Citation Nr: 21004318 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 15-35 529 DATE: January 26, 2021 ORDER Service connection for back disability is denied. Service connection for gastroesophageal reflux disease (GERD) is granted. Service connection for headaches is granted. REMANDED Entitlement to service connection for carpal tunnel syndrome, claimed as numbness of the hands, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a back disability that began during a period of active duty or that he had a back injury during a period of active duty service; or that he incurred a back injury or aggravated a back disability during active duty for training or inactive duty for training while with the National Guard or Reserves. 2. The Veteran’s GERD began during his full-time (State) Active Guard/Reserve (AGR) status. 3. The Veteran’s headaches were shown as chronic in AGR status and are not attributable to intercurrent causes. CONCLUSIONS OF LAW 1. The criteria for service connection for back disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for service connection for GERD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for headaches are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Alabama (State) National Guard from May 1984 to July 2005. He had Federal active duty from July 1985 to August 1985 and November 1990 to September 1991 to include service in Saudi Arabia from January 1991 to August 1991. He had full-time (State) Active Guard/Reserve (AGR) status from September 1985 to September 1986 and September 1988 to July 2005. This duty was authorized under 32 U.S.C. § 502(f) and is considered as “active duty for training” (ACDUTRA) for the VA compensation purposes. See 38 C.F.R. § 3.6(c)(3) (defining full-time duty performed by members of the National Guard of any State under 32 U.S.C. § 502 as “active duty for training”). Based on the Veteran’s active duty service in Saudi Arabia, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a November 2018 Board hearing before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In March 2019, the Board remanded the appeal for additional development. Except as addressed in the remand below, the Board finds that there has been substantial compliance with the Board’s prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Dyment v. West, 13 Vet. App. 141 (1999). Service Connection Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. “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 1363, 1366 (Fed. Cir. 2009). Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term MUCMI refers to 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. 38 C.F.R. § 3.317(a)(2)(ii). A multisymptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is “medically unexplained,” that is, the etiology and pathophysiology of the multisymptom illness, must be particular to the claimant’s case. Id. at 291. The laws governing members of a State’s Reserve or National Guard require some explanation. Title 32 activation of National Guard personnel creates entitlement to federal pay and benefits "as though they were in federal service" 38 U.S.C. § 502(f); see CRS: Report of Congress, Operation Noble Eagle, Enduring Freedom, and Iraqi Freedom: Questions and Answers About U.S. Personnel, Compensation, and Force Structure (updated February 16, 2005), p. 3. However, the benefits do not extend to Title 38 Veterans’ Benefits. Under the law, a member of the National Guard only serves in the Federal military when the member is formally called into the military service of the United States. Under 38 C.F.R. § 3.6 (c), (d), to have basic eligibility as a veteran based on a period of duty as a member of a State Army National Guard, a National Guardsman must have been ordered into Federal service under 32 U.S.C. §§ 316, 502, 503, 504 or 505. See Clark v. United States, 322 F.3d 1358, 1366 (Fed. Cir. 2003). National Guard duty is distinguishable from other Reserve service in that a member of the National Guard may be called to duty by the governor of their state. Members of the National Guard only serve the federal military when they are formally called into the military service of the United States; at all other times, National Guard members serve solely as members of the State militia under the command of a state governor. Allen v. Nicholson, 21 Vet. App. 54, 57 (2007). Therefore, to have basic eligibility for Veterans benefits based on a period of duty as a member of a state National Guard, a National Guardsman must have been ordered into Federal service by the President of the United States, see 10 U.S.C. § 12401, or must have performed “full-time duty” under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505. Id. In this case, the Veteran was ordered to Federal active duty from July 1985 to August 1985 and November 1990 to September 1991; also, he performed “full-time duty” for the State National Guard under section 502 of the United States Code from September 1985 to September 1986 and September 1988 to July 2005. Reserve and National Guard service generally means active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6(c). That usually includes two weeks of annual training and/or an initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (23); 38 C.F.R. § 3.6(d). With respect to National Guard service, service connection may only be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C. §§ 101 (24), 106, 1110, 38 C.F.R. §§ 3.6, 3.303, 3.304. Service connection is generally not legally merited when a disability incurred on INACDUTRA results from a disease process. See Brooks v. Brown, 5 Vet. App. 484, 487 (1993). The evidentiary presumptions-such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases that manifest to a degree of 10 percent or more within a specified time after separation from service-do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995); McManaway v. West, 13 Vet. App. 60, 67 (citing Paulson, 7 Vet. App. at 469-70, for the proposition that, “if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim.”). Here, the Veteran had full-time (State) National Guard Duty in AGR status under 32 U.S.C. § 502(f). Full-time National Guard duty performed pursuant to orders issued under Title 32, United States Code, is specifically excluded from the definition of “active duty.” 38 C.F.R. § 21.9505; see 38 U.S.C. §§ 101 (21),(22)(C) (likewise defining “active duty” to exclude full-time duty in the National Guard under 32 U.S.C. § 502); 38 C.F.R. § 3.6(c)(3) (defining full-time duty performed by members of the National Guard of any State under 32 U.S.C. § 502 as “active duty for training”). 1. Entitlement to service connection for a back disability The Veteran contends that his back disability began in service. See NOD (July 2014). He testified that back pain had onset in 1987 or 1988 with limited range of motion after physical training (PT) and has continued since service. See Hearing Transcript (November 2018). The Board notes that the Veteran did not serve on active duty in either 1987 or 1988 when he reports onset of back pain. Rather, he served in the Alabama National Guard from May 1984 to July 2005, with full time AGR status from September 1985 to September 1986 and September 1988 to July 2005. The Board concludes that, while the Veteran has been diagnosed with lumbosacral strain, the preponderance of the evidence weighs against finding that the Veteran’s back disability began during active service including ACDUTRA/INACDTURA or is otherwise related to an injury incurred during a period of active service or ACDUTRA/INACDUTRA. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303. Neither a back injury nor the claimed disability is shown during either period of active duty service; and the preponderance of the evidence is against finding that the Veteran sustained a back injury during ACDUTRA/INADUTRA with continuity of symptoms or related current back disability. Further, the Board concludes that the criteria for service connection under 38 C.F.R. § 3.317 are not met. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. It is noted that the Veteran is a Persian Gulf War veteran and, therefore, the Board has considered the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 even though the Veteran has not argued entitlement under these provisions. See Stewart v. Wilkie, 30 Vet. App. 383, 390 (2018) (holding that, in adjudicating claims for service connection for Veteran’s with service in Southwest Asia, the provisions regarding undiagnosed illness in 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 need to be considered). In this case, the evidence of record reflects that the Veteran’s back disability, diagnosed as lumbar strain, is neither an undiagnosed illness nor a MUCMI based on a November 2019 VA medical opinion. The November 2019 VA medical opinion reflects that lumbar strain is a “condition/ diagnosis with a clear and specific etiology and diagnosis . . . caused by mechanical stresses.” See C&P Exam (February 2020). The Veteran’s back disability is not an undiagnosed illness because it has a diagnosis, and it is not a MUCMI because both the etiology and pathophysiology of the condition are at least partially understood. Thus, presumptive service connection for lumbar strain under § 3.317 is not warranted. The remaining question is whether the Veteran’s current disability had its onset during active duty service or is related to injury incurred during ACDUTRA/INACDUTRA. Here, service treatment records (STRs) for the Veteran’s period of active duty from July 1985 to August 1985 reflect no complaints of or treatment for low back pain or findings for abnormal back pathology. A July 1985 separation examination reflects normal clinically evaluation of the spine. A July 1985 report of medical history completed by the Veteran reflects that he denied a history of having or ever having had swollen or painful joints, arthritis, and recurrent back pain. See STR (August 2005). National Guard medical records include an October 1989 report of medical examination, which reflects normal clinical evaluation of the spine and the Veteran’s denial of any history of recurrent back pain along with swollen or painful joints, or arthritis, on the associated report of medical history. It was noted that he was a supply sergeant. At this time, the Veteran denied having ever had any illness or injury other than those already noted. STRs associated with the Veteran’s second period of active duty from November 1990 to September 1991 includes an April 1991 “Release From Active Duty” (RFAD) examination report showing a history of recurrent back pain, described as “history of pain in lower back, no problems in last 6-8 months.” Essentially, the history provided by the Veteran placed the onset of back symptoms prior to his entry onto active duty in November 1990. The associated report of medical examination reflects abnormal clinical evaluation of the spine, but then described the abnormality which was characterized as “pectus excavatum (mild),” which involves the chest, not spine. It is noted that the Veteran’s history does not include report of any back injury during his State full-time AGR duty and National Guard records reflect no documented complaints for the back in the August through October 1990 timeframe, which is the period when the Veteran reported he had had back pain. National Guard records include an August 1991 Southwest Asia Demobilization/ Redeployment Medical Evaluation, which reflects that the Veteran reported he had had no diseases or injuries while in the Southwest Asia region. National Guard medical records contain no reports indicating an injury occurred in the line of duty. Indeed, October 1989, February 1994, March 1998, and January 2003 examinations reflect clinically normal spine with no musculoskeletal defect; and the accompanying medical histories shows that Veteran denied recurrent back pain. See STR (August 2005). A June 2001 treatment record shows the Veteran reported occasional sharp lower back pain off and on for 5 years (i.e. 1986) which had flared as a result of yard clean up; the assessment was musculoskeletal back pain. There was no indication of back injury in line of duty. A December 2002 treatment record reflects complaints of low back pain; the Veteran denied any trauma; he reported onset of symptoms after a fall 14 years earlier (i.e. 1988). An October 2004 treatment record shows that the Veteran complained of low back pain of 2 weeks duration that had onset with “moving office furniture” and treated with Aleve; the diagnosis was gluteus maximums and gluteus minimus strain. It was noted that there was full range of motion of the low back and mild tenderness of the gluteus maximus and minimus. He was treated with Naproxen and Methocarbamol. A March 2005 Report of Medical Assessment for retirement from the National Guard reflects a history of “Recurrent backpain or any back problem,” which was explained as “low back pains.” It was noted that his position was recruiter for Army (State) National Guard. VA received the Veteran’s claim for service connection for a back condition in January 2014. The record contains no relevant treatment record pertaining the Veteran’s back symptoms intervening his retirement from the State National Guard/Reserves. Private treatment records (Dr. V.) dated between February 2017 and March 2018 were submitted by the Veteran to support the appeal. These reflect that he presented to establish care in February 2017. At that time, he had no back complaints when otherwise reporting his chief complaints. No abnormal pathology of the spine was found on review of systems and the musculoskeletal exam showed normal range of motion. In November 2018, the Veteran testified that he had had no recent treatment for back symptoms, but that he had had ongoing symptoms since leaving the State National Guard/Reserves. See Hearing Transcript (November 2018). It is noted that, at the hearing, the Veteran’s attorney questioned the Veteran as to his back symptoms during his “20-plus years of service” and did not distinguish between his periods of Federal active duty status and his ACDUTRA status as a full-time active (State) National Guardsman. The Veteran did not identify any discrete back injury during his hearing testimony; rather, he vaguely reported having had limited range of motion “especially following PT-type exercises or road marches.” Id. at 4. A November 2019 VA examination noted review of the claims file, delineated periods of active duty service from National Guard service and diagnosed lumbosacral strain. See C&P Exam (February 2020). At this examination, the Veteran reported that the condition began in 1990 with an injury during physical training (PT) and loading and unloading military supplies. The Veteran reported back pain with minimal care since service. The VA examiner indicated that lumbar strain has a clear and specific etiology and diagnosis and is caused by mechanical stresses. Finding no evidence that the Veteran’s low back pain began during either period of active duty service, the examiner opined it was less likely low back pain was incurred in or caused by military service. After careful review of the evidence, the Board finds that the evidence shows that the Veteran’s back condition did not have its onset during a period of active duty. In other words, the evidence does not show that it began in the first period of active duty (July 1985 to August 1985) or the second period of active duty (November 1990 to September 1991). In this regard, the Veteran testified that his back condition began in either 1987 or 1988, which is outside his periods of active duty. Likewise, at his 2019 VA examination, the Veteran reported that his symptoms began in 1990, which is also outside his periods of active duty. An April 1991 STR (release from active duty), while showing a history of recurrent back pain, reflects that the onset was prior to his entry onto active duty in November 1990. Also, the Board finds that the Veteran did not incur or aggravate a back injury while performing ACDUTRA or INACDUTRA. While the Veteran is competent to report the onset of symptoms and the circumstances surrounding the onset of those symptoms, the Board finds that, to the extent he reports injury to the back during his State National Guard/Reserve ACDUTRA or INACDUTRA, this is not credible for the following reasons. First, the Veteran’s State National Guard/Reserve records, while including treatment notes showing back complaints, do not include any line of duty determination showing incurrence of an injury during a period of ACDUTRA or INACDUTRA. Second, the Veteran is an inconsistent historian as to the date of onset of his back symptoms. In this regard, a June 2001 NGR treatment record shows that the Veteran reported onset of back symptoms was in 1986. A December 2002 NGR treatment record reflects that he reported onset of back symptoms in 1988. He reported at his 2018 Board hearing the onset of symptoms in 1987 or 1988. Lastly, and most recently, he reported at his 2019 VA examination onset of symptoms in 1990. Third, the Veteran has been an inconsistent historian as to whether he sustained an injury to the back during his State National Guard/Reserve service. In this regard, a December 2002 NGR treatment record reflects that his back symptoms began after a fall in 1988—there was no indication that this was in the line of duty. At his 2018 Board hearing, he testified vaguely that symptoms were related to PT-type exercises or road marches, making no reference to any injury to the back during PT, or to any injury during a period of active duty or ACDUTRA/INACDUTRA. Also, at his 2019 VA examination, the Veteran reported that his back condition began after an injury during PT and loading and unloading military supplies. Fourth, the Veteran’s shifting history of back injury with ongoing symptoms is incongruous with his STRs and State ANG records, which reflect that he denied a history of recurrent back pain and/or injury on medical histories obtained in July 1985, October 1989, February 1994, March 1998, and January 1993. Notably, ANG treatment records document the Veteran’s report of occasional sharp lower back pain off and on for five years which had flared as a result of yard clean up in June 2001 and his report of low back pain in 2002 which had begun with a fall 14 years earlier (i.e. 1988) and did not result from a recent trauma. Therefore, his statements as to incurrence of back injury and onset of back symptoms have significantly diminished probative value. Neither the history as reported by the Veteran, nor the documented history, complaints, and treatment support a finding that the Veteran’s current back disability began during a period of active duty or that it was incurred or aggravated during a period of ACDUTRA or INACDUTRA. As there is no competent, credible evidence of an injury during active duty, a medical opinion addressing nexus is not required. Similarly, as there is no competent, credible evidence of a back injury incurred during line of duty while on ACDUTRA or INACDUTRA, a medical opinion addressing nexus is not required. See McLendon v. Nicholson, 20 Vet. App. 70 (2006); Waters v. Shinseki, 601 F.3d 1274, 1276 (2010). The Board acknowledges that a VA examination with a medical opinion was obtained in this matter and that the Veteran’s attorney argues in a July 2020 letter that it is inadequate. However, the Board assigns the opinion itself no probative value because, at this juncture in the appeal, the Board has made a credibility determination and found the Veteran not credible as to onset of his condition during a period of active duty or as having been incurred during a period of ACDUTRA or INACDUTRA, as explained above. The attorney argues that the November 2019 examinations/opinions do not provide sufficient detail or analysis to support the conclusions reached (e.g. that the claimed disabilities did not have their onset in service). However, whether the Veteran sustained an injury to the back during a period of ACDUTRA/INADUTRA is a question of fact and the Board is the finder of fact. Hence, as there is no outstanding medical question to resolve and the Board does not rely on the negative medical opinion, remand for a new medical opinion is not warranted. In the absence of competent, credible evidence of injury during either active duty or during a period of ACDTURA/INACDUTRA as discussed above, remand for another medical opinion would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran). It is noted that the Veteran and his attorney appear to have conflated the Veteran’s full-time State active military duty with the National Guard/Reserves with Federal active duty service. The Board has addressed this in detail above. It is well-established that persons in the Reserves or National Guard are not full-time active duty military personnel. The Board assigns greater probative value to STRs and NGR records, which show no abnormal pathology of the spine during both periods of active duty, and show no back injury during a period of ACDUTRA/INACDUTRA (e.g. a July 1985 normal clinical evaluation of the spine with the Veteran’s denial of back symptoms at that time; April 1991 RFAD examination report showing “history of pain in lower back, no problems in last 6-8 months.”). See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). On balance, the weight of the evidence is against the claim. Accordingly, the claims are denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). 2. Entitlement to service connection for GERD The Veteran seeks service connection for GERD which he testified began in service and was noted. See Hearing Testimony (November 2018). It is noted that the Veteran is a Persian Gulf War veteran and, therefore, the Board has considered the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 even though the Veteran has not argued entitlement under these provisions. See Stewart, supra. In this case, a November 2019 VA examination shows the Veteran has a diagnosis of GERD. As the Veteran’s GERD is a diagnosed condition, it cannot be considered an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii). Moreover, GERD is a structural gastrointestinal disorder and therefore not considered a MUCMI. 38 C.F.R. § 3.317(a)(2)(i)(B)(3); 76 Fed. Reg. 41,696 (Jul. 15, 2011); see Atencio v. O’Rourke, 30 Vet. App. 74, 83 (2018). Thus, presumptive service connection for GERD under § 3.317 is not warranted. The questions remaining for the Board are (1) whether GERD began during active service or is otherwise related to an in-service injury or disease; and (2) whether diagnosed GERD resulted from disease or injury incurred or aggravated while the Veteran performed ACDUTRA. The Board concludes that the Veteran has GERD that began during ACDUTRA. 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). November 2019 VA medical examination shows the Veteran has a current diagnosis of GERD characterized by symptoms of pyrosis (heartburn). See C&P Exam (February 2020). During ACDUTRA, the Veteran reported frequent indigestion of heartburn on January 2003 and March 2005 medical histories associated with NG and ANG retirement examinations. STR (August 2005, January 2014). Thus, the question becomes whether the current disability is related to service. The Veteran testified that reflux symptoms had persisted since service and flared once every four to five months depending on food type. See Hearing Transcript (November 2018). A November 2019 VA medical opinion noted the Veteran reported frequent indigestion and heartburn in January 2003 and March 2005. See C&P Exam (February 2020). The Board notes the Veteran was on AGR status at this time. Additionally, his symptoms of heartburn during AGR status are the same as his symptoms as reported on VA examination. Therefore, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current GERD arose in ACDUTRA. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for GERD is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for headaches The Veteran asserts that headaches began in service. He testified that headaches began in 1996 or 1997 while recruiting. See Hearing Transcript (November 2018). He took a trip to the emergency room for facial numbness and was diagnosed with a “cluster migraine.” Id. He reported that headaches had continued since. It is noted that the Veteran is a Persian Gulf War veteran and, therefore, the Board has considered the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 even though the Veteran has not argued entitlement under these provisions. See Stewart, supra. A November 2019 VA medical opinion found that, while the specific cause of headaches is unknown, in this case headache is a “condition/ diagnosis with a clear and specific etiology and diagnosis... medical records note it to be attributable to be stress.” See C&P Exam (February 2020). As emotional triggers can trigger a migraine, the examiner found the Veteran’s headaches were not attributable to an undiagnosed illness or MUCMI. Thus, presumptive service connection for headaches under § 3.317 is not warranted. The remaining question for the Board is whether it is as likely as not that the Veteran’s headaches manifested to a compensable degree in service or within the applicable presumptive period or is at least as likely as not related to an in-service injury or disease. The Board concludes that the Veteran’s migraine headaches began during ACDUTRA. 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). Headaches are first shown in the record in July 1997. The Veteran reported to the emergency room reporting numbness to the left side of his face for two days and “years of episodes like cluster migraines.” See STR (August 2005). On a September 2002 Initial Medical Review – Annual Medical Certificate, the Veteran reported migraine headaches since his last periodic physical examination. The Veteran reported a history of frequent and severe, stress related headaches since 1997 on a January 2003 periodic examination and frequent headaches 1 to 2 times per week on his March 2005 National Guard separation examination. Thus, the question becomes whether the current disability is related to service. The Veteran testified that migraines have persisted since 1997 and occur once per month. See Hearing Transcript (November 2018). A November 2019 VA medical opinion documented the Veteran’s report of onset of headaches in 1997 with sudden onset of pain on the side of head and face with numbness on the left side of face. See C&P Exam (February 2020). The Veteran reported no evaluation, tests, or treatments since. The examiner found no evidence the Veteran’s headaches were incurred in or caused by military service during the stated periods of active duty. However, the Board observes that the Veteran was on AGR status serving as a recruiter at the time of his 1997 emergency room visit. Therefore, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current headaches arose during his ACDUTRA. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. Entitlement to service connection for carpal tunnel syndrome is remanded. The issue of entitlement to service connection is remanded to correct a duty to assist error that occurred subsequent to the March 2019 Board Remand. The RO obtained a November 2019 examination report. However, this examination report is unclear regarding whether the Veteran’s carpal tunnel syndrome had onset during active duty service. July 1985 and April 1991 service separation examinations reflect normal clinical evaluation of all systems. October 1989, February 1994, and March 1998 National Guard examinations were clinically normal; and the Veteran denied swollen or painful joints and neuritis. The Veteran denied numbness or tingling and impaired use of the arms on examination in January 2003. On separation from the National Guard in March 2005, the Veteran reported bilateral hand numbness and tingling and was diagnosed with carpal tunnel syndrome. On examination, the Veteran reported that numbness and tingling of the arms and fingers began in 2001. See C&P Exam (February 2020). The November 2019 medical opinion reflects “[i]t is at least as likely as not that Veterans numbness tinging (sic) symptoms in-service were carpel tunnel, and it is also at least as likely as not that the carpal tunnel syndrome had its onset in-service.” However, noting that the only active duty periods to be considered in the case are from July 1985 to August 1985 and November 1990 to September 1991, the opinion also reflects that it is less likely than not the Veteran’s present symptoms of carpal tunnel syndrome and/or claimed numbness/tingling of arm, fingers was incurred in or caused by military service during the stated periods of active duty. The Board is unable to determine whether the Veteran’s carpal tunnel syndrome had onset during active duty service as the definition of “service” is not clear in the provided opinion in this matter. Accordingly, the matters are REMANDED for the following action: 1. Obtain an addendum opinion, supported by a complete rationale, from an appropriate clinician regarding the nature and etiology of the Veteran’s carpal tunnel syndrome. The medical opinion should detail the Veteran’s symptoms, onset, progression and treatment, if any, reflecting consideration of the Veteran’s service treatment records, National Guard medical records, post service medical records and history, lay statements, and the November 2019 private medical opinion. Address the following: (a.) Whether it is at least as likely as not that the Veteran’s carpal tunnel syndrome had its onset during active service or within one year after his discharge from a period of active service. (b.) Whether the Veteran’s carpal tunnel syndrome is at least as likely as not related to in-service injury or disease. (c.) Whether the Veteran’s carpal tunnel syndrome resulted from disease or injury incurred or aggravated while performing ACDUTRA. (d.) In forming an opinion, the examiner should clearly delineate periods of active service from Active Guard/Reserve service considering the following: i. The Veteran’s active duty dates are July 1985 to August 1985 and November 1990 to September 1991. ii. Full time Active Guard/Reserve (AGR) status in the Alabama National Guard service is specifically excluded from the definition of “active duty” but qualifies as active duty for training (ACDUTRA). 38 C.F.R. § 3.6(c)(3), 21.9505. (e.) If the above medical opinions are negative, then indicate the most likely etiology the Veteran’s complaints and/or disorders found involving hand numbness to the extent feasible. 2. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C.E., 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.