Citation Nr: 18145343 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 00-25 267 DATE: October 26, 2018 ORDER Entitlement to service connection for a right leg disability is denied. Entitlement to service connection for a disability manifested by jaundice, to include a liver disability, is denied. Entitlement to service connection for a bone disability, to include osteopenia, is denied. As new and material evidence has been received to reopen a claim of entitlement to service connection for a cardiac disability, the claim is reopened, and the claim is granted to that extent only. REMANDED 1. Entitlement to service connection for a cardiac disability is remanded. 2. Entitlement to service connection for a cervical spine disability is remanded. 3. Entitlement to service connection for radiculopathy of the cervical spine claimed is remanded. 4. Entitlement to service connection for degenerative disc disease/degenerative joint disease of the lumbosacral spine is remanded. 5. Entitlement to service connection for radiculopathy of lower extremities is remanded. 6. Entitlement to service connection for a left knee disability is remanded. 7. Entitlement to service connection for a left hand disability is remanded. 8. Entitlement to service connection for erectile dysfunction to include as secondary to an anthrax vaccination is remanded. 9. Entitlement to service connection for a right foot disability is remanded. 10. Entitlement to service connection for a left foot disability is remanded. 11. Entitlement to service connection for a disability manifested by symptoms to include joint and muscle pain and claimed as due to Persian Gulf War service is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a right leg disability, a disability manifested by jaundice (to include liver disease), and/or a bone disability, due to a disease or injury in service. 2. New and material evidence to reopen a claim of entitlement to service connection for a cardiac disability has been received. CONCLUSIONS OF LAW 1. The criteria for service connection for a right leg disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for a disability manifested by jaundice (to include liver disease) are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for a bone disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. Evidence received since the April 2004 RO decision that denied service connection for a cardiac disability, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C. §§ 1154 (a), 5108, 7105; 38 C.F.R. § 3.156, 20.200. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 1990 to April 1991. He also had service in the Puerto Rico National Guard from July 1968 to April 1998. He had verified active duty for training (ACDUTRA) on January 25, 1997. These matters come before the Board of Veterans’ Appeals (Board) on appeals from rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA) located in San Juan, Puerto Rico. The Veteran testified before a Veterans Law Judge (VLJ) at an April 2014 travel Board hearing. A transcript of the hearing is associated with the file. In May 2016 correspondence, the Board notified the Veteran that he was entitled to another hearing because the VLJ who had presided at his 2014 hearing was unavailable to participate in a decision in his appeal. The Veteran initially chose to have another hearing, but later withdrew that request. These matters were most recently before the Board in June 2015 when they were remanded for further development. The Veteran originally filed a claim of entitlement to service connection for a nervous condition, to include memory loss and a sleep disorder. As is discussed by the Board in 2012, it recharacterized this issue as one for entitlement to service connection for an acquired psychiatric disorder to include depression, posttraumatic stress disorder (PTSD) memory, and a sleep disorder. In a January 2016 rating decision, the Appeals Management Center (AMC) granted service connection for PTSD with memory loss and a sleep disorder; thus, this issue is no longer for appellate consideration. (The Board notes that in a September 2017 brief, the Veteran’s representative argued that the effective date for the award of service connection was arbitrary; however, there has not been a timely notice of disagreement or substantive appeal; thus, the issue is not before the Board.) The Veteran has filed claims for service connection for Persian Gulf Syndrome and for a disability manifested by joint and muscle pain. VA does not recognize a disability of “Persian Gulf Syndrome” but does recognize service connection for certain disabilities occurring in Persian Gulf veterans who have an undiagnosed illness or medically unexplained chronic multisymptom illness such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. Joint and muscle pain are considered as signs or symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness; thus, the Board has recharacterized the two previously identified issues into one issue. This recharacterization is not prejudicial to the Veteran and addresses his contentions. The Board acknowledges the contention of the Veteran’s representative in a September 2017 brief that the examiner who conducted the hepatitis/liver examination was an Internal Medicine physician rather than an “appropriate expert” as directed by the Board in its 2015 remand. The Board finds that there has been substantial compliance with the remand directive. There is no evidence that the examiner was not qualified to conduct an examination and render an opinion; thus, the examiner is presumed to be qualified. See Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir 2009)(confirming that the presumption of regularity does not only apply to procedural matters, but also applies to the competency of medical professionals). Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). New and Material Evidence RO decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.200. An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The Board must consider the question of whether new and material evidence has been received because it goes to the Board’s jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Barnett, supra. Further analysis beyond consideration of whether the evidence received is new and material is neither required nor permitted. Id. at 1384. See also Butler v. Brown, 9 Vet. App. 167, 171 (1996). “New” evidence is existing evidence not previously submitted to agency decision makers. “Material” evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). For evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. The VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the appellant in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999), but see 38 U.S.C. § 5103A (eliminating the concept of a well-grounded claim). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. The Veteran has not been shown to have the experience, training, or education necessary to make an etiology opinion as to the claimed disabilities. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to the complexities of his medical picture. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As is discussed in further detail, the preponderance of the evidence is against the claims decided below; thus, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 1. Entitlement to service connection for a right leg disability. The Veteran contends that while in basic training and/or annual training, he hurt his leg when he fell in a hole while running PT (physical training). He testified that he was on crutches for two weeks. He contends that this happened in 1968, approximately 1973, approximately1985, and/or approximately 1992 or 1993. (See Board hearing transcript, pages 17 and 18.) The current clinical records reflect a right ankle disability and bilateral hamstring shortening. The question before the Board is whether the Veteran has a current right leg disability causally related to service. The Veteran’s service treatment records (STRs) are negative for an ankle injury or hamstring disability. His September 1983 Report of Medical Examination reflects that he had abnormal feet upon evaluation in that he had flat feet, but notes no disability of the ankle or lower extremity. The Veteran’s May 1987 Report of Medical Examination reflects that he had normal feet and lower extremities upon examination. The Veteran’s March 1991 Report of Medical Examination for Separation purposes reflects that he had abnormal feet upon evaluation in that he had pes planus (flat feet), but again notes no complaints or disability of the ankle or lower extremity. A November 1991 private record reflects pain in the right foot. The Veteran’s September 1994 Report of Medical Examination for biannual purposes reflects that he had normal feet upon examination. An October 1999 record reflects tinea pedis; there was no edema. Additional clinical records in the ensuring years note complaints of the feet, but it is not until approximately 2007 that there was an assessment for the right ankle. The records also reflect that in November 2007, VA issued him a right foot/ankle metal brace due to an assessment of right leg foot ankle muscle atrophy and weakness. December 2008 and November 2009 VA podiatry records reflect that the Veteran sought treatment for difficulty with walking. He was given molded shoes with an added foot ankle metal brace. 2014 VA podiatry record reflects that the Veteran has bilateral pes planus, mild drop foot on the right, and bilateral fasciitis. There is no competent, credible evidence indicating a link between a right leg disability, to include the ankle or hamstring, and active service. Accordingly, further development for a VA examination and/or medical opinion is not required. The Board acknowledges the Veteran’s contentions as to injury/ies in service. The Board acknowledges that the Veteran is competent to describe an injury even though the symptoms were not recorded during service, but the STRs lack the documentation of the combination of manifestations sufficient to identify a chronic lower extremity disability, and the Veteran has been less than precise as to the year or times he allegedly injured his leg. There is no competent credible evidence of record that the Veteran has a right leg disability, to include the ankle or hamstring, which is as likely as not causally related to active service. Thus, service connection is not warranted. 2. Entitlement to service connection for a disability manifested by jaundice, to include a liver disorder. The Veteran is claiming entitlement to service connection for a disorder manifested by jaundice to include a liver disorder. He testified in April 2014 that he had been diagnosed by a VA health care provider as having jaundice due to medications ingested. Associated with the claims file are VA clinical records dated in September 1999 which include assessments of toxic hepatitis. A November 1999 record reflects “no jaundice”. A November 1999 laboratory “hepatitis profile” reflects that he was nonreactive for all hepatitis tests (except HAV IgG which is an “indictor of past infection. Useful in confirming previous exposure and immunity to Hepatitis A.”) A May 2002 VA clinical record includes the annotation that the Veteran had drug-induced hepatitis. An October 2015 VA examination report reflects that the Veteran reported that in September 1999 he was told that he was jaundiced due to anti-inflammatory medications that he was taking. He reported that in the following years, he was never diagnosed with, nor confirmed to have, a specific liver disease. He also denied a history of Hepatitis C, chronic liver disease, or cirrhosis. He indicated that he has never been treated for a liver disease. The examiner found that the Veteran did not have any signs or symptoms attributable to chronic or infectious liver disease, cirrhosis of the liver, biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis, and does not have a diagnosis of Hepatitis C or cirrhosis of the liver. The clinician also found, based on laboratory test results and the Veteran’s medical history, that there was no evidence of active or chronic liver disease, dysfunction or disability. It was noted that he had an acquired protection against Hepatitis B from a Hepatitis B vaccination, and an acquired natural immunity protection against Hepatitis A. The clinician also found, after a thorough review of the medical records, that the Veteran’s 1999 incident was most likely caused by or a result of overuse and overdose of medications from multiple providers, and was less likely as not related to service as it occurred more than eight years after service and there was no evidence of liver disease in the Veteran’s STRs. Moreover, the clinician found that the 1999 incident resolved without sequalae. As such, the Board finds that service connection is not warranted; a service connection claim requires, at a minimum, medical evidence of a current disability, Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board acknowledges that VA clinical records note an “active problem” list which includes a diagnosis of Hepatitis B on June 1, 2005. However, as noted above, the Veteran has reported that he has never been treated for a liver disease, and the clinical records do not support treatment or diagnosis for Hepatitis B based on an inquired infection, rather than a positive laboratory result due to a vaccination. Moreover, the June 1, 2005 VA clinical records do not note a positive Hepatitis B finding but reflect a past screening of Hepatitis C in March 2003 which was negative. There is no competent credible evidence of record that the Veteran has a disability manifested by jaundice, to include Hepatitis, which is causally related to, or aggravated by, active service. His Reports of Medical History dated in 1983, 1987, 1991, and1994 all reflect that he denied jaundice or Hepatitis. The Veteran has not been shown to have been on active duty or active duty for training, or even in any type of service (he separated from National Guard service in 1998) when he tested positive for Hepatitis, and he has not been shown to have a current disability of Hepatitis or a liver disability related to service. Based on the foregoing, service connection is not warranted. 3. Entitlement to service connection for a bone disability. In 2008, the Veteran filed a claim for service connection for a bone condition. The evidence of record reflects that the Veteran has been diagnosed with osteopenia. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. There is no competent credible evidence of a bone disability during service, and the Veteran denied a bone deformity and/or broken bones on his Reports of Medical History dated in 1983, 1987, 1991, and1994. Moreover, his corresponding Reports of Medical Examination are negative for any such abnormality. There is also no competent and credible indication that he has a bone disability causally related to, or aggravated by, service, so no further development is necessary. The Board concludes that, while the Veteran has a current diagnosis of osteopenia, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). 4. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a cardiac disability. The Veteran’s claim for service connection for a cardiac disability was denied in an April 2004 RO decision. At that time, the record included evidence that the Veteran had a myocardial infarction in 2001, hypertensive heart disease, an angioplasty in 2003, and coronary artery disease (see March 2004 VA examination report). The Veteran’s claim was denied because the evidence did not reflect that he had a cardiac disability incurred or related to active service/active duty for training. Since the last final denial, the Veteran has been granted service connection for an acquired psychiatric disability. Given the low threshold espoused in Shade v. Shinseki, 24 Vet. App. 110 (2010), the Board finds that new and material evidence has not been received; the claim is, therefore, reopened. REASONS FOR REMAND 1. Entitlement to service connection or a cardiac disability is remanded. The Veteran has been granted service connection for an acquired psychiatric disability. The Board finds that a VA clinical opinion as to whether it is as likely as not that his now service-connected acquired psychiatric disability caused, or aggravates, his cardiac disability may be useful to the Board. 2. Entitlement to service connection for a cervical spine disability is remanded. 3. Entitlement to service connection for radiculopathy of the cervical spine claimed is remanded. A VA clinical opinion reflects that the Veteran’s cervical spine disability is not related to his service-connected lumbar myositis (see January 2010 VA examination report ); however, the clinician did not discuss whether service connection was warranted on a direct incurrence or a secondary aggravation basis. The Veteran’s STRs reflect that in January 1997, a heavy object fell on top of him causing trauma to the neck (see clinical records and Statement of Medical Examination and Duty Status). A January 25, 1997 STR reflects that he had muscular spasm of the upper back; an X-ray revealed no fractures. A February 14, 1997 record reflects that the Veteran had mild to moderate stiffness and tenderness in the neck. 1998 records reflect complaints of the cervical spine (see March, May 1998 record, and July 1998 clinical record noting pain on the posterior neck and upper back; he presented with tenderness at palpation on the paravertebral muscles of the cervical-dorsal spine). A July 2002 VA record reflects mild right C7 radiculopathy and mild membrane instability. September 2002 radiology findings reflect, at various levels, cervical spine disc protrusion, osteophytes, bulging disc, and/or narrowing. Based on the foregoing, and with consideration of the 1997 injury, the Board finds that a clinical opinion on a direct incurrence basis is warranted to supplement the 2010 VA examination report. In addition, the claim for entitlement to service connection for radiculopathy is also remanded as there is an indication that radiculopathy is related to a spine disability. 4. Entitlement to service connection for degenerative disc disease of the lumbosacral spine is remanded. 5. Entitlement to service connection for radiculopathy of lower extremities is remanded. The Veteran is in receipt of service connection for lumbar myositis effective from 1999. He has also been diagnosed with degenerative disc disease for which he now seeks service connection. The Board is mindful that the Veteran is already in receipt of service connection for a back disability and that an April 2012 VA examiner has opined that it is not possible to differentiate the Veteran’s pain from his service-connected lumbar myositis from the pain from his non-service-connected back disability. Nevertheless, as the Veteran is also seeking service connection for radiculopathy as secondary to his disc disease, further development (i.e. an opinion on causation of his disc disease) is warranted. The evidence reflects that the Veteran had reports of back pain prior to active service (see October 1986 private medical certificate). An October 1993 private record reflects that he reported back pain from carrying boxes. His service treatment records (STRs) reflect that he reported on his September 1994 Report of Medical History for biannual purposes that he was taking Darvocet for back pain and that he had frequent back pains. An October 1996 clinical record also reflects complaints of thoracic pain. The STRs (during reserve duty) reflect that in January 1997, furniture fell on him when he was opening a truck door. He was initially seen for knee and cervical pain two days later: he reported upper back pain in the shoulder area. A September 1997 VA Form 10-10M reflects complaints of low back pain “since a couple of [weeks].” Records in October 1997 note low back pain and a diagnosis of iliolumbar myositis; however, a December 1997 record notes “lumbar DJD”. An April 1998 VA Form 3349 reflects that the Veteran was given a physical profile for chronic mechanical low back pain. In addition, several 1998 clinical records note complaints of the low back. February and May 1999 VA records reflects complaints of backache and radiculitis; it was noted that the back pain was in the paravertebral muscular area. An January 2001 record also notes low back pain. A June 2001 clinical record reflects that the Veteran had low back pain since 1992 when he had a job-related accident; he was diagnosed with chronic low back pain. A January 2002 Internal Medicine Evaluation reflects that the Veteran reported that he was in good health until July 2000 when he developed severe low back pain after lifting a fifty-pound refrigerator while working, and that he was referred to a provider where x-rays and a CT scan had shown discogenic disease. The Veteran reported that he received physical therapy and medication with partial improvement but that he had not returned to his usual job since July 2000. A Social Security Administration (SSA) record reflects that the Veteran reported that in July 2000 he injured his back when he grabbed a cooler that had fallen off a vehicle at his job. He reported that he felt strong pain in his lumbar area and has been disabled since then. 2001 and 2002 private records reflect a lumbar spine (L/S) sprain with an incident at work on July 5, 2000 (see December 2001, January – April 2002 private records). A March 2002 VA examination report reflects the opinion of the examiner that the Veteran’s degenerative joint disease of the lumbar spine was not related to his 1997 incident in service. The clinician’s opinion was based on the lack of notation as to direct trauma to the back in the description of the accident, the Veteran’s report of negative x-rays in service, and the lack of STRs supporting a causal relationship between his DJD and service. The clinician found that the Veteran’s lumbar myositis could be related to the 1997 incident. The clinician did not discuss whether the Veteran’s DJD was related to, or aggravated by, other periods of the Veteran’s service. A November 2004 VA clinical record reflects that the Veteran reported back pain which worsened “after trauma two months ago.” A January 2010 VA examination report reflects the opinion of the clinician that lumbar myositis is a condition related to soft tissue and not related to disc or nerve, there is no evidence in the literature that it can cause or produce disc herniation or radiculopathy, and that therefore, the Veteran’s lumbar herniated disc, cervical radiculopathy, and lumbar radiculopathy are not caused by or a result of his service connected lumbar myositis. A June 2010 VA examination report reflects the findings of the clinician that there is no evidence in the STRs that the Veteran had a lumbar injury that could have caused a herniated disc, that the Veteran worked in a civilian job which required heavy lifting, and that he started seeking medical care for his low back pain in 2002 (which is 11 years after separation from active service). However, this time-line is incorrect because the Veteran was seeking treatment (e.g. on profile) in 1992 (and 1997 and 1998 as noted above). A January 2013 VA clinical record reflects that the Veteran reported chronic low back pain stated in 1991 and was exacerbated in 1997 after a fall. Although two opinions have already been obtained, the Board finds that another opinion, which provides a more thorough rationale based on the evidence of record and discusses various avenues for service connection may be useful to the Board. In addition, the claim for entitlement to service connection for radiculopathy is also remanded as there is an indication that radiculopathy is related to a spine disability. 6. Entitlement to service connection for a left knee disability is remanded. November 1968, September 1983, May 1989, and March 1991 Reports of Medical History reflect that the Veteran denied a trick or locked knee, denied arthritis, rheumatism, or bursitis and denied lameness; he also noted that he was in good health. A September 1994 Report of Medical History reflects that the Veteran complained of knee pain but does not note that it was due to an in-service injury; rather, the only injured noted was a “work accident”. Lower extremities were noted to be normal upon clinical evaluation (see September 1983, and September 1994 Reports of Medical Examination). The Veteran’s STRs reflect that on January 23, 1997, while on active duty for training, he sustained a left knee injury when furniture fell from a vehicle onto him. He was seen on January 24, 1997 and noted to have an abrasion and limited range of motion due to pain. A January 25, 1997 STR reflects that he had no edema but still had pain; x-rays were negative. The STRs reflect that he had had a minimal abrasion upon evaluation on February 14, 1997. A May 1999 VA examination report reflects that there was no objective evidence of a knee disability. He had no crepitation, a negative patellar-grinding test, no dislocation, no subluxation, normal range of motion, and a negative musculoskeletal examination. X-rays of the knees were normal. An October 2015 VA examination report reflects the examiner also found it is less likely as not that the Veteran has a current knee disability causally related to service. The examiner noted that the 1997 injury was acute. The examiner noted that here was no evidence of continuity of treatment within two years after the 1997 incident, and a “gap” of follow up, complaints, and evaluations. The examiner also found that the Veteran’s degenerative changes of the left knee are an expected change related to the normal process of aging. The examiner also found that the Veteran’s left knee is of a different disease etiology to the Veteran’s myositis and therefore, not related to the Veteran’s back disability. The Board finds that a supplemental opinion with regard to aggravation is warranted. 7. Entitlement to service connection for a left hand disability is remanded. The Veteran has been diagnosed with left hand degenerative changes in the interphalangeal joints (e.g. see September 2003 private record and September 2012 VA x-ray record). A September 2003 x-ray notes that the carpal bones and radiocarpal joints appeared normal. The only degenerative change was in the 1st carpo-metacarpal joint of the left hand. The Veteran has indicated that he has a cervical herniated disc which causes hand disabilities. As noted above, the Veteran had active duty service from November 1990 to April 1991. The Veteran entered active duty on November 21, 1990. Prior to active service, the Veteran had surgery in the 1980s for excision of a ganglion cyst and decompression of the left median nerve at the wrist level. A December 1, 1990 STR reflects that the Veteran complained that he injured his left wrist in the motor pool three days earlier and had pain and decreased flexion. It was noted that he had had wrist surgery one year earlier (pre-active service). Upon examination, the Veteran’s left wrist was “only minimally swollen with slight decrease in flexion”. The Veteran was assessed with a left wrist contusion. He was given an ace wrap, motrin, and light duty. A follow-up STR three days later (December 4, 1990) reflects that he had pain in the left hand but had good grip strength. The assessment was “resolving hand pain.” A December 10, 1990 STR reflects that the Veteran was seen for follow up for his left wrist. It was noted that he had good left hand strength with mild pain on dorsum. The assessment was resolving trauma to the left wrist. A March 1991 Report of Medical History reflects a prior history of an operation on left hand/wrist but that the Veteran denied current complaints. He reported that he was in good health and taking no medication. Post service, the earliest evidence of a possible complaint of the left hand/wrist is not for more than a year after separation from service. A December 1992 record from Dr. C. Torres reflects, with regard to the left hand and wrist, that there was no bony erosion, sclerosis, articular marginal lipping or joint space narrowing observed. It was noted that the presence of tendonitis was not excluded. The record does not indicate the reason for the x-ray. The Veteran’s September 1994 Report of Medical Examination (bi-annual) reflects an abnormality of the left hand in that he had a scar from a carpal tunnel syndrome operation. No other abnormality was noted upon evaluation. A January 2001 clinical record reflects that the Veteran had hand pain for several days. There was mild tenderness on palpation. The assessment was left hand pain. Records reflect osteoarthritis of the left hand in February 2001. A May 2002 VA clinical record reflects that the Veteran had abnormal range of motion in the left hand. It was also noted that he had muscle strength diminished in the left upper extremity (and lower extremities). An October 2002 VA clinical record notes weakness in the hands, and a December 2002 record reflects complaints of left hand pain which was stabbing and radiating to upper arm; it was noted to be acute (less than three months in duration). The Veteran was assessed with tendinitis of wrist. A September 2002 private record (G. C. Munoz) reflects osteoarthritic changes in some of the joints. Additional records note complaints of left hand numbness (May 2003), that the Veteran wears a splint (September 2004), that he had a complaint of pain (November 2004), that he was wearing a “cock-up” splint (February 2006), that he wears a brace (May 2007), that he sustained a bite on the fourth finger (August 2009), and that he occasionally drops objects from his left hand and that he has stiffness. (2010). The Board finds, based on the above, that a VA opinion is warranted. 8. Entitlement to service connection for erectile dysfunction to include as secondary to an anthrax vaccination is remanded. The Veteran testified at the Board hearing that he has had erectile dysfunction since he returned from the desert (Gulf War) in 1991 and that his erectile dysfunction has been “linked” to his war service (e.g. See Board hearing transcript, page 21, December 2009 VA urology record, and November 2015 VA Form 21-4138.) He has also claimed that it is due to receiving the anthrax vaccination. (See May 2009 V Form 21-4138). He has been diagnosed with erectile dysfunction due to general medical condition; however, the “general medical condition” has not been more specifically explained, and he has also stated that pain interferes with sexual activity. As the Veteran is in receipt of service connection for two disabilities, and as other issues are being remanded, the Board finds that this issue must also be remanded for an opinion as to whether a service-connected disability is part of the reason why the Veteran has erectile dysfunction. 9. Entitlement to service connection for a right foot disability is remanded. 10. Entitlement to service connection for a left foot disability is remanded. The Veteran’s September 1968 Report of Medical examination for induction purposes reflects that he had normal feet upon evaluation. The Veteran’s September 1983 Report of Medical Examination reflects that he had abnormal feet upon evaluation in that he had flat feet. The Veteran’s May 1987 Report of Medical Examination reflects that he had normal feet upon examination. The Veteran’s March 1991 Report of medical Examination for Separation purposes reflects that he had abnormal feet upon evaluation in that he had pes planus (flat feet). A November 1991 private record reflects pain in the right foot. The Veteran’s September 1994 Report of Medical Examination for biannual purposes reflects that he had normal feet upon examination. An October 1999 record reflects tinea pedis; there was no edema. An October 2002 private record (Concordia Imaging Center) notes findings regarding the articular spaces of both feet. There were tiny subcortical cysts noted in the head of the first metatarsal. There was no evidence of osteophyte formation. A December 2002 VA clinical record reflects right heel pain. A private May 2005 record reflects degenerative changes and hallux valgus of the right foot. A June 2005 private record reflects left foot pain and requested foot fungus cream. An October 2010 VA podiatry record reflects bilateral pes planus, skin complaints, and difficulty with walking. A July 2011 private record (Metropolitano Ponce) record reflects osteopenia of the right foot, hallux valgus, and soft tissue swelling. VA records reflect bilateral mild hallux valgus deformity, tiny plantar and posterior calcaneal spurs, and metatarsal phalangeal joint OA (right) and metatarsal phalangeal joint suspicious for gout or pseudo-gout (left). 2014 VA podiatry record reflects that the Veteran has bilateral pes planus, mild drop foot on the right, and bilateral fasciitis. The Board finds based on the above that a clinical opinion is warranted. 11. Entitlement to service connection for a disability manifested by symptoms to include joint and muscle pain and claimed as due to Persian Gulf War service. The Veteran’s service personnel records confirm he had service in South West Asia from January 1991 to April 1991. In May 1997, he completed a Persian Gulf Registry Code Sheet/examination in which he reported, in part, experiencing multiple joint pain since September 1992, and reported frequent diarrhea episodes, insomnia, and other problems. An October 2015 VA examination report reflects that the Veteran does not meet the criteria for fibromyalgia, and that all of the Veteran’s symptoms and complaints could be explained by one of his diagnosed disabilities (e.g. osteoarthritis, hypothyroidism, deconditioning, carpal tunnel, depression, coronary artery disease). However, in its 2017 remand, the Board directed that the Veteran undergo another Gulf War examination and that the clinician make findings not just as to fibromyalgia but also as to chronic fatigue syndrome or other chronic multi-symptom illness. Thus, a remand for a more complete examination/opinion is warranted. Stegall v. West, 11 Vet. App. 268 (1998) The matters are REMANDED for the following action: 1. With regard to the Veteran’s cardiac disability, obtain a clinical opinion as to: (a.) whether it is as likely as not (50 percent or greater) that the cardiac disability is caused by the Veteran’s service-connected acquired psychiatric disability; and (b.) whether it is as likely as not (50 percent or greater) that the cardiac disability is aggravated by the Veteran’s service-connected acquired psychiatric disability If the clinician finds that the Veteran’s cardiac disability is aggravated by the Veteran’s service-connected disability, the clinician should state the degree of aggravation and note the baseline severity prior to aggravation. 2. With regard to the Veteran’s cervical spine disability, obtain a clinical opinion as to: (a.) whether it is as likely as not (50 percent or greater) that the cervical spine disability is casually related to active service; and (b.) whether it is as likely as not (50 percent or greater) that the cervical spine disability is aggravated by service-connected lumbar myositis. The clinician should consider the pertinent evidence of record to include: a). the January and February 1997 STRs noting negative x-rays but mild to moderate stiffness and tenderness in the neck after the Veteran was hit by falling objects; b.) 1998 records reflect complaints of the cervical spine (see March, May 1998 record, and July 1998 clinical record noting pain on the posterior neck and upper back; he presented with tenderness at palpation on the paravertebral muscles of the cervical-dorsal spine); and c.) July and September 2002 radiograph findings. A complete rationale should be provided for all clinical opinions offered. 3. With regard to degenerative disc disease and/or degenerative joint disease of the lumbosacral spine, obtain a clinical opinion as to: (a.) whether it is as likely as not (50 percent or greater) that the degenerative joint disease of the lumbar spine is casually related to active service; and (b.) whether it is as likely as not (50 percent or greater) that the degenerative joint disease of the lumbar spine disability is aggravated by service-connected lumbar myositis. The clinician should consider the pertinent evidence of record to include: a.) that the Veteran pre-service evidence of back pain (see October 1986 private medical certificate); b.) the September 1994 Report of Medical History for biannual purposes which notes that he was taking Darvocet for back pain, and that he had frequent back pains. c.) an October 1996 clinical record noting complaints of thoracic pain; d.) the January and February 1997 STRs noting cervical spine pain and the Veteran’s contention that he injured his low back at the same time; e.) a September 1997 VA Form 10-10M which reflects complaints of low back pain “since a couple of [weeks]”; f.) October 1997 records which note low back pain and a diagnosis of iliolumbar myositis; however a December 1997 record notes “lumbar DJD”; g.) an April 1998 VA Form 3349 reflects that the Veteran was given a physical profile for chronic mechanical low back pain and 1998 clinical records note complaints of the low back; h.) February and May 1999 VA records noting pain in the paravertebral muscular area; i.) a January 2002 Internal Medicine Evaluation and SSA records which reflect that the Veteran reported that he was in good health until July 2000 when he developed severe low back pain after lifting a fifty-pound refrigerator while working and was unable to work since then; j.) a March 2002 VA examination report ; and k.) a June 2010 VA examination report. If the clinician finds that the Veteran had DDD and/or DJD causally related to, or aggravated by, service, the clinician should state to which period of service it is related. (The Veteran is already in receipt of service connection for lumbar myositis). 4. With regard to a left knee disability, obtain a supplemental clinical opinion as to whether the disability is as likely as not (50 percent or greater) aggravated by a service-connected disability. If the clinician finds that the Veteran’s knee disability is aggravated by a service-connected disability, the clinician should state the degree of aggravation and note the baseline severity prior to aggravation. 5. With regard to a left hand/wrist disability, please specifically identify all such disabilities and, as to each disability found, obtain a clinical opinion as to: a. whether the disability is as likely as not (50 percent or greater) causally related to active service; and b. whether the Veteran’s pre-existing status post carpal tunnel surgery disability as likely as not (50 percent or greater) increased in severity during the 1990-91 period of service (please consider and discuss as necessary STRs documenting treatment for a 1990 motor pool injury involving the left wrist); and c. whether any increase in severity in service was clearly and unmistakably (obvious, manifest, undebatable) due to the natural progress of the pre-existing carpal tunnel disability The clinician should consider the pertinent evidence of record to include a.) the Veteran’s preservice carpal tunnel syndrome surgery in the 1980s; b.) the Veteran’s current disabilities; c.) the December 1990 STRs noting left wrist pain and decreased flexion; d.) a December 1992 record from Dr. C. Torres which reflects no bony erosion, sclerosis, articular marginal lipping or joint space narrowing observed. It was noted that the presence of tendonitis was not excluded. 6. With regard to erectile dysfunction, obtain a clinical opinion as to whether it is as likely as not (50 percent or greater) that the disability is caused by or worsened by a service-connected disability and/or medication taken for a service-connected disability. 7. With regard to right and left foot disabilities, obtain a clinical opinion as to whether it is as likely as not (50 percent or greater) that the Veteran has a disability caused by, or aggravated by, active service. The clinician should consider the pertinent evidence of record to include: a.) the September 1968 Report of Medical examination for induction purposes which reflects normal feet upon evaluation; b.) the September 1983 Report of Medical Examination which reflects flat feet; c.) the May 1987 Report of Medical Examination which reflects normal feet upon examination; d.) the March 1991 Report of medical Examination for Separation purposes reflects that he had pes planus; e.) the November 1991 private record reflects pain in the right foot f.) the September 1994 Report of Medical Examination for biannual purposes which reflects that he had normal feet upon examination; and g.) the Veteran’s current disabilities. If the clinician finds that the Veteran has a foot disability incurred or aggravated in service, the clinician should state the period of service. 8. With regard to a disability manifested by symptoms to include joint and muscle pain, schedule the Veteran for an appropriate medical examination (i.e. Gulf War examination). Based on review of the record, the examiner should provide an opinion that responds to the following: (a) Please identify all found diagnoses to which the Veteran’s symptoms of joint and muscle pain (see November 1998 record noting polyarthralgic syndrome of unknown etiology), gastrointestinal complaints, and other complaints identified in the 1997 Persian Gulf Registry examination report, are medically attributable. In responding to this item, please specifically confirm whether the Veteran has known medical diagnoses that account for the entirety of his complaints. (b). Please opine as to whether the Veteran’s symptoms are: i.) manifestations of a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders (excluding structural gastrointestinal diseases) and is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of portion to physical findings, and inconsistent demonstration of laboratory abnormalities; or. ii.) manifestations of an undiagnosed illness. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Wishard