Citation Nr: 21062556 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 17-37 971 DATE: October 8, 2021 ORDER New and material evidence having been received, the previously denied claim for service connection for a right knee disorder is reopened. Entitlement to service connection for a right knee disorder, diagnosed as patellofemoral pain syndrome and degenerative arthritis, is granted. Entitlement to service connection for a left knee disorder, diagnosed as residuals of meniscal tear, patellofemoral pain syndrome, and degenerative arthritis, is granted. REMANDED Entitlement to service connection for a cardiovascular disorder including hypertensive vascular disease and heart palpitations is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for joint and muscle pain in bilateral elbows is remanded. Entitlement to service connection for a sleep disorder is remanded. FINDINGS OF FACT 1. A February 1996 rating decision that denied the Veteran's claim to establish service connection for a right knee disorder was not appealed and became final. 2. Evidence received since the final February 1996 rating decision raises a reasonable possibility of substantiating the issue to establish service connection for right knee disorder, diagnosed patellofemoral pain syndrome, and degenerative arthritis. 3. The Veteran's right knee disorder, diagnosed as patellofemoral pain syndrome and degenerative arthritis, is related to his active service. 4. The Veteran's left knee disorder, diagnosed as residuals of meniscal tear, patellofemoral pain syndrome, and degenerative arthritis, is related to his active service. CONCLUSIONS OF LAW 1. The February 1996 rating decision that denied service connection for a right knee disorder is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. Evidence received since the February 1996 Board decision is new and material evidence sufficient to reopen the Veteran's claim for service connection for a right knee disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 3. The criteria for entitlement to service connection for a right knee disorder, diagnosed as patellofemoral pain syndrome and degenerative arthritis, are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for a left knee disorder, diagnosed as residuals of meniscal tear, patellofemoral pain syndrome, and degenerative arthritis, are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1984 to October 1995, including service in Southwest Asia from August 1990 to April 1991. He is a Veteran of the Gulf War era. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1996 rating decision, and a June 2016 rating decision, by a Department of Veterans Affairs (VA) Regional Office (RO), the agency of original jurisdiction (AOJ). In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the file. Whether New and Material Evidence has been Submitted to Reopen a Claim for Service Connection for a Right Knee Disorder Generally, a final decision issued by the Agency of Original Jurisdiction (AOJ) may not thereafter be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. §§ 7104, 7105(c), (d). The exception to this rule is found at 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim that has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence is evidence not previously received by agency decision makers. 38 C.F.R. § 3.156 (a). Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be either cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim. Id. For the purposes of reopening a claim, newly received evidence is generally presumed to be credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Even where the RO has reopened and adjudicated a claim on the merits, the Board must consider the question of whether new and material evidence has been received sufficient to reopen the previously denied claim without regard to the RO's decision. This is necessary to establish the Board's jurisdiction to address the underlying claim and to adjudicate the claim de novo. Jackson v. Principi, 265 F. 3d 1366, 1369 (Fed. Cir. 2001). The Veteran was previously denied service connection for a right knee disorder in a February 1996 rating decision, on the basis that although there was a record of treatment in service for patellofemoral syndrome, right knee, there were no symptoms of permanent residual or chronic disability subject to service connection. He did not appeal and that decision became final. Service treatment records showing right knee pain with patellofemoral syndrome were associated with the file in April 2015. The Veteran filed a new claim that was received on December 9, 2015 (and reopened by the AOJ and denied in a June 2016 rating decision). The Veteran submitted evidence including a private physician's statement dated December 2015 that "Given his relatively young age and 12 years history of Marine Corps service, it is as likely as not that [the Veteran's] prior military occupation is at least partly responsible for his degenerative joint disease." A VA medical opinion dated January 2016 was associated with the file. Other evidence submitted included statements from the Veteran dated January 2016 and January 2017. The Board finds that this evidence is "new" as it was not previously considered at the time of the February 1996 rating decision, and "material" as it raises the reasonable possibility of substantiating the Veteran's claim. The Board finds that new and material evidence has been submitted to reopen the issue of entitlement to service connection for a right knee disorder, now diagnosed as degenerative arthritis. The previously denied claim is reopened. Service Connection 1. Entitlement to service connection for a right knee disorder 2. Entitlement to service connection for a left knee disorder Service Connection In order to establish service connection for the claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including lay evidence, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). If a chronic disease, is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). Continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Analysis The Veteran has been diagnosed with patellofemoral pain syndrome, residuals of left knee meniscal tear, and arthritis. Service treatment records show that the Veteran was diagnosed and treated for patellofemoral syndrome of his right knee during service. In October 1993, he complained of right knee pain for three months. In December 1993, he was diagnosed with right knee patellar tendonitis. He described that he was running in July 1993 when he felt a "burn" in his right knee and the pain progressively worsened. He reported constant pain and aching that is aggravated by strengthening exercises. He denied experiencing locking or giving way. He was prescribed naproxen and underwent therapy. He was provided with a patellar sleeve brace. A March 1994 service treatment record notes the Veteran's reports of right knee pain for 8 months and failed conservative treatment. June 1994, October 1994, February 1995, and September 1995 service treatment records note patellofemoral syndrome treated with naproxen. The Veteran's separation examination in June 1995 notes patellar-femoral syndrome. The Veteran was afforded a VA examination in November 1995. The examiner noted a diagnosis of patellofemoral syndrome in 1991 or 1992. The Veteran reported that his right knee symptoms began while running during service in 1993. While running at two-mile mark, he experienced burning in right knee. He was treated with physical therapy knee brace, and naproxen. He continued to run 15 to 18 miles per week. The examiner indicated that the Veteran stated most of his symptoms are gone but he does have intermittent knee pain particularly in cold weather and occasional crepitus. A March 2015 private treatment record notes that the Veteran reported swelling and fluid retention of his right knee with no specific injury or cause. He was referred to an orthopedic surgeon who diagnosed patellofemoral syndrome. In December 2015, the Veteran's private physician noted progressive bilateral knee pain. The Veteran underwent meniscus repair of his left knee in 2014. He continued to complain of joint pain and stiffness affecting both knees. The physician indicated that the Veteran's symptoms are constant and appeared to be worsening; it was difficult to stand or walk for long periods of time. The Veteran reported that knee supports were not helpful. He wears orthotic inserts to help alleviate the pain. The physician stated that he suspects the Veteran has some degree of ostearthritis in both knee joints. He noted that the most common symptoms of osteoarthritis are pain and stiffness. The Veteran reported that he cannot run on hard surfaces and has a hard time getting in and out of his car. The physician stated that "Given his relatively young age and 12 years history of Marine Corps service, it is as likely as not that [the Veteran's] prior military occupation is at least partly responsible for his degenerative joint disease. It is a slowly debilitating and chronic condition that warrants further work-up by an orthopedics or rheumatologist." The Veteran was afforded a VA examination for knee and lower legs in January 2016. The examiner noted diagnoses of left knee meniscal tear in 2014 and patellofemoral pain syndrome, bilateral knees, in 1993. The date of onset of the symptoms was reported as 1993. The Veteran reported that right knee symptoms began during service in 1993, and left knee symptoms began in 2012. The examiner noted that both knees have gotten progressively worse. The flare-ups of the right knee were described as fluid, swelling, pain, popping, grinding, and loss of strength. The flare ups of the left knee can be described as fluid, swelling, pain, popping, grinding, and loss of strength. The Veteran described functional loss due to his knee disorder as being unable to run at this time. Range of motion (ROM) testing for the Veteran's right knee was noted as 0-120 degrees. No pain was noted on examination. ROM testing for the Veteran's left knee was noted as 0-120. No pain was noted on examination. Objective evidence of localized tenderness or pain on palpation of the joint was noted. Functional impact was noted as no running, jumping, climbing, or squatting. The examiner opined that the Veteran's bilateral knee disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that the Veteran had a well-documented strain injury to his right knee during his military service beginning in 1993 to 1994. The Veteran's service treatment records do not document any left knee condition. The Veteran's right knee pain was treated conservatively with physical therapy, NSAID's and soft brace. The condition resolved during military service, and was noted to be asymptomatic in 1995 on his exit exam in 1995. The Veteran has served as a police officer since his separation and has had a laparoscopic meniscectomy for his left knee in 2014. The examiner continued: "I would opine that all things considered that his resolved right knee strain in 1993 during his military service would be unlikely to have caused his left Meniscus injury in 2014. I would opine that his service in the Police Department would be more of an etiology for his current left Meniscus Tear, and his right knee pain, and not a result of his right knee strain in 1993." The Veteran submitted a statement in January 2016 that he first experienced joint pain in 1993 when he was diagnosed with patellofemoral syndrome in his right knee at a VA facility at Camp Pendleton. He stated that his right knee has progressively worsened to include pain, swelling, loss of motion, and loss of strength. He noted that he needed to get cortisone injections. He stated that he also has the same symptoms in his left knee, which required knee surgery in 2013. In May 2016 the Veteran was afforded a Gulf War examination. The examiner noted the Veteran's MOS as a bulk fuel man and that he was deployed to Saudi Arabia from August 1990 to April 1991. The Veteran reported that he was currently employed full time as a police officer. He denied any time lost in the prior 12 months. He reported joint pain including bilateral knee pain. He stated that he had cortisone shots and surgery on his left knee. He stated that his left knee pain began four years prior to the examination, and his right knee pain began three years prior. He stated that during service he was diagnosed with patellofemoral syndrome. He indicated that he has mild arthritis in his knees. The Veteran was afforded a VA examination for non-degenerative arthritis in May 2016. The Veteran complained of joint pain in his bilateral knees. The examiner noted that there was no diagnosis associated with the claimed condition of joint pain. The Veteran reported surgery and cortisone shots on his left knee. He stated that his left knee pain began four years prior to the examination and his right knee pain began three years prior. He reported that he was diagnosed with patellofemoral syndrome during service and that he had mild arthritis in his knees. X-rays in May 2016 showed mild degenerative disc disease and small 2 mm anterior vertebral osteophytes at C5-6, with a diagnostic code of "minor abnormality." The examiner stated that the Veteran's report of joint pain, the examination, and the x-ray findings are not consistent with the diagnosis of non-degenerative arthritis. The examiner indicated that the Veteran's report of joint pain is more likely than not related to patellofemoral syndrome (Veteran stated that he was diagnosed with PFS during active duty), age related changes, and to his duties as a police officer. The Veteran submitted a statement in January 2017 that his service treatment records show treatment for left and right knees in service. He stated that at times this condition was so bad during service that he had difficulty walking. He asserted that his left and right knee disorder began during service and has continued to the present day. Pursuant to a May 2017 deferred rating decision, a new medical opinion was submitted in June 2017 because the prior examiner's opinion as to the right knee was found to be inadequate. The request noted that the Veteran was previously denied service connection for his right knee in 1996 due to no symptoms. The request noted that the Veteran had symptoms with a diagnosis of right knee patellofemoral pain syndrome and had a previous diagnosis of patellofemoral pain syndrome during service. An opinion was requested as to whether the Veteran's current diagnosis of patellofemoral syndrome is related to the Veteran's in-service diagnosis. The request noted service treatment records showing right knee pain with patellofemoral syndrome; the December 2015 private nexus opinion (received January 2016); the January 2016 examination diagnosing right knee patellofemoral syndrome; the Veteran's January 2016 statement; and the Veteran's January 2017 statement asserting a right knee disorder since service. In June 2017, the examiner opined that the Veteran's right knee disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale offered was that the Veteran was seen for right knee patellofemoral syndrome during active duty. At separation, his right knee was reported as asymptomatic, suggesting that the episodes in service were acute and transitory, and not representing a chronic disability. Further, the examiner noted that the service treatment records do not document objective findings consistent with a high energy injury to the soft tissue or osseous structures of the Veteran's knees such as fracture, internal derangement, tendon/ligament tear or dislocation. The examiner found that in the absence of such findings, a post traumatic or chronic inflammatory process is less likely than not. The examiner also found that the Veteran's post service career as a police officer would likely expose him to trauma that would be a risk factor for chronic right knee symptoms. The Board finds that the June 2017 medical opinion is also inadequate as the rationale provided failed to address all of the evidence, including the evidence cited in the deferred rating. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examiner did not address the Veteran's lay statements including January 2016 and January 2017 statements. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The examiner also did not address the December 2015 positive nexus statement by the Veteran's private physician. This evidence is favorable to the Veteran's claim. Thompson v. Gober, 14 Vet. App. 187, 188 (2000). The Board notes that the Veteran's service treatment records from 1993 to 1995 indicate a diagnosis and treatment of patellofemoral syndrome, right knee. The Veteran submitted competent lay statements that his right knee disorder began during service and did not resolve. In this case, throughout the duration of the appeal, the Veteran testified at the hearing and submitted numerous written statements which indicate a continuity of symptomatology. The Board observes that "symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488 (1997). The Board finds the Veteran's statements to be credible and highly probative evidence as to the onset of his knee symptoms during service and progression of his knee disorder. Post-service, the Veteran continued to complain of joint pain and stiffness affecting both knees. In addition, the Veteran' private physician submitted a December 2015 statement that noted progressive bilateral knee pain. The physician indicated that the Veteran's symptoms are constant and appeared to be worsening. The Veteran's private physician stated that he suspects the Veteran has some degree of ostearthritis in both knee joints. The physician provided a positive nexus statement that "Given his relatively young age and 12 years history of Marine Corps service, it is as likely as not that [the Veteran's] prior military occupation is at least partly responsible for his degenerative joint disease. It is a slowly debilitating and chronic condition that warrants further work-up by an orthopedics or rheumatologist." Finally, at the June 2016 non-degenerative arthritis examination, the examiner indicated that the Veteran's report of joint pain is more likely than not related to patellofemoral syndrome (noting that the Veteran stated that he was diagnosed with PFS during active duty), age related changes, and to his duties as a police officer. The Board finds that this opinion supports a finding that the Veteran's current knee disorder is related to his diagnosis of patellofemoral syndrome during service and is entitled to high probative weight. The Board notes that if it is not possible to separate the effects of service-connected from nonservice-connected conditions, reasonable doubt, under 38 C.F.R. § 3.102, should be resolved in the Veteran's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181, 182 (1998). It is not necessary to find that the Veteran's patellofemoral syndrome diagnosed during service was the only cause of the Veteran's current knee disorder, it is only necessary to find it was one cause. The Board notes that in July 2017, the Veteran submitted a statement disagreeing with the assessment made by the VA examiner that his right knee pain was asymptomatic in 1995 at his discharge examination. He stated that his right knee disorder was not resolved during service. He noted his service in Southwest Asia during the Gulf War. He indicated that within a year after his return from deployment, his joint pain began. He stated that the pain became unbearable in 1993 and he sought treatment at that time. The Veteran also testified at the July 2021 hearing that he began to have severe issues with his knees during active service. He believes his bilateral knee disorders were caused by overuse during service. He stated that he spent a lot of time in a field and training environment. He developed a knee condition, which he sought treatment for during service. He testified that the went to sick call multiple times for his knees and that he was given medication and a brace and went through physical therapy. The Veteran stated that he began seeking treatment with a private doctor a couple of years after service. He had physical therapy, was prescribed painkillers, and used a brace. He was applying to become a police officer and was sent for a physical examination after which he was disqualified due to his knee issues. Thereafter, he declined to seek treatment and dealt with it himself for some time because it was interfering with employment. He stated that he couldn't climb stairs. He overcompensated with his right knee due to the left knee pain. He took extensive time off from work for about 10 months and had some light duty time to recover. His duties required him to be behind a desk which kept him off of his feet. He stated that his knee disorder affected his work and quality of life. He stated that when he again sought medical treatment, the cartilage in his left knee was severely damaged and he had cortisone shots and ultimately, he had arthroscopic surgery in 2015. He stated that his knee condition continued from service to the present day. The Veteran reported that both knees hurt but his left knee is worse than his right knee. The Veteran is currently diagnosed with degenerative arthritis, which is considered a "chronic" disease under 38 C.F.R. § 3.309 (a). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). Continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board finds that the evidence is at least in equipoise that the Veteran's patellofemoral pain syndrome had its onset during service, and that symptoms continued after service and progressively worsened, and resulted in both arthritis and the need for left knee meniscal repair. The June 2016 examiner's opinion that the Veteran's report of joint pain is more likely than not related to patellofemoral syndrome is highly probative on this issue. His private physician's opinion that it is as likely as not that [the Veteran's] prior military occupation is at least partly responsible for his degenerative joint disease is also entitled to high probative weight. The Veteran's statements and testimony support a finding of a continuity of symptomatology since service as to all of the Veteran's knee disabilities. Providing the benefit of the doubt to the Veteran, service connection is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a cardiovascular disorder to include hypertensive vascular disease is remanded. In November 2013, a private physician noted that the Veteran had presented to the ER with complaints of heart palpitations and dizziness. The Veteran presented with elevated blood pressure and had a past medical history of hypertension. An EKG indicated frequent premature ventricular contractions. X-ray showed right perihilar prominence, otherwise normal. The Veteran reported that he was at home at rest when he suddenly developed the sensation that his heart was beating fast. This lasted for approximately 30 minutes and was accompanied by diffuse cephalgia (headache). There was no dyspnea or chest pain. The Veteran stated that his blood pressure was high but he did not remember the number. The episode spontaneously resolved. He had no previous similar episodes. The physician indicated possible supraventricular tachycardia. The Veteran submitted a statement in February 2016 in which he stated that from 2013 to 2015, he sought treatment on multiple occasions for unexplained instances of a racing heartbeat and high blood pressure. A February 2016 Gulf War Registry examination noted a diagnosis of borderline dilated aorta suggestive of systemic hypertension. In May 2016, the Veteran was afforded a Gulf War examination. The examiner noted the Veteran's MOS as a bulk fuel man and that he was deployed to Saudi Arabia from August 1990 to April 1991. The Veteran reported being exposed to fuels, pesticides, bombmaking material, and nerve gas. He denied any exposures prior to military service, post deployment, or post military service. He stated he was currently employed full time as a police officer. He denied any time lost in the prior 12 months. His blood pressure was noted as 150/87. In May 2016, the Veteran was afforded a VA examination for heart conditions. The examiner noted no diagnosis of a heart disorder. The Veteran reported that he went to the emergency room for his symptoms and stated that his blood pressure and pulse were "through the roof." He was monitored for a few hours and it went back to normal. He denied any medical intervention. he first experienced heart problems three years prior to the examination. "Every so often my heart starts racing." He further indicated that his symptoms "occur at different times and last for 5-10 minutes or up to an hour or two. I could be laying in bed, and it happens." An interview-based METS test indicated that the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. The examiner opined that the Veteran's heart palpitations/intermittent tachycardia was more likely than not related to his untreated hypertension. The examiner also opined that the Veteran's heart palpitations/intermittent tachycardia is not a chronic multisymptom illness or a symptom thereof, or related to any specific exposure event during his service in Southwest Asia. In July 2017, the Veteran submitted a statement that he has no family history of cardiovascular issues. He never had issues with his heart or heart related conditions prior to serving in the Gulf and his doctors do not have an explanation. He stated, "There is no explanation other than Gulf War syndrome to explain my cardiovascular issues." The Veteran more recently testified at the July 2021 hearing that he believes the stressors of his active service contributed to his hypertension. He did not have high blood pressure prior to service, went to sick call multiple times during service, and that his blood pressure was slightly elevated but he did not require medication. He stated that he was diagnosed two or three years after service and was prescribed medication. The Veteran testified at the hearing that he experienced a racing heartbeat/palpitations which his doctor said might be stress-related. The Veteran was last afforded a VA examination for heart conditions in May 2016. No diagnosis was provided. The Board finds that a contemporaneous examination is necessary, requiring a remand. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The examiner should address the diagnosis of a systolic heart murmur in June 2014. In addition, an examiner attributed the Veteran's heart palpitations/intermittent tachycardia to be more likely than not related to his untreated hypertension. A diagnosis of hypertension requires diastolic blood pressure of predominantly 90 mm. or greater, or systolic blood pressure of predominantly 160 or greater, and for VA purposes, must be confirmed by readings two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101 n.1. A remand is therefore also necessary to afford the Veteran a VA examination for hypertension. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for headaches including migraines is remanded. The Veteran was afforded a VA examination for headaches in November 1995. The examiner noted that during service he dove into a shallow pool and hit is head against the bottom. He had rocks embedded in his skin and injuries to his scalp including bleeding. He did not lose consciousness. He was observed for four hours in a VA hospital. The examiner noted that he reported occasional headaches at the time of the examination, with no other neurological symptoms. He was diagnosed with concussion, with current minimal residual symptoms. March 1994 service treatment records note a head injury in June 1993. A June 1995 service treatment record noted that the Veteran presented with symptoms of headache and neck pain radiating to his shoulder blade following a motor vehicle accident. He was diagnosed with cervical neck strain. The Veteran submitted a statement in February 2016 that he deployed to Saudi arabia in support of Operation Desert Storm/Desert Shield from August 1990 until April 1991. In 1991, after he returned from deployment, he started experiencing frequent unexplained headaches and insomnia. These headaches were a daily occurrence and the insomnia would occur three to four days a week. He stated that he regularly takes ibuprofen for these debilitating headaches. He stated that he has lived with these daily headaches and insomnia to the current day. The Veteran was afforded a VA examination in June 2016. A diagnosis of tension headaches from 2013 was noted by the examiner. The Veteran reported that he started experiencing headaches "forever ago, like 15 years ago." He denied any injuries or incidents at that time. He stated, "I get migraines pretty often." There was no history of being evaluated or treated for his headaches. He reported that headaches occurred "almost every day." He described pulsating or throbbing headache pain on both sides of his head lasting less than one day. He did not report characteristic prostrating attacks. He reported that headaches last for 15 minutes until medication takes effect and did not impact his ability to work. The examiner found that tension headache is a diagnosable condition and not a chronic multisymptom illness (CMS) or a symptom of a CMI or related to any specific exposure event during the Veteran's service in Southwest Asia. The Veteran later testified at the July 2021 hearing that he began having headaches during service which he believes is related to his hypertension. He stated that his headaches increased in frequency after a head injury. He stated that he had rocks and pebbles embedded in his head after a fall. He indicated that he went to sick call with complaints of headaches. He sought treatment immediately after discharge with a private doctor. He stated that he has dealt with the headaches on a weekly basis and that "every other day I'd have a pretty decent headache usually 1000 milligrams of ibuprofen would take care of it." He stated the headaches continued after service and never went away. The Board finds that remand for a contemporaneous VA examination and opinion is necessary to determine the nature and etiology of the Veteran's headaches. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). While the June 2016 examiner noted tension headaches, the Veteran asserts that he also experiences migraines. In addition, a medical opinion is needed as to whether it is at least as likely as not that the Veteran's current headache disorder is related to his documented in-service head injury. The Veteran has asserted that his headaches began during service and worsened in frequency after his head injury. In addition, the examiner should address whether it is at least as likely as not that the Veteran's current headaches are related to complaints of headaches following the documented in-service motor vehicle accident that caused a cervical strain. 3. Entitlement to service connection for joint, muscle pain in bilateral elbows is remanded. The Veteran was afforded a non-degenerative arthritis examination in May 2016. He stated that the pain in his elbows started two years prior to the examination, pain in his left wrist started one year prior. He denied injuries to his elbows or wrist. The examiner found that the Veteran's report of joint pain, the examination, and x-ray findings are not consistent with a diagnosis of non-degenerative arthritis. The examiner found that the Veteran's report of joint pain is more likely than not related to his in-service diagnosis of patellofemoral syndrome, age related changes, and to his duties as a police officer. The Veteran reported bilateral elbow and left wrist joint pain during a Gulf War examination in May 2016. The Veteran then testified at the July 2021 hearing that he believes his bilateral elbow pain is due to overuse, noting that his MOS of bulk fuel specialist required heavy lifting, moving heavy hoses and heavy fuel bladders. He stated that his elbow joints were stressed and he refueled planes and helicopters but not from a fixed refueling station; they moved all of the equipment to a specific location and had to construct the station. He stated that he has tendonitis in his left arm and right arm that was diagnosed within a couple of years of discharge. He treated with the same doctor who treated his knees for 20 years. He indicated that his doctor agreed that his tendonitis is consistent with the type of overuse he described and that his doctor believes it is related to service. The Veteran reported that he takes over the counter medication and has a brace for his elbows. He reported that his joint pain affects his daily life. The Board finds that a remand is also required for a contemporaneous medical examination and opinion addressing the nature and etiology of the Veteran's elbow pain, to include a peripheral nerves examination. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). 4. Entitlement to service connection for a sleep disorder is remanded. The Veteran submitted a statement in February 2016 that he deployed to Saudi arabia in support of Operation Desert Storm/Desert Shield from August 1990 until April 1991. In 1991, after he returned from deployment, he started experiencing insomnia. The insomnia would occur three to four days a week. He stated that his symptoms continue to the present day. The Veteran also testified at his Board hearing that his MOS duties involved working odd hours which he believes contributed to his sleep disorder and that "being in Southwest Asia did not help." He refueled aircraft during service; out of a 24-hour day there were five or six hours where they were no flight operations. They would be expected to work rotating schedules sometimes during the daytime, many times at night so "I'm ready to go at night." He described the rotating schedules as "kind of tough." In 1994 he became a drill instructor so he got even less sleep. He averaged about three or four hours per night. He stated that he went to sick call once or twice but they didn't offer much help so he just dealt with it. A year or two after service he talked to his primary care provider who wanted him to see a sleep apnea specialist but he had a new job and was not willing to jeopardize it. After service he worked in law enforcement and had to work the graveyard shift and his sleep became even more erratic. He stated that his wife has complained about his snoring. He retired in October 2020. He indicated that his headaches interfere with sleeping and also affect the quality of sleep as headaches come at odd hours. The Board finds that a remand is necessary for a VA examination to determine the nature and etiology of any sleep disorder. McLendon v. Nicholson, 20 Vet. App. 79 (2006), to include a sleep study to determine whether the Veteran has a diagnosis of sleep apnea and whether any diagnosed sleep disorder is related to the Veteran's headache disorder. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any heart disorder . The following opinions are requested: Whether the Veteran has any diagnosis of a heart disorder related to his symptoms of heart palpitations/intermittent tachycardia and if so, whether his heart disorder is at least as likely as not (50 percent or greater probability) caused by or related to active service. The examiner should address the diagnosis of a systolic heart murmur in June 2014. 2. Schedule the Veteran for a VA examination for hypertension. The following opinions should be requested: Whether the Veteran has been diagnosed with hypertension and if so, whether the Veteran's hypertension is at least as likely as not (50 percent probability or higher) caused by or related to active service. 3. Schedule the Veteran for a VA headaches examination to clarify the nature and etiology of the Veteran's headaches. The following opinions are requested: (a.) Whether the Veteran has a current diagnosis of a headache disorder, to include migraines, and if so, whether the Veteran's headaches were at least as likely as not (50 percent or grated probability) caused by or related to active service. (b.) Whether any current headache disorder is at least as likely as not (50 percent probability or greater) related to the Veteran's in-service head injury. (c.) Whether any current headache disorder is related to the Veteran's documented in-service motor vehicle accident. (d.) Whether the Veteran's headaches are caused or aggravated by his hypertension. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his bilateral elbow pain. The following opinion is requested: Whether the Veteran's bilateral elbow joint and muscle pain is at least as likely as not (50 percent or greater probability) caused by or related to active service. The examiner should address the Veteran's assertion of overuse related to the duties of his MOS of bulk fuel specialist. 5. Schedule the Veteran for a VA sleep disorders examination, to include a sleep study. The following opinions are requested: (a.) Whether the Veteran has a diagnosis of any sleep disorder, to include sleep apnea. (b.) Whether it is at least as likely as not (50 percent or greater probability) that any sleep disorder was caused by or related to active service. (c.) Whether it is at least as likely as not (50 percent probability or greater that any sleep disorder was caused or aggravated by any headache disorder. If any disorder remains undiagnosed, a new Gulf War opinion should be requested. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any such undiagnosed disorder is related to the Veteran's service in the Southwest Asia, including a chronic undiagnosed illness and/or medically unexplained chronic multisymptom illness (MUCMI). Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debra B. McLoughlin, 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.