Citation Nr: 21004183 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 15-06 520A DATE: January 26, 2021 ORDER Whether new and material evidence was received to reopen a claim for service connection for a heart murmur is denied. Entitlement to service connection for headaches, to include as due to an undiagnosed illness is granted. Entitlement to service connection for bilateral tinnitus is granted. Entitlement to service connection for fatigue, to include as due to an undiagnosed illness is denied. Entitlement to service connection for sleep disturbances, to include as due to an undiagnosed illness is denied. Entitlement to service connection for an upper respiratory disorder, to include as due to an undiagnosed illness is denied. Entitlement to service connection for allergic rhinitis, to include as due to an undiagnosed illness is denied. Entitlement to service connection for generalized joint pain, to include as due to an undiagnosed illness is denied. Entitlement to service connection for Gulf War syndrome is denied. Entitlement to service connection for arthritis of the feet and hands is denied. REMANDED Entitlement to service connection for bilateral knee tendonitis, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a bilateral ankle disorder, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a skin disorder involving the face and neck, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a bilateral shoulder disorder is remanded. Entitlement to a compensable disability rating for beta thalassemia minor (BTM) is remanded. Entitlement to a disability rating in excess of 10 percent for lumbar spine degenerative disc disease (DDD) is remanded. Entitlement to a disability rating in excess of 30 percent for bilateral pes planus is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. In an unappealed rating decision, dated in November 2005, the AOJ denied a claim of service connection for a heart murmur. 2. Evidence associated with the claims file since the November 2005 rating decision is not cumulative or redundant but fails to raise a reasonable possibility of substantiating the claim of entitlement to service connection for a heart murmur. 3. The Veteran’s tension headaches are secondary to his service-connected psychological disorder. 4. The evidence is at least in relative equipoise that the Veteran’s bilateral tinnitus was the result of military noise exposure. 5. The Veteran’s fatigue is a symptom of his service-connected beta thalassemia minor and was not incurred in service to include as due to an undiagnosed illness. 6. The preponderance of the evidence of record is against finding that the Veteran has had a diagnosed sleep disorder at any time during or approximate to the pendency of the claim. 7. The preponderance of the evidence of record is against finding that the Veteran has had an upper respiratory disorder at any time during or approximate to the pendency of the claim. 8. The Veteran’s allergic rhinitis was not incurred or a result of active duty service to include as due to an undiagnosed illness. 9. The preponderance of the evidence of record is against finding that the Veteran has had generalized joint pain at any time during or approximate to the pendency of the claim. 10. The preponderance of the evidence of record is against finding that the Veteran has had Gulf War syndrome at any time during or approximate to the pendency of the claim. 11. The Veteran’s feet and hand arthritis was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The November 2005 rating decision that, among other issues, denied entitlement to service connection for a heart murmur was final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 20.302(b), 20.1103 (2019). 2. New and material evidence has not been received since the AOJ’s November 2005 rating decision, thus the claim for service connection for a heart murmur is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2019). 3. The criteria for service connection for headaches as secondary to service-connected psychological disorder are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2019). 4. The criteria for entitlement to service connection for bilateral tinnitus are met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 5. The criteria for service connection for fatigue, to include as due to an undiagnosed illness are not met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). 6. The criteria for service connection for sleep disturbances, to include as due to an undiagnosed illness are not met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). 7. The criteria for service connection for upper respiratory disorder, to include as due to an undiagnosed illness are not met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). 8. The criteria for service connection for allergic rhinitis, to include as due to an undiagnosed illness are not met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). 9. The criteria for service connection for generalized joint pain, to include as due to an undiagnosed illness are not met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). 10. The criteria for service connection for Gulf War syndrome. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). 11. The criteria for service connection for arthritis of the feet and hands are not met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the U.S. Army from April 2001 to April 2004, with service in the Southwest Asia theater of operations. This case comes before the Board on appeal of multiple rating decisions. This case was previously before the Board in June 2018, where the issues on appeal were remanded for further evidentiary development. The Board notes that the Veteran’s service connection claim for plantar warts was granted in an August 2020 rating decision. Therefore, as the service connection claim has been granted, it is resolved and no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). The Board adds that in the May 2005 rating decision, the AOJ granted service connection for bilateral pes planus with a 10 percent disability rating. Then, in an October 2005 rating decision, the rating was reduced to noncompensable. The Veteran timely filed a notice of disagreement in January 2006 but failed to perfect his appeal after the December 2006 statement of the case (SOC). Subsequently, the Veteran filed an increased rating claim for his bilateral pes planus in April 2013. Thus, there is no claim for an increased rating for his bilateral pes planus prior to April 26, 2013. New and Material Evidence Generally, a claim that has been denied in a final unappealed RO decision may not be reopened and re-adjudicated. 38 U.S.C. § 7105(c) (2012). An exception to that rule is that if new and material evidence is presented or secured with respect to a claim, which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108 (2012). A claim may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence is considered “new” if it was 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 final 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) (in determining whether evidence is new and material, the “credibility” of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). Service Connection Generally, to establish service connection 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted through the application of statutory presumptions for chronic conditions, which includes arthritis and tinnitus. See 38 C.F.R. §§ 3.303(b), 3.309(a) (2017); see also 38 U.S.C. §§ 1112, 1137 (2012). First, a claimant may benefit from a presumption of service connection where a chronic disease has been shown during service. 38 C.F.R. § 3.303(b). In the alternative, if a chronic disease was not shown in service, but manifested to a degree of 10 percent or more within some specified time after separation from active service, such disease shall be presumed to have been incurred or aggravated in service, even if there is no evidence of such disease during service. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. § 3.307(a)(3) (2017). The application of these presumptions operates to satisfy the “in-service incurrence or aggravation” element and establish a nexus between service and a present disability, which must be found before entitlement to service connection can be granted. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been “shown in service,” there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in-service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. Additionally, service connection may be granted on a secondary basis. Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310 (2019). To prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Moreover, service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability either during active service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. §§ 1117, 1118 (2012); 38 C.F.R. § 3.317 (a)(1). A “Persian Gulf Veteran” is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. Id. A “qualifying chronic disability” is defined as: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as fibromyalgia, chronic fatigue syndrome, or a functional gastrointestinal disorder) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2)(B); 38 C.F.R. § 3.317. The term “medically unexplained chronic multi-symptom illness” means 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 proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Objective indications of a chronic disability include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317 (a)(4). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Likewise, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b) (2012). 1. Whether new and material evidence was received to reopen a claim for service connection for a heart murmur At the outset, the AOJ’s rating decision in November 2005, which among other issues, denied the Veteran’s claim of service connection for a heart murmur, was final. At the time of the November 2005 rating decision, the evidence of record consisted of the Veteran’s service treatment records (STRs), post-service VA treatment records and two VA examinations from September and October 2005. In the November 2005 rating decision, the AOJ explained that the STRs did not show that the Veteran was ever diagnosed with or treated for symptomatic manifestations of any valvular heart disease. Further, the AOJ stated that although the VA examination showed positive findings of a heart murmur, the heart function was normal and there was no evidence of any valvular heart disease. The AOJ continued that heart murmurs, in and of themselves, are often functional and do not produce any actual heart disease or disability. The AOJ explained that a heart murmur is not considered an actually disabling condition. Thus, the AOJ denied the Veteran’s claim. Since the November 2005 rating decision, a May 2013 VA treatment record noted the Veteran’s heart had abnormal sounds and murmurs. However, subsequent records routinely indicated that the Veteran’s cardiovascular system was normal with no murmurs and regular heart rate and rhythm. See VA treatment records. Moreover, there is no medical evidence that the Veteran suffers from any disabling heart condition. Therefore, although the medical records since the November 2005 rating decision are considered new, it is not material as it fails to raise a reasonable possibility of substantiating the claim on appeal. Accordingly, the Veteran’s claim of entitlement to service connection for a heart murmur is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). 2. Entitlement to service connection for headaches, to include as due to an undiagnosed illness Here, the Veteran contends that his headaches were incurred in service, to include as due to an undiagnosed illness. Based on the evidence, the Board finds that the Veteran’s headaches are secondary to his service-connected psychiatric condition. At the outset, the Veteran was diagnosed with tension headaches dating back to 2005. See March 2013 VA examination. Thus, the first element of secondary service connection is met. Likewise, the second element is met. The Veteran is currently service-connected for posttraumatic stress disorder (PTSD). Therefore, to warrant service connection, there must evidence of a nexus, or link, between the Veteran’s tension headaches and his psychological disorder. In that regard, in the March 2013 VA examination, the examiner opined that the Veteran’s tension headaches are at least as likely as not related to his posttraumatic stress disorder with insomnia and nightmares. The examiner remarked that headaches are tension type and appeared to be aggravated by lack of sleep and stress. The Board finds the examiner’s opinion to be competent, credible and highly probative. The examiner reviewed the pertinent evidence, evaluated the Veteran, accounted for his lay statements and provided an opinion based on medical principles and the evidence. Accordingly, as the preponderance of the evidence supports the claim, entitlement to service connection for tension headaches is granted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.310. 3. Entitlement to service connection for bilateral tinnitus Here, the Veteran contends that his bilateral tinnitus was incurred or the result of active duty service. Resolving reasonable doubt in the Veteran’s favor, the Board agrees. At the outset, the Board notes that tinnitus is, by definition “a noise in the ears, such as ringing, buzzing, roaring, or clicking. It is usually subjective in type.” Dorland’s Illustrated Medical Dictionary, 1914 (30th ed. 2003). As such, tinnitus is “subjective,” as its existence is generally determined by whether or not the Veteran claims to experience it. For VA purposes, tinnitus has been specifically found to be a disorder with symptoms that can be identified through lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002). Importantly, if a veteran reports ringing in his or her ears, then a diagnosis of tinnitus is generally applied without further examination. In this instance, the Veteran reported the onset of tinnitus in 2005. See January 2014 VA examination. The Veteran explained that his ears started ringing a whole lot in 2005. The Veteran reported exposure to military noise and added that he believed his tinnitus caused his migraine headaches. However, the audiologist opined that the Veteran’s tinnitus was less likely than not caused by or a result of military noise exposure. The examiner reasoned that due to the date of onset and lack of evidence showing acoustic trauma in service, it is considered less likely than not that his tinnitus was caused by or a result of military service. The audiologist explained that the Veteran served as a cook from 2001 to 2004, but reported his tinnitus first began in 2005. She stated that tinnitus is not known to have a delayed onset. Furthermore, the Veteran had normal hearing sensitivity in both ears. The Board notes that the Veteran is competent to report that he first experienced symptoms of tinnitus within a year of discharge from service and that the symptoms have continued since that time, as tinnitus is a condition that is subjective and capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002) (finding lay person competent to attest to in-service acoustic trauma, in-service symptoms of tinnitus, and post-service continuous symptoms of tinnitus “because ringing in the ears is capable of lay observation”). Although the audiologist opined that it was less likely than not that the Veteran’s tinnitus was related to noise exposure in service, the Board finds the Veteran’s report of tinnitus occurring within a year of discharge from service to be sufficiently credible to support the claim. As tinnitus is a purely subjective disability, the Board finds the evidence is at least in relative equipoise as to whether the current tinnitus arose in service. Accordingly, resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral tinnitus is warranted. 38 U.S.C. § 5107 (b). 4. Entitlement to service connection for fatigue, sleep disturbances, upper respiratory disorder, allergic rhinitis and generalized joint pain, to include as due to an undiagnosed illness Here, the Veteran contends that he has fatigue condition, sleep disturbances, upper respiratory disorder, allergic rhinitis and generalized joint pain that was incurred during service or due to an undiagnosed illness. Based on the evidence, the Board disagrees. At the outset, the Veteran has not been diagnosed with a fatigue condition, a sleep disorder, an upper respiratory disorder, or generalized joint pain. Specifically, in the March 2013 VA examination, the examiner indicated that the Veteran’s claim of fatigue was a symptom of his service-connected beta thalassemia minor, an inherited condition with resultant microcytic anemia. As it pertains to his claim for sleep disturbances, there was no diagnosis of a sleep disorder. In fact, in the November 2017 hearing, the Veteran testified that his back and feet pain affected his ability to sleep. He explained that he did not have an inability or problem sleeping before he suffered from back and feet problems. Moreover, in VA treatment records, the Veteran related trouble sleeping to his pain. Similarly, the Veteran has not been diagnosed with an upper respiratory disorder. In the March 2013 VA examination, the examiner indicated that the Veteran did not have nor ever had a respiratory condition. The examiner explained that the Veteran had exertional shortness of breath since childhood, along with seasonal allergies. In fact, chest x-rays from March 2013, showed no acute cardiac or pulmonary abnormality. Likewise, pulmonary function tests did not reveal any abnormalities. Additionally, as it pertains to generalized joint or muscle pain, there was no diagnosis of a condition. The Veteran reported mild thoracic pain, but x-rays indicated scoliosis. Moreover, the Veteran is service-connected for a lumbar spine disorder. Based on the examination, the examiner indicated that the Veteran did not suffer from generalized muscle or joint pain. The Board notes that where the evidence does not support a finding of a current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Additionally, even under the Gulf War presumption, the Veteran must exhibit objection indications of a qualifying chronic disability to warrant entitlement; however, in this instance, there is no objective evidence of a chronic disability that is part of chronic multi-symptom illness or an undiagnosed illness. Lastly, in regard to the Veteran’s claim for allergic rhinitis, the March 2013 examination showed that the Veteran did have allergic rhinitis and acute sinusitis. He complained of nasal congestion, rhinorrhea, sneezing, rare postnasal drainage and itchy eyes. He reported occasional acute sinus infections which needed treatment with antibiotics. The examiner explained that a CT scan for headaches indicated acute sinusitis in 2012. Thus, the first element of service connection is met. However, based on the Veteran’s own report, he had allergies prior to joining military service and there was no indication of worsening. The Veteran’s STRs were silent for any complaints of or treatment for allergic rhinitis. The Veteran did receive treatment for strep throat in January 2003, but it resolved. In fact, in his December 2003 post-deployment questionnaire, he denied difficulty breathing, chronic cough, runny nose, redness of eyes or fever. Given the foregoing, the Veteran’s allergic rhinitis was not incurred or aggravated during military service. Accordingly, as the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application and the claims must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 5. Entitlement to service connection for Gulf War syndrome As discussed above, the Veteran does not have any objective indications of a chronic disability that would be a sign of Gulf War syndrome. The Veteran’s complaints of fatigue, a skin disorder, sleep disturbances, upper respiratory disorder, allergic rhinitis and generalized joint pain have not been shown to be part of an undiagnosed illness or medically unexplained chronic multi-symptom illness. Specifically, in the March 2013 VA examination, the examiner remarked that the Veteran’s tension headaches were related his PTSD with insomnia and nightmares, with a known etiology and diagnosis. The Veteran’s allergic rhinosinusitis was a condition prior to join military service, as reported by the Veteran. The examiner continued that the Veteran reported exertional shortness of breath prior to joint the military. His younger brother has severe asthma and mother had severe allergies. The Veteran reported playing basketball in high school which needed only short bursts of activity. Likewise, he had problem with endurance prior to joining the military, and stated that he had difficulty completing basic training. The examiner explained that the Veteran can run a mile comfortably but reported fatigue with the second mile. The examiner stated that he had exercised induced asthma that was mild and intermittent, but predated military service. In regard to muscle pains, the examiner stated that the Veteran complained of mid thoracic pain, but no complaints of generalized muscle or joint pains. Likewise, x-rays indicated scoliosis, which is a diagnosable condition with known etiology. Regarding his skin condition, the Veteran had pseudofolliculitis barbae (PFB) in his beard area, which has a known etiology and not related to service. The examiner added that there were no other chronic multi-system illnesses with unknown, partially known or undiagnosable illnesses identified after the examination. The Board finds the examiner’s remarks to be competent, credible, and highly probative. The examiner reviewed the pertinent evidence, examined the Veteran, accounted for his lay statements, and provided an opinion based on medical principles. Moreover, although the Board acknowledges the Veteran’s contentions, he does not possess the medical training or expertise to determine whether he has Gulf War syndrome. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 6. Entitlement to service connection for arthritis of the feet and hands Here, the Veteran contends that he has arthritis of his hands and feet that were incurred in or a result of military service. Based on the evidence, the Board disagrees. At the outset, the Veteran has a current diagnosis of osteoarthritis of his hands and feet. See VA treatment records. Thus, the first element of service connection is met. However, the second element is not met. Specifically, the Veteran’s STRs are silent for any complaints of, treatment for, or a diagnosis of arthritis of the hands and feet. The Veteran has numerous complaints regarding callouses on his feet, hammertoes and pes planus, but there was no indication of arthritis. The Board notes that the Veteran marked yes to numbness or tingling in hands or feet in his post-deployment questionnaire, but this related to his feet as he was referred to podiatry for an evaluation. Moreover, the Veteran was not diagnosed with osteoarthritis in his hands and feet for more than a decade after discharge from service. As such, the Veteran is not entitled to the presumption as his arthritis did not manifest to a compensable degree within a year of discharge from service. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2019). 1. Entitlement to service connection for bilateral knee tendonitis, to include as due to an undiagnosed illness is remanded. Here, the Veteran contends that his bilateral knee tendonitis was incurred or caused by military service. Based on the evidence, a remand is necessary. Specifically, the Veteran reported that he had bilateral knee tendonitis. To support his claim, VA treatment records showed the Veteran had a past medical history of bilateral knee tendonitis. See also VA treatment records. Additionally, the Veteran testified that he was told he had tendonitis in his knees during service. Treatment records from August 2005 showed the Veteran had a history of bilateral knee pain and knee tendonitis. However, a subsequent VA examination from October 2005 showed the Veteran had normal knees bilaterally. As there is conflicting evidence regarding whether the Veteran has bilateral knee tendonitis, a remand is necessary to determine whether the Veteran has a current bilateral knee condition and if so, whether the condition was incurred or a result of active duty service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for a bilateral ankle disorder, to include as due to an undiagnosed illness is remanded. Similarly, the Veteran contends that he has a bilateral ankle disorder that was incurred or a result of active duty service. Again, VA treatment records from August 2005 showed the Veteran had a history of bilateral swelling ankles during exertion. Moreover, recent treatment records show that the Veteran has bilateral ankle problems. However, in an October 2005 VA examination, the examiner indicated that the Veteran had a left ankle sprain but normal right ankle. Additionally, the Veteran testified that he was prescribed ankle braces. The Board notes that current treatment records do not provide a clear diagnosis of a bilateral ankle disorder. As delineated in 38 C.F.R. § 3.159 (c)(4), a VA examination to address the question of etiology as related to service is required when the Veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, on remand, the Veteran should be afforded a VA examination to determine the etiology of the any diagnosed bilateral ankle condition. 3. Entitlement to service connection for a skin disorder involving the face and neck, to include as due to an undiagnosed illness is remanded. Here, the Veteran contends that he has a skin disorder to was incurred or a result of active duty service. The Board notes that there are various medical records that show the Veteran had diagnoses of pseudofolliculitis barbae, folliculitis, and seborrheic dermatitis of the scalp. These records span from 2005 to present. As delineated in 38 C.F.R. § 3.159 (c)(4), a VA examination to address the question of etiology as related to service is required when the Veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, on remand, the Veteran should be afforded a VA examination to determine the etiology of the Veteran’s skin condition. 4. Entitlement to service connection for a bilateral shoulder disorder Here, the Veteran contends that he has a bilateral shoulder disorder that was incurred during active duty service. Based on the evidence, a remand is necessary. Specifically, the Veteran testified that he dealt with rotator cuff injuries to his bilateral shoulders during military service. Current VA treatment records show that the Veteran has bilateral shoulder pain, but there is no diagnosis of a condition. Moreover, the Veteran’s STRs showed that in November 2003, he complained of shoulder pain and was diagnosed with a rotator cuff injury. Given the foregoing, an etiology opinion is warranted. As delineated in 38 C.F.R. § 3.159 (c)(4), a VA examination to address the question of etiology as related to service is required when the Veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the Veteran should be afforded a VA examination to determine the etiology of any diagnosed bilateral shoulder condition. 5. Entitlement to a compensable disability rating for Beta Thalassemia Minor Here, the Veteran contends that his service-connected beta thalassemia minor warrants a compensable rating. Based on the evidence, a remand is necessary. Specifically, the Veteran was last afforded a VA examination more than a decade ago. Generally, a stale examination is not enough to require a remand for a new examination; however, the Veteran reported that he was concerned with his fatigue and blood and reported very severe fatigue and energy loss. See 2017 VA treatment records. VA’s duty to assist includes providing a new medical examination when a veteran assert’s or provides evidence that a disability has worsened, and the available evidence is too old for an adequate evaluation of the current condition. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that VA should have ordered a contemporaneous examination of veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). Accordingly, a more contemporaneous VA examination is required to provide a current picture of the Veteran’s BTM. 38 C.F.R. §§ 3.326, 3.327 (2019). 6. Entitlement to a disability rating in excess of 10 percent for lumbar spine degenerative disc disease (DDD) is remanded. Similarly, the Veteran was last afforded a VA examination for his lumbar spine in September 2013. As explained above, a stale examination is not enough to require a remand for a new examination; however, the Veteran testified that his lumbar spine pain had worsened. He described it as excruciating pain without relief. See Hearing testimony. As such, a more contemporaneous VA examination is required to provide a current picture of the Veteran’s lumbar spine disability. 38 C.F.R. §§ 3.326, 3.327 (2019). 7. Entitlement to a disability rating in excess of 30 percent for bilateral pes planus is remanded. Likewise, the Veteran was last afforded a VA examination for his pes planus in September 2013. He testified in November 2017 that his feet, along with his back caused excruciating pain. He explained that he has problems walking because of his pes planus. Given the Veteran’s testimony, a more contemporaneous VA examination is required to provide a current picture of the Veteran’s bilateral pes planus. 38 C.F.R. §§ 3.326, 3.327 (2019). 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Here, the claim for entitlement to a TDIU is inextricably intertwined with the issues being remanded above. Therefore, a final decision on the issue of entitlement to a TDIU cannot be rendered now. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records, and any private treatment records identified by the Veteran. All records and/or responses received should be associated with the claims file. 2. After all outstanding treatment records have been associated with the claims file, schedule the Veteran for VA examinations to determine the current severity of his (a) lumbar spine; (b) beta thalassemia minor; and (c) bilateral pes planus. The VA examiner must review the complete claims file and must note that review in the report. 3. Additionally, schedule the Veteran for VA examinations to determine the etiology of his: (a) bilateral knee disability, if diagnosed; (b) bilateral ankle disability; (c) bilateral shoulder disability; and (d) skin disorder. A copy of this REMAND must also be provided to the VA examiner. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. The VA examiner should address the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s bilateral knee disability, if diagnosed, had its onset during service or is otherwise causally related to any event or circumstance of the Veteran’s service. (b.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s bilateral ankle disability, if diagnosed, had its onset during service or is otherwise causally related to any event or circumstance of the Veteran’s service. (c.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s bilateral shoulder disability had its onset during service or is otherwise causally related to any event or circumstance of the Veteran’s service. (d.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s skin disorder had its onset during service or is otherwise causally related to any event or circumstance of the Veteran’s service. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. 4. The examiner should cite to the pertinent medical and competent lay evidence of record and explain the rationale for all opinions given. If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated, and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation. 5. After undertaking any additional development deemed necessary, the AOJ must readjudicate the claims on appeal, including the inextricably intertwined claim. If any claim remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and afforded the requisite opportunity to respond before the case is returned to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Umo, 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.