Citation Nr: 20052998 Decision Date: 08/10/20 Archive Date: 08/10/20 DOCKET NO. 15-45 694 DATE: August 10, 2020 ORDER Entitlement to a rating in excess of 10 percent for lumbosacral strain prior to July 24, 2013, is denied. Entitlement to a 20 percent rating from July 24, 2013, to April 11, 2019, for lumbosacral sprain is granted. Entitlement to a rating in excess of 20 percent for the period beginning on April 11, 2019, for lumbosacral strain is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for a gastrointestinal condition is denied. REMANDED Entitlement to a rating in excess of 20 percent for degenerative joint disease of the cervical spine is remanded. FINDINGS OF FACT 1. Prior to July 23, 2013, the Veteran’s degenerative arthritis of the thoracic-lumbar spine was not manifested by forward flexion limited to 60 degrees, a combined range of motion limited to 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, ankylosis, or any incapacitating episodes, and functional loss of pain. 2. From July 24, 2013, the Veteran’s lumbosacral strain has been manifested by functional loss due to muscle spasms and pain requiring frequent rests, but not limitation of flexion to less than 30 degrees, favorable ankylosis of the thoracolumbar spine, or incapacitating episodes. 3. There is no evidence of a combat related stressor or a verified stressor in service. 4. The preponderance of the evidence does not support that the Veteran has a current gastrointestinal condition that is etiologically linked to his active duty service. CONCLUSIONS OF LAW 1. Prior to July 24, 2013, the criteria for entitlement to a rating in excess of 10 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237. 2. From July 24, 2013, the criteria for entitlement to a rating in excess of 20 percent, but no higher, for lumbosacral strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5237. 3. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f). 4. The criteria for service connection for a gastrointestinal condition have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1977 to February 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of September 2012 and July 2014 rating decisions of the Agency of Original Jurisdiction (AOJ). In November 2018, the Board remanded the matter to the AOJ for further evidentiary development, which included verifying the Veteran’s claimed PTSD stressor, providing adequate medical opinions, and obtaining new medical examinations compliant with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board is obligated by law to ensure that the AOJ complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the AOJ has substantially complied with the Board’s remand directives. 1. Entitlement to a rating in excess of 10 percent for lumbosacral strain prior to April 11, 2019, and in excess of 20 percent thereafter Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2017). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2017). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). The Board will also consider entitlement to staged ratings to compensate for times since the claim was filed when the disability may have been more severe than at other times during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area of the spine affected by the residuals of injury or disease, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees but not greater than 235 degrees; or, muscle spasm or guarding or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling, and unfavorable ankylosis of the entire spine is evaluated as 100 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5237. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. In DeLuca, it was held that when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be “‘portray[ed]’ (38 C.F.R. § 4.40 ) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.” Id. at 206. For the following reasons, the Board finds that an increased rating is not warranted. At a June 2012 VA examination, the Veteran reported that he experienced pain, stiffness, spasms and decreased motion but not fatigue, paresthesia and numbness. The Veteran denied ever being hospitalized or having surgery and denied any incapacitation in the last twelve months. He reported functional impairment related to prolonged sitting and standing. Physical examination revealed posture and gait within normal limits. Walking was steady and he did not require any assistive device for ambulation. As to the thoracolumbar spine, there was no evidence of radiating pain on movement and muscle spasm was absent. Despite the Veteran’s report of muscle spasm there was no indication that such spasms or guarding resulted in abnormal gait or spinal contour. Muscle tone and musculature were normal. Straight leg raise testing was negative bilaterally and there was no atrophy in the limbs or ankylosis. During range of motion testing, flexion was to 90 degrees with pain at 80 degrees. Extension, left lateral flexion, left lateral rotation, right lateral flexion, and right lateral rotation to 30 degrees with no objective evidence of painful motion. Range of motion was the same following repetitions and did not result in any additional degree of limitation of motion. Neurological examination of the lower extremities was normal, and peripheral nerve involvement was not evident during the examination, the lower extremities showed no signs of pathologic reflexes. There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. In addition, there was no evidence of any other neurologic abnormality. Additional factors contributing to the disability included interference with sitting, standing and/or weight-bearing. In a Notice of Disagreement (NOD) received on July 24,2013, the Veteran stated that his back was getting progressively worse and that he had been ordered by a VA doctor to get up every 5-10 minutes to prevent spasms. He also reported that his back spasms caused him to walk with abnormal gait. In September 2014, the Veteran applied for extended leave from work due to his service-connected neck and back conditions and a nonservice-connected thumb condition. A private physician indicated the Veteran would be incapacitated for a single continuous, but unknown, period of time due to all three conditions. The application indicates that severe pain limits prolonged sitting required for work. November 2014 VA treatment records reveal the Veteran was treated for increased back pain. The Veteran described pain that would awaken him at night and intermittently radiated to both hips. There was no evidence of paresthesias on examination and no bowel or bladder symptoms reported. In April 2015 VA treatment records, the Veteran reported continued back pain with no radiation of pain and no bowel or bladder symptoms. At a November 2015 VA contract examination, the Veteran reported experiencing increased back pain. He denied experiencing flare-ups but reported functional impairment including “increased sickness”. During range of motion, flexion was to 75 degrees, extension to 20 degrees, left lateral flexion to 30 degrees, left lateral rotation to 30 degrees, right lateral flexion to 30 degrees, and right lateral rotation to 30 degrees. The examiner noted pain in forward flexion, extension and right lateral rotation resulted in functional loss. There was no evidence of localized tenderness or pain on palpation, nor was there evidence of pain with weight bearing. The Veteran was able to perform repetitive testing with at least three repetitions, but this did not result in additional loss of function or range of motion. The examiner noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Although there was guarding, it did not result in abnormal gait or spine contour and there was no localized tenderness. There were no additional factors contributing to disability. Straight leg raise testing was negative bilaterally and there were no signs of radiculopathy or other neurologic abnormalities. The Veteran did not have intervertebral disc syndrome. The examiner summarized the functional impact of the Veteran’s spine disability as requiring the Veteran to take sick days due to back pain. The Veteran’s back condition was evaluated again in April 2019. The Veteran reported spasms 2-3 times a month and sharp pains in his lower back that he felt could be due to his bowels being backed up. Forward flexion was to 70 degrees, extension bilateral lateral rotation and bilateral lateral flexion were to 15 degrees. Pain was noted on exam as causing functional loss in the Veteran’s ability to pick items up off the floor. There was no objective evidence of localized tenderness or pain on palpation. However, the examiner documented evidence of pain with weight bearing. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. The examiner opined that pain would significantly limit functional ability with flare-ups and repeated use over time but would not result in additional loss of range of motion. The Veteran reported spasm, difficulty moving and difficulty getting comfortable with flare ups. The examiner also found guarding against spasm resulting in abnormal gait or spinal contour. There were no additional factors contributing to disability. Straight leg raise testing was negative bilaterally and there were no signs of radiculopathy or other neurologic abnormalities. The Veteran did not have ankylosis or intervertebral disc syndrome. The examiner noted that the Veteran needed to be able to change position frequently and limit his walking/standing to about 30 minutes at a time. Based on the above, there is no basis to grant an increased rating under the schedular criteria governing the assignment of evaluations for low back conditions at any time during the appeal period. The June 2012 examination showed forward flexion to 90 degrees, a combined range of motion of 240 degrees which, when taking into account pain, was 230 degrees. Although the November 2015 examination revealed worsening limitation of motion, Forward flexion to was limited only to 75 degrees. The Veteran’s combined range of motion when accounting for pain was 215 degrees. Further, the April 2019 examination showed range of motion of forward flexion to 70 degrees, extension, bilateral lateral rotation and bilateral lateral flexion were to 15 degrees, for a combined rating of 145 degrees. All above the criteria for a higher rating under Diagnostic Code 5237. 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Board notes that while ratings can also be assigned under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, in this case, at each examination, the Veteran denied any incapacitation in the last twelve months and the examiner found no signs of intervertebral disc syndrome. Accordingly, a higher rating cannot be assigned under these criteria. The Board also notes that any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, are evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1) (2016). In this case, although the Veteran reported bowel dysfunction at the April 2019 examination, the most probative evidence of record shows that there are no neurological abnormalities attributable to the Veteran’s degenerative arthritis of the spine. In this regard, the April 2019 examiner was unable to attribute any bowel symptoms to the Veteran’s lumbar spine disability. He also found that neurological examination of the lower extremities was normal, and that peripheral nerve involvement was not evident. Similarly, no examiner found signs of radiculopathy or other neurologic abnormalities and straight leg raise was consistently negative bilaterally. Therefore, any separate or additional compensation for neurological manifestations of the Veteran’s spine disorder is not warranted. When considering functional loss, the Board finds that the 10 percent rating assigned adequately compensates the Veteran for his pain and other symptoms prior to July 24, 2013. Thus, an increase greater than 10 percent prior to this date is not warranted. However, as of July 24, 2013, the Veteran reported a worsening of symptom including spasms and requiring him to move every 10 minutes supported by medical evidence from private physicians and VA treatment records showing increased pain and guarding. Accordingly, under 38 C.F.R. §§ 4.40, 4.45, 4.59 (2019), the Board finds that a 20 percent, but no higher, is warranted from July 24, 2013, based on functional loss. A higher rating for functional loss is not appropriate after April 11, 2019, as the Veteran’s symptoms are already compensated in the assigned 20 percent rating. The 20 percent rating awarded effective April 11, 2019 contemplates the Veteran’s symptoms of muscle spasms during flare-ups, pain and functional loss. In sum, the preponderance of the evidence establishes that the Veteran’s service-connected lumbosacral strain warrants no higher than a 10 percent rating for the period prior to July 24, 2013, a 20 percent rating, but no higher, is warranted from July 24, 2013. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2017). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107 (b). 2. Entitlement to service connection for PTSD There are particular requirements for establishing PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). The sufficiency of a stressor is a medical determination and is presumed by a medical diagnosis of PTSD. Cohen, 10 Vet. App. at 140. Section 3.304 (f)(2) provides that in the absence of clear and convincing evidence to the contrary and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the occurrence of the claimed in-service stressor may be established by the veteran’s lay testimony alone where the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat. 38 C.F.R. § 3.304 (f)(2) (2019). Additionally, if a stressor claimed by a Veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided 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. 38 C.F.R. § 3.304 (f)(3) (2019). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). There is no dispute that the Veteran was diagnosed with PTSD by a VA physician in April 2009. The April 2009 diagnosis was confirmed by a VA clinical psychologist and VA clinical social worker. Additionally, a private LPC diagnosed the Veteran with PTSD in October 2014. Thus, a current diagnosis is established. Where, a claimed stressor is not related to combat, a veteran’s lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must contain service records or other corroborative evidence which substantiates or verifies the Veteran’s testimony or statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). In a February 2011 statement the Veteran reported that he was in Kuwait from October 1989 to February 1990. He explained that he assisted in a detail where human remains were disposed in mass graves. In October 2011, the Veteran submitted a statement claiming he was deployed to Kuwait from June to October 1991 to transfer equipment to the 8th Infantry Division. He reported that he saw dismembered body parts on several occasions along the side of the roads traveled. In a June 2013 NOD, the Veteran claimed a similar stressor took place in Iraq in 1991. Finally, a June 2013 Mental Health Note indicates the stressor occurred in Iran. In January 2016, the Veteran submitted a statement from a fellow soldier who served with the Veteran in Germany. D.P. recalled that the Veteran deployed twice from Germany to Kuwait, once for approximately three months and once for approximately six months. Initially, the Board notes that to the extent that any of the Veteran’s stressors are combat related during service in the Persian Gulf, the record does not support a finding that the Veteran engaged in combat. The Veteran’s military occupational specialties, awards and medals are not indicative of combat, nor doe his personnel records indicate any combat service. As such, the Board finds that the Veteran did not engage in combat, and the combat provisions are not for application. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304 (f)(2). Further, the Board has reviewed the Veteran’s personnel records, DD 214, and service treatment records, and finds that the his only foreign service was in Germany. While the Board acknowledges the Veteran’s and his fellow soldier’s lay statements regarding his service, the Board finds that the probative value of the service records outweighs that of the lay statements. Accordingly, the Board finds that there preponderance of the evidence fails to establish that the Veteran served in the Southwest Asia theater of operations. The Board acknowledges that the April 2009 and October 2014 PTSD diagnoses were based on the Veteran’s report of a stressors during Persian Gulf service that could qualify as “fear of hostile military forces” under section 3.304(f)(3) to establish the stressor; however, as discussed above, the Board finds that the record contains clear and convincing evidence contradicting the Veteran’s assertion that he served in combat related to the Gulf War and finds that his claimed combat stressor is not consistent with the types, places, and circumstances of the Veteran’s service. As addressed, he did not receive any combat medals or commendations and did not serve in the Persian Gulf. Thus, the provisions of section 3.304(f)(3) regarding the establishment of a stressor are not applicable in this case. 38 C.F.R. § 3.304 (f)(3). Turning to the Veteran’s other claimed stressors, his non-combat stressors, the Board finds there is no credible corroborating evidence to establish that the asserted recovery of human remains or witness of body parts occurred. As noted, the Board has reviewed the Veteran’s records in their entirety and finds that the evidence does not establish that the Veteran was ever deployed to the Persian Gulf , Iran, or Iraq, or involved in the recovery or disposal of human remains. Service records reveal service in Germany, but no other foreign locations and no indication of temporary duty assignments. The Board accords great evidentiary weight to the evidence of record including the Veteran’s military personnel records, treatment records, and DD 214, that fail to establish that the noncombat incidents occurred given that there is no corroborative evidence in the Veteran’s service records supporting the claimed deployments. A medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Cohen v. Brown, 10 Vet. App. 128, 142 (1997). Further, in determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges the April 2009 VA physician and October 2014 counselor both diagnosed the Veteran with PTSD based on the claimed combat related stressor, however, as the Board has found that the Veteran did not have Persian Gulf service, the basis of the diagnosis is factual inaccurate. Both opinions appear to be based solely on the Veteran’s own account without assessing the accuracy of that account. Thus, since the opinions are based on an erroneous factual premise, the opinions have no probative value. The Board finds there is no credible, reliable, persuasive, or probative evidence in the record that either of the Veteran’s claimed in-service stressors occurred. The preponderance of the evidence is against the claim for service connection for PTSD. As the preponderance of the evidence is against the claim, the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 3. Entitlement to service connection for a gastrointestinal condition The Veteran is seeking service connection for a gastrointestinal condition contending that the condition began in service. After review of the lay and medical evidence, the Board finds that service connection is not warranted for a gastrointestinal condition. The record reveals a diagnosis of chronic diarrhea in 2009. The Veteran has also competently and credibly reported persistent symptoms including constipation and abdominal pain. The Veteran’s service treatment records (STRs) contain complaints of stomach pain and constipation in July 1979 and October 1988 respectively. In January 1993, the Veteran was also seen with complaints of diarrhea. Therefore, the first and second elements of service connection are established. Nevertheless, the claim must fail for lack of nexus. September 2008 and September 2010 VA treatment records reveal a normal colon. In June 2014, the Veteran was treated for constipation and diarrhea. He reported that he ate two meals per day and less on the weekends. He noted that he took MiraLax powder as needed for constipation. The Veteran was afforded his first VA examination in May 2014. The examiner recorded a 2009 diagnosis of chronic diarrhea. The Veteran reported loose to watery bowel movements 3-5 times per day and some incontinence of the bowels with the excessive diarrhea. The examiner opined that gastrointestinal condition occurred long after separation from military service and thus was unrelated. The Veteran was afforded a second VA examination in November 2015. The examiner opined there was no biologic basis for a muscular condition of the back to affect the gastrointestinal track. Additionally, the examiner found the Veteran’s history suggests occasional episodes of constipation, not a diagnosed condition of chronic constipation which is a specific medical syndrome. Occasional constipation is not uncommon and generally has no specific cause. The May 2014 and November 2015 opinions were deemed inadequate in the November 2018 Board remand, and the Veteran was afforded a new examination in April 2019. The April 2019 examiner found the Veteran’s post-service record did not support either chronic diarrhea or chronic constipation. Nevertheless, the examiner opined as to whether the Veteran’s symptoms were related to service. The examiner found no evidence of chronic diarrhea during service. Additionally, she found no record to support an in-service incurrence that would contribute to the Veteran’s current diarrhea and constipation. Rather, the examiner opined that the Veteran’s alcohol dependence, tobacco use disorder, hepatitis B, chronic hepatitis C, cirrhosis and chosen dietary habits contributed to his irregular bowel habits. The examiner also noted that the Veteran’s lumbar strain could not physiologically cause or worsen the Veteran’s diarrhea or constipation because he had no neuropathic involvement. The Veteran has alleged that the he had service in Kuwait, the Southwest Asia theater of operations, after August 2, 1990. Therefore, the Board also considered whether service connection may be granted on a presumptive basis due to service in the Persian Gulf under 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). However, as noted above the Veteran’s symptoms cannot be attributed to service in Southwest Asia as there is no evidence that the Veteran actually had active service in the Persian Gulf. For these reasons, the Board finds that service connection is not warranted as the Veteran does not have service in the Persian Gulf, nor have the Veteran’s conditions been etiologically linked to his active duty service. In the absence of a nexus, there can be no valid claim. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board finds the April 2019 VA examiner’s opinion probative as she based her opinions on a full examination of the Veteran, with consideration of the Veteran’s medical history, and her opinion was supported with detailed medical rationale. As such, the Board finds the preponderance of evidence weighs against the claims and the benefit of the doubt doctrine does not apply. Accordingly, the claim for service connection for a gastrointestinal condition is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to a rating in excess of 20 percent for degenerative joint disease of the cervical spine is remanded. In a July 2020 statement, the Veteran identified missing treatment records relating to his cervical spine condition. Consequently, VA should make reasonable efforts to obtain these records for the Veteran’s claim upon remand. See 38C.F.R. §3.159 (c)(3); Sullivan v. McDonald, 815 F.3d 786, 791-92 (Fed. Cir. 2016). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment related to his increased rating claim for degenerative joint disease of the cervical spine. The AOJ should specifically request that the Veteran provide authorization to obtain treatment records from the Baptist Medical Center. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records. 2. The AOJ should also consider whether the Veteran is entitled to a TDIU. In so doing, the AOJ may decide to pursue further development of the Veteran’s employment history and/or obtain additional medical evidence or a medical opinion. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Sherman Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.