Citation Nr: 18155447 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 07-26 531 DATE: December 4, 2018 ORDER Entitlement to service connection for a right shoulder disability, to include rheumatoid arthritis, as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service is denied. Entitlement to service connection for a bilateral hip disability as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service is denied. Entitlement to service connection for pericarditis with syncope as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service is denied. Entitlement to service connection for hypertension as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service is denied. FINDINGS OF FACT 1. The medical evidence indicates that the Veteran has diagnosed right shoulder disabilities which have medically understood and identifiable mechanical causes. 2. The medical evidence indicates that the Veteran has a diagnosed hip disability which has medically understood and identifiable causes. 3. The medical evidence indicates that the Veteran had diagnosis of pericarditis, which resolved, and that his pericarditis was short lived rather than chronic and limited to one body system. 4. The medical evidence indicates that the Veteran has a diagnosis of hypertension, which is associated with one body system, has documented risk factors and an underlying medical pathology. CONCLUSIONS OF LAW 1. The criteria for service connection for a right shoulder disability, to include rheumatoid arthritis, as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 2. The criteria for service connection for a bilateral hip disability as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 3. The criteria for service connection for pericarditis with syncope as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 4. The criteria for service connection for hypertension as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1986 to February 1994, with additional periods of National Guard service. This matter came before the Board of Veterans Appeals (Board) on appeal from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In July 2010, the Board denied the Veteran’s appeal. The Veteran appealed the Board’s denial to the United States Court of Appeals for Veterans Claims (Court). The Veteran and VA filed a Joint Motion for Partial Remand (JMPR) with the Court. In a September 2011 Order granting the JMPR, the Court did not disturb the portion of the Board’s July 2010 decision finding that service connection was not warranted for the claimed disabilities on a direct basis, but remanded the issues on appeal to the Board to readjudicate the question of whether service connection was warranted on a presumptive basis. Specifically, the Court instructed the Board to address whether the claimed disabilities may be due to a medically unexplained multi-symptom illness. In January 2012, the Board remanded this matter for further evidentiary development to comply with the directives of the JMPR. The Board again remanded the matter in June 2016 and April 2017 for further evidentiary development. Service Connection Service connection may be established for a Persian Gulf Veteran for a qualifying chronic disability which manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). A “Persian Gulf Veteran” is a veteran with active service in the Southwest Asia theater of operations during the Persian Gulf War. A “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders. 38 C.F.R. § 3.317(a)(2)(i). 1. Entitlement to service connection for a right shoulder disability, to include rheumatoid arthritis, as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service The Veteran contends that his right shoulder disability is due to a medically unexplained chronic multi-symptom illness (MUCMI) due to his Persian Gulf service. The Board concludes that the Veteran’s right shoulder disability is not due to an undiagnosed illness or a MUCMI and that service connection on a presumptive basis is therefore not warranted. 38 C.F.R. § 3.317. April 2016 VA treatment records indicate that the Veteran has been diagnosed with rotator cuff syndrome. A November 2009 VA examiner diagnosed right shoulder inflammatory polyarthropathy. An April 2013 Gulf War examination found that the Veteran did not have any signs or symptoms that might represent an undiagnosed illness or MUCMI aside from his claimed right shoulder, bilateral hip, pericarditis and hypertension conditions. A July 2016 VA opinion found that the Veteran’s shoulder disability was not likely due to either an undiagnosed illness or part of a MUCMI. The provider noted that the Veteran had been diagnosed with right shoulder strain and right shoulder inflammatory arthropathy, though laboratory and rheumatology had failed to confirm the latter diagnosis. The examiner opined that neither diagnosis was part of an undiagnosed illness as they were diagnosable conditions. The provider noted the Veteran’s exposures to asbestos, burn pits and other toxic chemicals during active duty. The provider also noted the article “Gulf War Syndrome Veterans have Damage in Specific Portion of Nervous System,” but found that was unrelated to the Veteran’s hypertension, pericarditis, shoulder conditions and hip conditions and did not establish a cause and effect relationship between Gulf War exposures and the claimed conditions. An April 2017 addendum opinion from the same provider gave additional rationale for the findings that the Veteran’s disability was not due to an undiagnosed illness or a MUCMI. The provider noted that the Veteran had various right shoulder diagnoses of impingement, rotator cuff syndrome and shoulder strain and detailed the likely underlying cause of each diagnosis. Regarding shoulder impingement, the provider stated that it is mainly caused by repetitive activity at or above the shoulder, and that increasing age increased the risk. The provider noted that the underlying mechanism of injury occurs when the rotator cuff, subacromial bursa and other soft tissues are compressed between the humeral head and the undersurface of the acromion, acromioclavicular joint, or the coracoacromial arch. The provider noted that a number of anatomic and mechanistic factors play a role in this mechanism and that age and comorbidities can play a role. Regarding rotator cuff syndrome, the provider noted that the major risk factor is repetitive overhead activity, along with anatomic variants and tensile overload during muscle contraction. Regarding strain, the provider noted that strain is overstretching of muscle tissue, usually caused by overuse. In conclusion, the provider opined that all of the Veteran’s shoulder conditions “have a cause and are diagnosable.” The provider further explained that these diagnoses were not due to a MUCMI but rather to specific causes as detailed in the opinion. Finally, the provider noted that the medical record since 2005 contained no indication that the Veteran had been evaluated or diagnosed with a MUCMI. At the outset, the Board finds that the VA examinations are adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran’s statements, review of medical records and the examiners’ observations, and have clear rationales, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Board finds that the competent medical evidence of record indicates that the Veteran’s right shoulder disability is not likely due to an undiagnosed illness. The Veteran has been diagnosed with impingement, rotator cuff syndrome and shoulder strain. As the Veteran has shoulder diagnoses, the Board cannot conclude that his right shoulder disability constitutes an undiagnosed illness. “The very essence of an undiagnosed illness is that there is no diagnosis.” Stankevich v. Nicholson, 1 Vet. App. 589, 593 (1991). The medical evidence of record also indicates that the Veteran’s right shoulder disability is not likely due to a MUCMI. The April 2013 VA examiner and the July 2017 opinion indicated that the record does not contain medical evidence of signs or symptoms of a MUCMI. Moreover, the April 2017 addendum opinion provided a detailed medical explanation of the likely mechanical causes of the Veteran’s various right shoulder diagnoses, indicating that repetitive activity and overstretching of muscle tissue were the likely causes. As a clear medical explanation for the Veteran’s diagnosed right shoulder disabilities has been identified, and fibromyalgia has ot been diagnosed, the Board cannot conclude that the Veteran’s right shoulder disability is linked to a MUCMI. The Board therefore finds that the preponderance of the evidence indicates that the Veteran’s right shoulder disability is not likely due to an undiagnosed illness or to a MUCMI. Service connection is therefore not warranted. 38 C.F.R. § 3.317. 2. Entitlement to service connection for a bilateral hip disability as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service The Veteran contends that his bilateral hip disability is due to a MUCMI due to his Persian Gulf service. The Board concludes that the Veteran’s bilateral hip disability is not due to an undiagnosed illness or a MUCMI and that service connection on a presumptive basis is therefore not warranted. 38 C.F.R. § 3.317. A November 2009 VA examination found decreased motion of the hips, which the examiner opined was likely due to decondition caused by lower extremity peripheral neuropathy. An April 2013 Gulf War examination found that the Veteran did not have any signs or symptoms that might represent an undiagnosed illness or MUCMI aside from his claimed right shoulder, bilateral hip, pericarditis and hypertension conditions. A July 2016 VA opinion found that the Veteran’s bilateral hip disability was not likely either an undiagnosed illness or part of a MUCMI. The examiner noted decreased motion of the hips due to generalized deconditioning caused by non-service-connected peripheral neuropathy and a diagnosis of bilateral hip strain. The provider noted that these conditions are diagnosable and therefore not part of an undiagnosed illness. The provider also noted the Veteran’s exposures to asbestos, burn pits and other toxic chemicals during active duty. The provider also noted the article “Gulf War Syndrome Veterans have Damage in Specific Portion of Nervous System,” but found that it was unrelated to the Veteran’s hypertension, pericarditis, shoulder conditions and hip conditions and did not establish a cause and effect relationship between Gulf War exposures and the claimed conditions. An April 2017 addendum opinion from the same provider gave additional rationale for the findings that the Veteran’s disability was not due to an undiagnosed illness or a MUCMI. The provider noted that the Veteran’s bilateral hip strain, by definition, is classified as the overstretching of muscle tissue and that it is diagnosable. The provider noted that extra-articular injury of muscles and tendons are the largest source of hip pain in active adults. The identified likely causes were injury of hip adductor muscles during intense, repetitive, weight-bearing activity, which the provider noted could be sustained either by acute injury as in a classic groin strain or by repetitive activity. The provider also noted that proximal hamstring strain was the most common muscle injury causing hip pain. The provider further opined that hip strain was not due to a MUCMI but to the specific causes identified in the opinion. Finally, the provider noted that the medical record since 2005 contained no indication that the Veteran had been evaluated or diagnosed with a MUCMI. At the outset, the Board finds that the VA examinations are adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran’s statements, review of medical records and the examiners’ observations, and have clear rationales, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Board finds that the competent medical evidence of record indicates that the Veteran’s bilateral hip disability is not likely due to an undiagnosed illness. The Veteran has been diagnosed with bilateral hip strain. As the Veteran has a hip diagnosis, the Board cannot conclude that his bilateral hip disability constitutes an undiagnosed illness. “The very essence of an undiagnosed illness is that there is no diagnosis.” Stankevich v. Nicholson, 1 Vet. App. 589, 593 (1991). The medical evidence of record also indicates that the Veteran’s bilateral hip disability is not likely due to a MUCMI. The April 2013 VA examiner and the July 2017 opinion indicated that the record does not contain medical evidence of signs or symptoms of a MUCMI. Moreover, the April 2017 addendum opinion provided a detailed medical explanation of the likely mechanical etiologies of the Veteran’s bilateral hip strain indicating that repetitive activity and overstretching of muscle tissue were the likely causes. As a clear medical explanation for the Veteran’s bilateral hip strain has been identified, and fibromyalgia has not been diagnosed, the Board cannot conclude that the Veteran’s bilateral hip strain is linked to a MUCMI. The Board therefore finds that the preponderance of the evidence indicates that the Veteran’s bilateral hip disability is not likely due to an undiagnosed illness or chronic medically unexplained multi-symptom illness. Service connection is therefore not warranted. 38 C.F.R. § 3.317. 3. Entitlement to service connection for pericarditis with syncope as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service The Veteran contends that he has a current disability of pericarditis with syncope due to a MUCMI due to his Persian Gulf service. The Board concludes that pericarditis is not due to an undiagnosed illness or a MUCMI and that service connection on a presumptive basis is therefore not warranted. 38 C.F.R. § 3.317. May 2005 emergency room records note a diagnosis of pericarditis. A June 2005 statement from a private doctor states that the Veteran was diagnosed with pericarditis with syncope. A December 2005 VA cardiology consultation did not find pericarditis and an echocardiogram was “perfectly normal”. A November 2009 VA cardiology evaluation noted that the prior symptoms had improved after a few weeks and had not recurred. Upon examination, the cardiologist found no symptoms consistent with pericarditis and the echocardiogram showed no pericardial effusion. A November 2009 VA examination found that the Veteran’s diagnosis of pericarditis was questionable as echocardiograms did not indicate pericarditis. An April 2013 VA examination found no current or prior heart condition. Diagnostic tests, including an EKG and echocardiogram, were normal. The Veteran reported that he had no heart problems and denied shortness of breath, syncopal episodes, chest pain or history of heart attack. The examiner also noted the internet article the Veteran provided on Gulf War Syndrome and heart rate variability and found that there was no objective evidence that the Veteran’s heart rate was consistent with the parasympathetic gulf war syndrome mentioned in the article. The examiner also found that the Veteran did not have any signs or symptoms that might represent an undiagnosed illness or MUCMI aside from his claimed right shoulder, bilateral hip, pericarditis and hypertension conditions. A July 2016 VA opinion found that it was possible that the Veteran had acute pericarditis that had resolved. The provider noted that evaluations after the initial ER diagnosis did not confirm the diagnosis and that echocardiograms and cardiology consultations after May 2005 had not found pericarditis. The provider opined that acute pericarditis, resolved, was not an undiagnosed illness and is not part of a MUCMI due to the Veteran’s Gulf War service. The provider noted that pericarditis is a diagnosable condition and therefore is not an undiagnosed illness. The provider also noted the Veteran’s exposures to asbestos, burn pits and other toxic chemicals during active duty. The provider also noted the article “Gulf War Syndrome Veterans have Damage in Specific Portion of Nervous System,” but found that was unrelated to the Veteran’s hypertension, pericarditis, shoulder conditions and hip conditions and did not establish a cause and effect relationship between Gulf War exposures and the claimed conditions. An April 2017 addendum opinion from the same provider gave additional rationale for the findings that the Veteran’s disability was not due to an undiagnosed illness or a MUCMI. The provider noted that the objective evidence found an absence of chronic pericarditis, and opined that a condition that resolved cannot be part of a MUCMI. Finally, the provider noted that the medical record since 2005 contained no indication that the Veteran had been evaluated or diagnosed with a MUCMI. A March 2018 VA opinion from a chief cardiologist found that the Veteran as likely as not had a disability of pericarditis at his May 2005 ER visit, but found that any pericarditis was short lived and resolved by December 2005, when an expert cardiology consultation and echocardiogram did not diagnose pericarditis. The provider noted that out of 10 total assessments for pericarditis, only 2 had diagnosed pericarditis, and the December 2005 expert cardiology opinion did not. While finding that it was possible that the Veteran had pericarditis that later resolved, the examiner found that pericarditis was not likely individually or collectively linked to an undiagnosed illness or a MUCMI due to Gulf War service. As a rationale, the provider stated that the weight of medical literature does not support such a relationship and noted that pericarditis may be caused by chronic infections and a host of other causes. Regarding the question of a MUCMI, the provider specifically stated that pericarditis is confined to the heart, that the heart is one system and that it is not a multi-symptom illness. The provider also noted that the Veteran’s pericarditis was not part of a MUCMI as it was short-lived and has not recurred and therefore cannot be characterized as chronic. At the outset, the Board finds that the VA examinations are adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran’s statements, review of medical records and the examiners’ observations, and have clear rationales, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Board finds that the competent medical evidence of record indicates that the Veteran’s pericarditis is not due to an undiagnosed illness. The March 2018 expert cardiology opinion found that the Veteran likely had a short-term diagnosis of pericarditis. The July 2016 VA opinion also noted that pericarditis is a diagnosis rather than an undiagnosed illness. As the Veteran’s pericarditis has been diagnosed, the Board cannot conclude that it constitutes an undiagnosed illness. “The very essence of an undiagnosed illness is that there is no diagnosis.” Stankevich v. Nicholson, 1 Vet. App. 589, 593 (1991). The Board also finds that medical evidence of record indicates that the Veteran’s pericarditis is not likely due to a MUCMI. The April 2013 VA examiner and the July 2017 opinion indicated that the record does not contain medical evidence of signs or symptoms of a MUCMI. The March 2018 expert cardiology opinion found the Veteran’s pericarditis had resolved and therefore was not part of a chronic multi-system illness as it was a short term, resolved illness rather than a chronic illness. The provider also opined that pericarditis was limited to the heart and did not involve other systems. As the medical evidence of record indicates that pericarditis was short-term and resolved rather than chronic and is limited to one body system the Board cannot conclude that it is likely linked to a MUCMI. The Board therefore finds that the preponderance of the evidence indicates that the Veteran likely had a disability of acute pericarditis, resolved, during the pendency of the appeal, but that the Veteran’s pericarditis is not due to an undiagnosed illness or MUCMI. Moreover, it neither manifested during active service in Southwest Asia nor manifested to a degree of 10 percent or more after service. Service connection is therefore not warranted. 38 C.F.R. § 3.317. 4. Entitlement to service connection for hypertension as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of Persian Gulf War service The Veteran contends that his hypertension is due to a MUCMI due to his Persian Gulf service. The Board concludes that hypertension is not due to an undiagnosed illness or a MUCMI and that service connection on a presumptive basis is therefore not warranted. 38 C.F.R. § 3.317. VA treatment records indicate that the Veteran is diagnosed with hypertension. A November 2009 VA examination diagnosed hypertension and noted that the Veteran had a strong family history of hypertension. An April 2013 VA Gulf War examination noted that the Veteran did not have any undiagnosed conditions and opined that his claimed disabilities were not associated with exposure to asbestos, burn pits or toxic chemicals. The examiner also found that the Veteran did not have any signs or symptoms that might represent an undiagnosed illness or MUCMI aside from his claimed right shoulder, bilateral hip, pericarditis and hypertension conditions. A July 2016 VA opinion found that the Veteran had hypertension. The provider opined that hypertension is not an undiagnosed illness and that it is not part of a MUCMI and could not be collectively linked to such an illness with the Veteran’s other claimed conditions. In rendering the opinion, the provider noted the Veteran’s exposures to asbestos, burn pits and other toxic chemicals during active duty. The provider also noted the article “Gulf War Syndrome Veterans have Damage in Specific Portion of Nervous System,” but found that it was unrelated to the Veteran’s hypertension, pericarditis, shoulder conditions and hip conditions and did not establish a cause and effect relationship between Gulf War exposures and the claimed conditions. An April 2017 VA addendum opinion from the same provider provided additional rationale for the opinion, noting that the etiology of primary hypertension was unknown but there are many risk factors including, age, family history, race, kidney disease, high sodium diet, alcohol consumption, physical inactivity, diabetes, dyslipidemia and depression. Review of medical literature did not indicate that hypertension was likely part of a MUCMI. The provider also noted that hypertension is extremely common in the general population. Finally, the provider noted that the medical record since 2005 contained no evaluation or diagnosis indicating that the Veteran had a MUCMI. A March 2018 expert cardiology opinion found that hypertension was less likely individually or collectively linked to an undiagnosed illness or to a MUCMI. As a rationale, the provider stated that hypertension is due to pathology of the arteriole walls and that this involves one body system, rather than being part of a multi-symptom illness. At the outset, the Board finds that the VA examinations are adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran’s statements, review of medical records and the examiners’ observations, and have clear rationales, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Board finds that the competent medical evidence of record indicates that the Veteran’s hypertension is not likely due to an undiagnosed illness. The medical evidence of record consistently documents a diagnosis of hypertension. As the Veteran has a clear diagnosis of hypertension, the Board cannot conclude that it constitutes an undiagnosed illness. “The very essence of an undiagnosed illness is that there is no diagnosis.” Stankevich v. Nicholson, 1 Vet. App. 589, 593 (1991). The medical evidence of record also indicates that the Veteran’s hypertension is not likely due to a MUCMI. The April 2013 VA examiner and the July 2017 opinion indicated that the record does not contain medical evidence of signs or symptoms of a MUCMI. The November 2009 VA examiner noted that the Veteran has a strong family history of hypertension. The April 2017 opinion also noted that hypertension has many documented risk factors, including family history. Moreover, the March 2018 expert cardiology opinion opined that hypertension is not due to a multi-system illness as it involves one body system. The March 2018 opinion also identified an underlying medical pathology, stating that hypertension is due to pathology of the arteriole walls. As the medical evidence of record indicates that hypertension is associated with one body system and has an underlying pathology as well as many documented risk factors, the Board cannot conclude that it is likely linked to a MUCMI. The Board therefore finds that the preponderance of the evidence indicates that the Veteran’s pericarditis is not likely due to an undiagnosed illness or to a MUCMI. Service connection is therefore not warranted. 38 C.F.R. § 3.317. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Arnold, Associate Counsel