fully-informed decision.  
Initially, the Board notes that 38 C.F.R. § 3.304(f)(3) provides that, if the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.  Unfortunately, the only available official records with regard to the Veteran’s period of service in Iraq from September 9, 2004 to March 1, 2005 is his DD Form 214 showing his MOS and unit and a few service treatment records.  However, his service treatment records appear to indicate he was in Kuwait for at least part of that time.  Therefore, more information is needed as to the Veteran’s service in the Southwest Asia theater of operations to ensure that his reported stressors are consistent with the places, types, and circumstances of such service.
In addition, while the Veteran has a current diagnosis of PTSD that appears to be related to fear of hostile enemy or terrorist activity, no VA psychiatrist or psychologist has confirmed that a claimed in-service stressor is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the claimed stressor(s).  See 38 C.F.R. § 3.304(f)(3).  Thus, remand is required for such examination.  
However, as instructed by the December 2013 VA examiner, the Veteran is advised that it is his responsibility to cooperate with VA in the development of his claim, including the examination process.  See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992).  That includes being fully honest and forthright with the VA examiner in his responses to the questions asked so that a complete examination can be obtained.  The Veteran’s failure to do so could have a negative impact on the outcome of his claim.  
6. Entitlement to service connection for residuals of traumatic brain injury (TBI) (also claimed as short-term memory loss, concussions, problem focusing and balance off) is remanded. 
The Veteran contends he sustained a head injury during an accident during a convoy in Iraq.  There is conflicting reports from the Veteran as to whether he had loss of consciousness.  The Veteran has reported that an accident occurred in the convoy he was riding in because an IED exploded and his truck hit the back bumper presumably of the truck in front of hit.  He sustained a gash to his head when it hit the center beam of the truck he was riding in (he was not wearing a helmut) and he had to be pulled out of his vehicle.  He reported that, as he was in the field, he was not evaluated for a concussion, but that they would not let him sleep although he wanted to.  He also stated that he believes he had a TBI at that time because of his headaches.  
The Board cannot make a fully-informed decision on this issue because no VA examiner has evaluated the Veteran’s claim for residuals of TBI, which were claimed as short-term memory loss, concussions, problem focusin and balance off.  In addition, at the May 2018 Board hearing, the Veteran testified that he believes he had a TBI in service because of his headaches.  However, he has a separate claim for headaches so his claim that for a TBI should also be considered along with his claim for headaches. 
7. Entitlement to service connection for headaches, to include as secondary to a TBI, is remanded.
In November 2013 correspondence, the Veteran reported that, while in Iraq, he had constant headaches due to his helmet bouncing on his head and loud noise.  Furthermore, while still on active duty in Charleston, South Carolina, he began to get headaches while working at the back gate.  He stated that, after numerous people complained, an outside source did a study that showed a paint manufacturing company was within feet of the back gate.  In support of his claim, he submitted a lay statement from a buddy who served with him while in Charleston, South Carolina, who states that the Veteran constantly complained of headaches while they served there.  He stated that other workers in this area where the Veteran worked also complained of headaches, and an air study done showed that paint and paint thinner was in the air as there was a paint producer within 100 feet of their work station.  He reported that the Veteran still complains of painful headaches.  
However, at the March 2018 Board hearing, the Veteran’s attorney only pointed to the Veteran’s in-service report of having headaches while on deployment in Iraq on the Post-Deployment Health Assessment and had the Veteran testify that he still has headaches today.  The Veteran further related his headaches to a TBI he claims he incurred from a head injury sustained in an accident while in Iraq, which is not documented.  
VA treatment records are silent for any complaints of or treatment for headaches except at a September 2013 mental health initial evaluation note in which the Veteran reported the TBI and, in doing, the Veteran reported as one of the residuals “having headaches that were not there before.”  However, a private treatment note from March 2017 the Veteran submitted shows he requested a refill of Ibuprofen for “occasional headaches.”  The Veteran’s complaints of headaches were not evaluated at the December 2013 VA examination.
Based upon the Veteran’s submision of the March 2017 private treatment note, it appears there may be relevant outstanding private treatment records relevant to his claim.  Hence, remand is required to allow VA to obtain authorization and request these records.
Furthermore, given the notation of headaches on active duty in February 2005 along with the Veteran’s current report of chronic headaches, remand is required because no VA examiner has opined whether the Veteran’s has a chronic headache disability that may be related to the headaches he reported during service.  
8. Entitlement to service connection for left and right wrist disorders (claimed as wrist pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
In January 2013, the Veteran reported to a VA primary care physician that his bilateral wrist pain was due to physical training and doing pushups in service.  In November 2013 correspondence, the Veteran reported an injury to his right wrist in an accident while driving an ATV while on active duty while at Charleston, South Carolina.  At the December 2013 VA examination, the Veteran attributed his bilateral wrist pain to an accident that occurred while he was on active duty in Iraq in which the Humvee he was driving accidently hit the one in front of his and, upon impact, he used his hands to brace himself and the force went from his hands, to his wrists and then to his elbows.  After the accident, he used an ace wrap and took care of it himself.  He also reported that shooting a 40-caliber gun hurt his left wrist.  He went to sick call for the left wrist after returning from Iraq and was given Ibuprofen.  At the March 2018 Board hearing, the Veteran, via his attorney, related his bilateral wrist pain to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions (especially his conditions involving the joints, gastrointestinal system, skin, vision, sinuses and sleep disturbance) combine into a medically unexplained chronic multi-symptom illness (MUCMI).  
Service treatment records are silent for complaints or treatment relating to the bilateral wrists.  The January 2013 Primary Care note showed the Veteran had tenderness to palpation of the bilateral medial and lateral wrists on examination and the assessment was bilateral wrist pain.  However, VA examination in December 2013 of the bilateral wrists was essentially normal and, therefore, no diagnosis of a bilateral wrist disorder was rendered.  However, it was noted that X-rays taken showed the Veteran had mild degenerative joint disease of the left first metacarpophalangeal joint.  Private treatment records from 2017 do not show complaints of or treatment for bilateral wrist pain and the Veteran did not provide testimony at the March 2018 hearing as to his current symptoms relating to his bilateral wrists. 
The Veteran indicated treatment for his left wrist after he returned from Iraq but while he was still on active duty.  However, a review of the claims file does not find that his service treatment records contain any record of such treatment, as well as other treatment he reports.  Thus, it appears his service treatment records are incomplete.
Given the Veteran’s submission of private treatment records, it appears there may be outstanding private treatment records relevant to his claims.  Hence, remand is required to allow VA to obtain authorization and request these records.
Furthermore, remand is required because no VA examiner has opined whether the Veteran’s right wrist disorder, if any, is related to an injury reportedly incurred during his period of active duty from August 2004 to August 2005, to include due to an automobile accident while in Iraq, an ATV accident while in Columbia, South Carolina and/or physical training such as pushups.  Moreover, the Veteran contends that his bilateral wrist pain is due to an undiagnosed illness, to include as part of a MUCMI.  Such should be considered by the VA examiner on remand.
9. Entitlement to service connection for left and right hip disorders (claimed as hip pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
On VA examination in December 2013, the Veteran attributed his bilateral hip pain to prolonged sitting in Humvees while in Iraq.  On physical examination, range of motion testing showed flexion of the bilateral hips was limited to 110 degrees with pain starting at 90 degrees and bilateral hip extension greater than 5 degrees with pain starting at 5 degrees.  There was also tenderness to palpation of both hips.  However, the VA examination did not render a diagnosis despite these objective findings.  VA and private treatment records are silent for any hip complaints or treatment.  At the March 2018 Board hearing, the Veteran, via his attorney, related his bilateral hip pain to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  
Initially, the Board notes that, simply because the Veteran does not have a diagnosis to explain his bilateral hip pain does not mean it does not qualify as a disability.  The United States Court of Appeals for the Federal Circuit recently held that “pain in the absence of a presently-diagnosed condition can cause functional impairment” and, therefore, can qualify as a disability.  Saunders v. Wilkie, 886 F.3d 1356, 1368-69 (2018).  However, the December 2013 VA examiner remarked that the Veteran did not have any functional loss and/or impairment of the hip and thigh and his hip and/or thigh condition did not impact his ability to work.  
However, despite this examination being a Gulf War General Medical examination and the VA examiner considering whether the Veteran’s other claimed conditions were an undiagnosed illness, when actually faced with a claimed condition with positive objective findings but no diagnosable disorder, the VA examiner failed to address whether the positive objective findings were related to an undiagnosed illness.  Thus, this examination is inadequate and a new one must be obtained.  On re-examination, the new examiner must also address the Veteran’s contention that all of his conditions together constitute a MUCMI. 
10. Entitlement to service connection for a left and right ankle disorder (claimed as ankle pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
At the March 2018 Board hearing, the Veteran, via his attorney, related his bilateral ankle pain to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  However, a January 2013 initial VA Primary Care treatment note shows the Veteran related he had bilateral ankle pain after sprains he received while playing basketball throughout service, but no objective findings or assessment was made relating to his ankles.  X-rays taken of the bilateral feet in June 2013 showed the suggestion of mild degenerative joint disease in the subtalar and talonavicular joints with subchondral sclerosis bilaterally.  In addition, X-rays noted in a September 2013 VA Physical Therapy consultation note indicated a 4 mm well-corticated ossification seen overlying the medial malleolus consistent with an old avulsion fracture fragment in the right ankle.  The Veteran’s ankles were not evaluated during the December 2013 VA examination.  These X-ray findings were not made in conjunction with treatment for his ankles, but were incidental findings made while he was being treated for his bilateral knees and feet.  It is noted that the Veteran has bilateral hallux valgus, degenerative joint disease of the first metatarsophalangeal joint and plantar fasciitis of the bilateral feet, as well as the degenerative joint disease of the bilateral knees.  
However, given the Veteran’s contentions and the findings in the VA treatment records, the Board finds that remand is required for a VA examination to obtain a medical opinion as to whether has a current bilateral ankle disorder that may be related to an injury incurred during his military service.  The VA examiner should also consider the Veteran’s contention that his bilateral ankle pain is due to an undiagnosed illness, to include that all of his conditions combined together constitute a MUCMI.
11. Entitlement to service connection for left and right knee disorders (claimed as knee pain, joint pain and tendinitis), to include as due to an undiagnosed illness, is remanded.
In November 2013 correspondence, the Veteran reported injuring his right knee in an ATV accident while on active duty at Charleston, South Carolina, in 2005.  However, on physical therapy consult at VA in September 2013, the Veteran reported long-standing bilateral knee pain since 2007.  On VA examination in December 2013, he reported the onset of bilateral knee problems before he went to Iraq in September 2004 but that it worsened while in Iraq.  He attributed his knee pain to military training exercises such as low crawling and hitting his left knee on the dashboard when he braced himself during an accident in Iraq.  At the March 2018 Board hearing, the Veteran, via his attorney, related his bilateral hip pain to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  
Both VA treatment records and the December 2013 VA examination show he has been diagnosed to have degenerative joint disease of the bilateral knees as demonstrated by X-ray evidence.  
Although the VA examiner opined that the Veteran’s degenerative joint disease of the bilateral knees is a disease with a clear and specific etiology and diagnosis and, therefore, it is less likely than not that his bilateral knee degenerative joint disease is related to an environmental exposure in the Persian Gulf Region (in other words, not an undiagnosed illness), the VA examiner failed to address the Veteran’s contentions that his bilateral knee degenerative joint disease is directly related to injury during his active duty service.  Consequently, remand is required to obtain such an opinion.  In addition, an opinion should be obtained as to the Veteran’s contentions that his various conditions taken together constitute a MUCM.
12. Entitlement to service connection for left and right elbow disorders (claimed as elbow pain and joint pain), to include as due to an undiagnosed illness, is remanded.
At the March 2018 Board hearing, the Veteran, via his attorney, related his bilateral elbow pain to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  However, at the December 2013 VA examination, in addition to relating his low back pain to exposure to a Gulf War Environmental hazard, the Veteran attributed his bilateral elbow pain to his time in Iraq and physical training, such as low crawling, having to constantly hold a gun and constantly transporting heavy objects.  He reported recalling taking pain medication for his elbows.  
VA and private treatment records are silent for elbow complaints or treatment.  The VA examiner diagnosed the Veteran to have bilateral elbow epicondylitis.  
Although the VA examiner opined that the Veteran’s bilateral elbow epicondylitis is a disease with a clear and specific etiology and diagnosis and, therefore, it is less likely than not that it is related to an environmental exposure in the Persian Gulf Region (in other words, not an undiagnosed illness), the VA examiner failed to address the Veteran’s contentions that bilateral elbow pain is directly related to injury during his active duty service.  Consequently, remand is required to obtain such an opinion.  In addition, an opinion should be obtained as to the Veteran’s contentions that his various conditions taken together constitute a MUCMI.

13. Entitlement to service connection for left and right little finger disorders (claimed as left pinky finger injury), to include as due to an undiagnosed illness, is remanded.
A January 2013 VA Primary Care initial note shows the Veteran reported having pain to the bilateral little fingers following fracture while playing football in the military.  In his November 2013 correspondence, the Veteran reported he broke his right pinky finger while on active duty at Langley Air Force Base during forklift training.  However, at the March 2018 Board hearing, the Veteran testified that he broke his right pinky doing pushups while on ACDUTRA at Charleston, South Carolina.  
As for his left little finger, the Veteran reported in his November 2013 correspondence that his left pinky was broken while performing training exercises while on active duty at Charleston, South Carolina and was reinjured while still on active duty at Langley Air Force Base.  At the March 2018 Board hearing, however, the Veteran testified that, while assigned to security forces doing field exercises, his left pinky was broken when it got caught in the guard rail of an M-4.  He went to physical therapy for six months.  
Initially the Board notes that the RO characterized the Veteran’s claim for a left pinky injury as “mild degenerative joint disease, left first metacarpophalangeal joints” based upon the diagnosis of the December 2013 VA examiner.  However, this diagnosis appears to be a misstatement of the X-ray findings it is based upon.  Significantly, the X-rays were of the wrist, not the entire hand.  More importantly, the findings on the X-ray report were in the singular – “the left first MCP joint” – versus the plural “joints” used by the examiner in his diagnosis.  Given that the X-ray was of the wrist and in the singular, it is most likely that the first MCP joint referred to is that of the thumb since that is in the area of the wrist, unlike those of the other fingers.  Furthermore, this examination from which the RO took this diagnosis was of the wrists, not the fingers.  The VA examiner did not actually evaluate the Veteran’s fingers in this examination.  His diagnosis is based merely upon the finding in the X-ray report.  Given these facts, the Board finds the RO mischaracterized this issue and the Board has recharacterized it as service connection for a left little (pinky) finger disorder.  
The Veteran indicated at the March 2018 Board hearing that he received treatment for both injuries to his right and left little fingers.  However, a review of the claims file does not find that his service treatment records contain any record of such treatment, as well as other treatment he reports.  Thus, it appears his service treatment records are incomplete.
The January 2013 VA Primary Care note shows examination revealed the Veteran had tenderness to palpation at both little fingers with limited flexion at the bilateral proximal and distal interphalangeal joints.  However, the December 2013 VA examination did not evaluate the Veteran’s claims relating to the bilateral little (pinky) fingers.  The Board cannot make a fully-informed decision on because no VA examiner has opined whether the Veteran’s current bilateral little (pinky) finger disorders are related to any injury received in service as claimed by the Veteran, to include whether his symptoms are due to an undiagnosed illness or part of a MUCMI.
14. Entitlement to service connection for bilateral plantar fasciitis and bilateral hallux valgus with degenerative joint disease of the first metatarsophalangeal joint (claimed as feet problems), to include as due to an undiagnosed illness, is remanded.
In his November 2013 correspondence, the Veteran reported that, while on active duty in Charleston, South Carolina, he performed security forces duties that required him to stand for 12 to 13 hour shifts and his feet became tender and very sore, as well as his heels became hard and tender.  On VA examination in December 2013, the Veteran attributed his feet pain from prolonged standing while in technical school in 2000, as well as while he was in Iraq and Charleston, South Carolina.  However, at the March 2018 Board hearing, the Veteran, via his attorney, related his bilateral feet problems to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  
VA treatment records and the December 2013 VA examination have diagnosed the Veteran to have bilateral plantar fasciitis, bilateral hallux valgus, and degenerative joint disease of the first metatarsophalangeal joint of both feet.  
A January 2009 service treatment note comments that the Veteran was wearing orthotics.  The Veteran reports onset on his bilateral foot pain during either his initial period of ACDUTRA from September to December of 2000 or active duty from August 2004 to August 2005.  However, a review of the claims file does not find that his service treatment records contain any record of treatment, as well as other treatment he reports.  Thus, it appears his service treatment records may be incomplete.
Furthermore, although the VA examiner opined that the Veteran’s bilateral plantar fasciitis, hallux valgus and degenerative joint disease of the first metatarsophalangeal joint are diseases with a clear and specific etiology and diagnosis, and, therefore, they are less likely than not related to any exposure event experienced by the Veteran during service in Southwest Asia (in other words, not an undiagnosed illness), the VA examiner failed to address the Veteran’s contentions that his bilateral foot diagnoses are directly related to injury during his military service.  Consequently, remand is required to obtain such an opinion.  In addition, an opinion should be obtained as to the Veteran’s contentions that his various conditions taken together constitute a MUCMI.
15. Entitlement to service connection for lumbar spine disorder (claimed as back pain), to include as due to an undiagnosed illness, is remanded.
In his November 2013 correspondence, the Veteran reported that, while in Iraq, he suffered backaches from carrying rucksacks.  At the December 2013 VA examination, in addition to relating his low back pain to exposure to a Gulf War Environmental hazard, the Veteran attributed his back pain to a car accident in Iraq in addition to carrying 60 to 70-pound rucksacks.  However, at the March 2018 Board hearing, the Veteran, via his attorney, related his back problems to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  
A January 2013 VA Primary Care initial note shows the Veteran complained of low back pain and he had mild lower lumbar tenderness on examination.  On VA examination in December 2013, he was diagnosed to have mild lower lumbar spondylosis per X-ray imaging. 
Although the VA examiner opined that the Veteran’s lumbar spondylosis is a disease with a clear and specific etiology and diagnosis, and, therefore, it is less likely than not that it is related to specific exposure in Southwest Asia (in other words, not an undiagnosed illness), the VA examiner failed to address the Veteran’s contentions that his current lumbar spine disorder is directly related to the reported injuries during his military service.  Consequently, remand is required to obtain such an opinion.  In addition, an opinion should be obtained as to the Veteran’s contentions that his various conditions taken together constitute a MUCMI.
16. Entitlement to service connection for a cervical spine disorder, to include as due to undiagnosed illness, is remanded.
In his November 2013 correspondence, the Veteran stated that he had neck pain while in Iraq from wearing a helmet.  At the December 2013 VA examination, the Veteran attributed his neck pain to the sleeping conditions in Iraq in that he never had a pillow, as well as wearing a Kevlar helmet.  However, at the March 2018 Board hearing, the Veteran, via his attorney, related his neck pain to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).   
VA and private treatment records are silent for neck complaints or treatment.  On VA examination in December 2013, the Veteran was diagnosed to have cervical spondylosis per X-ray imaging.  
Although the VA examiner opined that the Veteran’s cervical spondylosis is a disease with a clear and specific etiology and diagnosis, and, therefore, it is less likely than not that it is related to specific exposure in Southwest Asia (in other words, not an undiagnosed illness), the VA examiner failed to address the Veteran’s contentions that his current cervical spine disorder is directly related to the reported injuries during his military service.  Consequently, remand is required to obtain such an opinion.  In addition, an opinion should be obtained as to the Veteran’s contentions that his various conditions taken together constitute a MUCMI.
17. Entitlement to service connection for sleep apnea, to include as due to an undiagnosed illness, is remanded.
The Veteran indicated that his sleep apnea was diagnosed via a sleep study while he was on active duty with his Reserve unit in Charleston, South Carolina, and given a CPAP machine.  However, a review of the claims file does not reveal any records in the available service treatment records to indicate such treatment.  
Moreover, the Veteran’s DD Form 214 shows he served on active duty from August 2004 to August 2005 with deployment to Iraq from September 9, 2004 to March 1, 2005.  However, there is no record of where he served the remainder of his active duty.  In addition, at the Board hearing, it was indicated that the Veteran was on ACDUTRA when he was at Charleston, South Carolina, when discussing a different claim.  As a time reference for when that injury occurred was not given, it is unclear whether the Veteran meant a different period of service or the same period as when he was diagnosed to have sleep apnea.  The available service records are of no assistance in clarifying this question.  
The Board cannot make a fully-informed decision on the issue of service connection for sleep apnea because no VA examiner has opined whether it had its onset in or is otherwise related to the Veteran’s period of active duty service from August 2004 to August 2005, to include whether it is due to an undiagnosed illness to include consideration of whether it is part of a medically unexplained multi-symptom illness (MUCMI). 
18. Entitlement to service connection for erectile dysfunction, to include as secondary to an acquired psychiatric disorder or as due to an undiagnosed illness, is remanded.
At the March 2018 Board hearing, the Veteran contended that his erectile dysfunction is inextricably intertwined with his claims for PTSD and undiagnosed illness although he also testified that his problems with this began during service (unclear whether this means during active duty or simply while he was still in the Reserves).  However, he clearly contends that this is secondary to his mental health problems.  His attorney argued that it is part of his undiagnosed illness claims and should be taken together with the rest of his conditions to be considered as a MUCMI.  
A January 2013 VA Primary Care initial note shows the Veteran complained of having erectile dysfunction.  In June 2013, he was given a trial of Viagra.  Private treatment records provided by the Veteran do not show treatment for erectile dysfunction.  However, the Veteran testified at the Board hearing he is currently taking Cialis.  Therefore, there appears to be outstanding relevant private treatment records not associated with the claims file.  A remand is required to allow VA to obtain authorization and request these records.
The Veteran was afforded VA examination in December 2013 but did not complain of any problem with erectile dysfunction.  Thus, this condition was not evaluated.  However, at the Board hearing, the Veteran’s attorney requested he be given a VA examination.  Given the Veteran’s contentions, the Board finds it cannot make a fully-informed decision on the issue because no VA examiner has opined whether he has erectile dysfunction that may be related to his active military service or to another disability for which the Veteran has claimed service connection such as his mental health problem.  Furthermore, the Veteran’s contentions that it is related to an undiagnosed illness, to include a MUCMI, need to be considered by a medical professional.
19. Entitlement to service connection for a skin disorder (claimed as dry skin on both arms, back of neck and small of back with itching), to include as due to an undiagnosed illness, is remanded.
In his November 2013 correspondence, the Veteran reported that, while on regular Reserves duty during an exercise in full MOP gear in the middle of July, he began to itch on his forearms and in the small of his back and he has daily itching on both his forearms and back till the skin is raw.  However, at the March 2018 Board hearing, the Veteran, via his attorney, related his skin problems to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  
A June 2013 VA Primary Care note shows the Veteran reported itchy lesions on both his arms.  Examination revealed eczematous rash on both that was assessed to be dermatitis and treated with Triamcinolone cream.  However, on VA examination in December 2013, the Veteran neither complained of dry skin nor was any rash or other skin disorder found on his forearms or back (or back of neck as he reported on his claim).  
At the Board hearing, the Veteran’s attorney requested he be given a VA examination.  Given the Veteran’s contentions and the post-service evidence of a current disability, the Board finds it cannot make a fully-informed decision on the issue because no VA examiner has opined whether he has a skin disorder, manifested by dry skin on the forearms, back of the neck and low back, that may be related to his active military service.  Furthermore, the Veteran’s contentions that it is related to an undiagnosed illness, to include a MUCMI, need to be considered by a medical professional.

20. Entitlement to service connection for a sinus disorder (claimed as sinus problems), to include as due to an undiagnosed illness, is remanded.
At the March 2018 Board hearing, the Veteran, via his attorney, related his sinus problems to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  However, on VA examination in December 2013, in addition to relating his sinus problems to exposure to a Gulf War Environmental hazard, the Veteran reported the onset of his sinus problems when stationed at Charleston Air Force Base in 2006.  He later stated he also had sinus problems from dust while in Iraq and multiple nose bleeds.  When he returned from Iraq, he was given Nasonex and Flonase and sinus pills.  He reported they did allergy testing in Charleston and found multiple allergens.  
Service treatment records show the Veteran reported on his June 2000 Report of Medical History that he had a history of allergy to pollen with sneezing, although no nose or sinus problems were noted on examination either at that time or on examination in April 2004, prior to the Veteran’s entrance into active duty in August 2004.  
The Veteran reported at the December 2013 VA examination that onset of his sinus problems with treatment was during his active duty from August 2004 to August 2005.  However, a review of the claims file does not find that his service treatment records contain any record of treatment, as well as other treatment he reports.  Thus, it appears his service treatment records may be incomplete.  
The December 2013 VA examiner diagnosed the Veteran to have allergic rhinitis.  He did not find evidence of sinusitis or epistaxis (nosebleed) on examination and file review.  The examiner opined that the Veteran’s allergic rhinitis is a disease with a clear and specific etiology and diagnosis and, therefore, it is less likely as not it is related to a specific exposure event experienced by the Veteran during service in Southwest Asia (in other words, not an undiagnosed illness).  
The examiner further noted that the Veteran’s Report of Medical History from June 2000 was positive for allergy to pollen, which is a risk factor for allergic rhinitis, which is an allergic inflammation of the nasal airways occurring when an allergen, such as pollen, dust or animal dander, is inhaled by an individual with a sensitized immune system.  The examiner opined that there is no evidence of aggravation of the pre-existing allergies as records are silent for chronic nasal inflammation.  Unfortunately, the examiner answered the wrong question.  Even though the Veteran may have reported he had an allergy to pollen on his enlistment Report of Medical History, there was no nose or sinus defect noted on entry.  Therefore, the Veteran must be taken as sound for any nose or sinus condition, including allergic rhinitis.  Thus, the question to be answered was not whether the Veteran’s pre-existing pollen allergy was aggravated but whether the Veteran’s allergic rhinitis was at least as likely as not related to any exposure to allergens during service.  Simply because he is sensitive to an allergen does not mean that excessive exposure to such allergen during service that causes a chronic disorder would preclude him from service connection for such chronic disorder.  
Consequently, the Board finds it cannot make a fully-informed decision on the issue because no VA examiner has opined whether he has a sinus disorder that may be related to his active military service, specifically his period of active duty from August 2004 to August 2005.  Furthermore, the Veteran’s contentions that his sinus problems are related to an undiagnosed illness, to include a MUCMI, need to be considered by a medical professional.
21. Entitlement to service connection for a disability manifested by hair loss, stomach pain, and groin problems as due to an undiagnosed illness is remanded.
At the March 2018 Board hearing, the Veteran, via his attorney, related his hair loss, stomach pain and groin problems and pain to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI).  The Board notes that other than his initial claims and the statements made at the Board hearing, the Veteran has not provided any statements to explain what he means by his claims of hair loss, stomach pain and groin problems.  The medical records and December 2013 VA examination report are also silent for any complaints of or treatment for problems relating to hair loss, the stomach or the groin.  
However, given the requests herein for further development of both service and post-service medical records, the Board finds it would be premature to make a final adjudication of these claims as relevant evidence may be obtained on remand.  See Brambley v. Principi, 17 Vet. App. 20, 24 (2003); Harris v. Derwinski, 1 Vet. App. 180 (1991).  Consequently, the Board defers deciding these claims and remands them pending the development herein requested.  
22. Entitlement to service connection for a right eye disorder (claimed as weakness and pink eye), to include as due to an undiagnosed illness, is denied.
In his November 2013 correspondence, the Veteran stated that, while in basic training during his initial period of ACDUTRA, it was determined the vision in his right eye was weak.  Then later, while on active duty at Langley Air Force Base, he caught pink eye from a fellow coworker.  However, at the March 2018 Board hearing, the Veteran, via his attorney, related his vision problems to an undiagnosed illness and specifically argued that the December 2013 VA examiner failed to consider whether all his complained of conditions combine into a medically unexplained chronic multi-symptom illness (MUCMI). 
The Veteran’s June 2000 Report of Medical Examination for his enlistment into the Air Force Reserve shows it was noted that his uncorrected distance visual acuity in the right eye was 20/400, corrected to 20/200, which is defective as 20/20 is normal.  Distance visual acuity in the left eye was normal at 20/20.  In addition, his uncorrected near visual acuity was 20/400, not corrected.  Under the Summary of Defects and Diagnoses, it was noted the Veteran had defective distant vision and anisometropia.  On his PULHES profile, his vision was rated as two.  On a September 2000 PES/Optometry Processing form at the time the Veteran entered into his initial period of ACDUTRA, it was noted that his distance visual acuity continued to be 20/400 in the right eye.  
The Board notes that generally, congenital defects are not diseases for VA compensation purposes.  38 C.F.R. § 3.303 (c) (2017).  In the absence of a superimposed disease or injury, service connection may not be allowed for congenital defects or refractive errors of the eyes, even if visual acuity decreased in service, as these are not diseases or injuries within the meaning of applicable legislation relating to service connection.  Id.  Thus, VA regulations specifically prohibit service connection for either a congenital defect or a refractive error of the eye unless such a defect was subjected to a superimposed disease or injury that created additional disability.  See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (July 18, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury).
In this case, while the Veteran entered service with defective vision, he reported that while on active duty at Langley Air Force Base, he caught pink eye from a fellow coworker.  On remand, a medical opinion should be obtained to determine whether the Veteran’s right eye defective vision was subjected to a superimposed disease or injury, to include pink eye, that created additional disability.  Furthermore, the Veteran’s contentions that his right eye disability is related to an undiagnosed illness, to include a MUCMI, need to be considered by a medical professional.
23. Entitlement to a compensable disability rating for service-connected pseudofolliculitis barbae is remanded.
At the March 2018 hearing, the Veteran testified that his pseudofolliculitis barbae is manifested by a burning sensation, bumps with hair coming out and pus.  He also contends he has painful and unstable scarring from his pseudofolliculitis barbae and, therefore, his pseudofolliculitis barbae should be rated under the rating criteria for painful scars.  
The Veteran was afforded a VA examination in December 2013 but only complained of bumps after shaving and a burning sensation.  Consequently, the Board finds that his testimony appears to indicate his pseudofolliculitis barbae has worsened since his last VA examination.  As such, VA is required to afford him a contemporaneous VA examination to assess the current nature, extent and severity of his psychiatric disability.  See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Thus, the Board has no discretion and must remand this claim.
24. Entitlement to a compensable disability rating for service-connected dermatophytosis is remanded.
At the March 2018 Board hearing, the Veteran testified that he has lost several toenails and has numbness and problems with his toes since he lost the toenails due to the service-connected dermatophytosis.  He stated he has no feeling on the tops of his toes and, because of this, he often bleeds when he cuts his toenails because he does not know where to stop.  
Based on the Veteran’s testimony, the Board considers it likely that there are relevant outstanding treatment records related to his claim that have not been obtained.  A remand is required to allow VA to obtain authorization and request these records.
The Veteran was afforded a VA examination in December 2013.  None of the things reported at the May 2018 hearing were reported at this examination.  Consequently, the Board finds that the Veteran’s testimony appears to indicate his dermatophytosis has worsened since his last VA examination.  As such, VA is required to afford him a contemporaneous VA examination to assess the current nature, extent and severity of his psychiatric disability.  See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Thus, the Board has no discretion and must remand this claim.
25. Entitlement to non-service-connected disability pension is remanded.
The Veteran is seeking non-service-connected disability pension due to his nonservice-connected disabilities.  He primarily contends he has difficulties since 2013 maintaining employment due to his mental health symptoms and joint pains.  See March 2018 Board hearing testimony.   
At the March 2018 Board hearing, the Veteran reported he last worked in 2013 as a railroad conductor but was fired for his own safety because of a failure to adapt, inability to perform the vigorous duties of the job, and inability to focus on the job because of short attention span.  He also reported he was constantly missing work and late because of his lack of sleep.  However, there are inconsistent reports that he never held legitimate civilian employment and that he has only held part-time seasonal employment with friends.  See December 2013 VA examination reports.  Remand is required to obtain a detailed employment and income history from the Veteran as to his previous employers.  Any employers identified should be contacted regarding the Veteran’s employment.  
Evidence of record also shows the Veteran was attending or planning to attend college during the Fall semester of 2013.  Furthermore, the record shows the Veteran provided inconsistent reports as to his education history at the various VA examinations held in December 2013.  Remand is required to obtain more information regarding the Veteran’s educational history, to include obtaining all college transcripts.  
In December 2013, the Veteran was afforded a VA examination in which the examiner opined that his medical conditions (mild degenerative joint disease of the bilateral acromioclavicular joints, degenerative joint disease of the bilateral knees, bilateral shin splint pain, bilateral hallux valgus, bilateral first metatarsophalangeal joint degenerative joint disease, bilateral plantar fasciitis, bilateral lateral epicondylitis, hypogonadism, pseudofolliculitis barbae, dermatophytosis, elevated liver function tests, fatty liver, allergic rhinitis, mild lumbar spondylosis and cervical spondylosis) did not prevent him from securing or following a substantially gainful occupation.  Unfortunately, this opinion did not include a mental health diagnosis.  However, none was given by the PTSD VA examiner because, as previously discussed, the Veteran’s presentation was such that the examiner stated no mental health diagnosis could be rendered.  
However, in May 2018, the Veteran submitted an April 2018 Clinical Progress Summary report from a private mental health care provider in which it was stated that the Veteran had been receiving treatment since June 2017 and he has not been able to maintain consistent employment due to the severity of symptoms, which has resulted in an inability to be consistent with attending treatment due to financial constraints.  His treating provider further stated that, because of his symptoms, the Veteran has not been able to maintain a social life, consistent employment, stays away from large crowds, struggles to attend Christian religious services, and shies away from the general public.  These are all impacts of his daily functioning.  As of this day, he still struggles to maintain a normal life. 
VA nonservice-connected pension benefits are payable to a veteran who is permanently and totally disabled from nonservice-connected disability or disabilities, which is not the result of willful misconduct, but only where the veteran has the requisite active wartime service.  38 U.S.C. § 1521(a); 38 C.F.R. §§ 3.3, 3.314(b).  The Veteran in the present case meets the wartime service requirement.  The question is whether he is permanently and totally disabled.  
For VA pension purposes, all veterans who are basically eligible and who are unable to secure and follow a substantially gainful occupation by reason of disabilities which are likely to be permanent shall be rated as permanently and totally disabled.  38 C.F.R. § 3.17.  Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.  38 C.F.R. § 3.340(a).
It is not clear given the evidence of record whether the report that the Veteran’s inability to maintain “consistent” employment reported by the April 2018 private mental health care provider is the same as an inability to follow and sustain a substantially gainful occupation.  Since the Board is already remanding for a new VA mental health examination, however, the examiner can definitely address the Veteran’s occupational functioning and the impact his mental health disorder, if any, has had on his ability to be employed.  
The matters are REMANDED for the following action:
1. Obtain the Veteran’s complete service personnel and treatment records for his entire period of service with the U.S. Air Force Reserve, to include requesting records directly from any medical facility at any military base he was assigned.
2. Ask the Veteran to complete a VA Form 21-4142 for all private medical care providers who have treated him for his claimed conditions of headaches, bilateral wrists, erectile dysfunction, and dermatophytosis.  Make two requests for the authorized records from medical care providers identified unless it is clear after the first request that a second request would be futile.
3. Obtain the Veteran’s VA treatment records for the period from January 2017 to the Present.
4. Confirm the Veteran’s locations and dates thereof during his deployment to Southwest Asia from September 9, 2000 to March 1, 2005.  Thereafter, if necessary, attempt to corroborate his in-service stressors, including receiving small arms fire and having an IED exploding on a convoy, are consistent with the place, types and circumstances of his deployment.  If more details are needed, contact the Veteran to request the information.
5. Contact the Veteran and request he provide the following information and evidence relating to his claim for non-service-connected disability pension:
(a.) A detailed employment history with employer name and address.
(b.) Income information since he filed his claim in November 2012.  
(c.) A detailed education history to include providing school transcripts or other proof of completion of a degree or training program.
6. After items # 2 and 3 above are completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected pseudofolliculitis barbae and dermatophytosis.  The examiner should provide a full description of the Veteran’s disabilities and report all signs and symptoms necessary for evaluating them under the rating criteria.  The examiner must attempt to elicit information regarding their severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups, if any.  To the extent possible, the examiner should identify any symptoms and functional impairments due to pseudofolliculitis barbae and dermatophytosis alone and discuss the effect of the Veteran’s disabilities on any occupational functioning and activities of daily living.  If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).
7. After items # 1 through 3 above are completed, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral shin splints.  The examiner must opine whether it is at least as likely as not that his bilateral shin splints are related to an in-service injury, event, or disease, including running for physical training with a rucksack on every day during basic training at Lackland Air Force Base from September to October 2000.
Furthermore, in relation to the Veteran’s claim for non-service-connected disability pension, the examiner should be asked to identify, to the extent possible, any symptoms and functional impairments due to any identified bilateral shin splints alone and discuss the effect of they have on the Veteran’s occupational functioning.  
8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral shoulder disorders (previously diagnosed as mild degenerative joint disease of the acromioclavicular joints).  The examiner must opine whether it is at least as likely as not that any current bilateral shoulder disorders are related to an in-service injury, event, or disease, including the Veteran’s contentions that they had their onset during his initial period of ACDUTRA from September to December of 2000.  The VA examiner should be advised that, despite the report of pre-service bilateral shoulder dislocations seen in the service treatment records, he is presumed to have been in sound condition upon entry in this period of service because no defect of the bilateral shoulders was noted on his June 2000 enlistment Report of Medical Examination or on the September 2000 recertification and the Veteran’s report alone is insufficient to rebut the presumption of soundness.  
Furthermore, in relation to the Veteran’s claim for non-service-connected disability pension, the examiner should be asked to identify, to the extent possible, any symptoms and functional impairments due to any identified bilateral shoulder disorders alone and discuss the effect of they have on the Veteran’s occupational functioning.  
9. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any residuals of cold weather injuries that he may have to the bilateral feet (claimed as frostbite).  The examiner must opine whether it is at least as likely as not that any identified residuals of cold weather injuries are related to an in-service injury, event, or disease, including the Veteran’s contention that they had their onset during his initial period of ACDUTRA from September to December of 2000, specifically from frostbite sustained while at Fort Leonard Wood, Wisconsin.
Furthermore, in relation to the Veteran’s claim for non-service-connected disability pension, the examiner should be asked to identify, to the extent possible, any symptoms and functional impairments due to any identified cold weather injury residuals alone and discuss the effect of they have on the Veteran’s occupational functioning.  
10. After items #1 through 4 above have been completed, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any mental health disorder, to include PTSD.  If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor or to a stressor that is related to the Veteran’s fear of hostile military or terrorist activity.  
If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include those claimed by the Veteran as PTSD stressors.  
Furthermore, in relation to the Veteran’s claim for non-service-connected disability pension, the examiner should be asked to identify, to the extent possible, any symptoms and functional impairments due to any identified mental health disorders alone and discuss the effect of they have on the Veteran’s occupational functioning.  
11. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any residuals of TBI that he may have (to include short-term memory loss, problem focusing and balance off).  The examiner must opine whether it is at least as likely as not that any identified residuals of TBI are related to an in-service injury, event, or disease, including the Veteran’s contention that he sustained a head injury during a motor vehicle accident while in Iraq during his period of active duty from August 2004 to August 2005.
Furthermore, in relation to the Veteran’s claim for non-service-connected disability pension, the examiner should be asked to identify, to the extent possible, any symptoms and functional impairments due to any identified TBI residuals alone and discuss the effect of they have on the Veteran’s occupational functioning.  
12. After items # 2 through 3 above are completed, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his headaches.  The examiner must opine whether it is at least as likely as not his headaches are related to an in-service injury, event, or disease, including running for physical training with a rucksack on every day during basic training at Lackland Air Force Base from September to October 2000.
Furthermore, in relation to the Veteran’s claim for non-service-connected disability pension, the examiner should be asked to identify, to the extent possible, any symptoms and functional impairments due to any headaches alone and discuss the effect of they have on the Veteran’s occupational functioning.  
13. After items # 1 through 3 above are completed, schedule the Veteran for a Gulf War General Medical examination by an appropriate clinician to determine the nature and etiology of any bilateral wrist disorders, bilateral ankle disorders, bilateral hip disorders, bilateral knee disorders, bilateral elbow disorders, bilateral little finger (pinky) disorders, bilateral plantar fasciitis, bilateral hallux valgus, degenerative joint disease of the bilateral first metatarsophalangeal joint, lumbar spine disorder, cervical spine disorder, sleep apnea, erectile dysfunction, skin disorder (claimed as dry skin), sinus disorder, groin disorder, stomach disorder, right eye disability, and a disability manifested by hair loss, which conditions are all claimed as either directly related to an incident incurred during service or as due to an undiagnosed illness, to include that combined they constitute a medically unexplained chronic multi-symptoms illness (MUCMI).  
If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine as to whether it is at least as likely as not that there are symptoms due to an undiagnosed illness or MUCMI resulting from Veteran’s service in Southwest Asia from September 2004 to March 2005.  If so, the examiner should comment on the severity of such symptomatology and report signs and symptoms necessary for evaluating the illness under the rating criteria.
The examiner is asked to respond to the following:
(a)  Are there objective indications that the Veteran is suffering from chronic disability of the knees; the examiner must determine whether these symptoms can be attributed to any known clinical diagnosis or to a chronic multisymptom illness, such as chronic fatigue syndrome, IBS, or fibromyalgia. 
For those symptoms and conditions that cannot be attributed to a known clinical diagnosis or chronic multisymptom illness, the examiner must determine if there is affirmative evidence that the undiagnosed illness was not incurred during active service during the Persian Gulf War, or that the undiagnosed illness was caused by a supervening condition or event that occurred since the Veteran’s departure from service during the Persian Gulf War.
(b)  With respect to any currently diagnosed disability, is it at least as likely as not (50 percent or greater probability) that such disability is etiologically related to the Veteran’s active service, to specifically include complaints and assessments seen during service.  In rendering an opinion, the examiner should consider and discuss the Veteran’s specific reports attributing certain conditions to his military service as discussed in this remand.
Furthermore, in relation to the Veteran’s claim for non-service-connected disability pension, the examiner should be asked to identify, to the extent possible, any symptoms and functional impairments due to each diagnosed disorder alone and any undiagnosed illness or MUCMI and discuss the effect of they have on the Veteran’s occupational functioning.  
After all additional development has been completed, the Veteran’s claim for service connection for a right disorder should be readjudicated with consideration of whether there was a superimposed disease or injury on the congenital defective distance vision (weakness) during service.  If so, please identify the superimposed disease or injury, as well as the resultant disability due to superimposed disease or injury.    

 
JENNIFER HWA
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	S.M. Kreitlow