Citation Nr: 21065072 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 12-34 932 DATE: October 25, 2021 REMANDED Entitlement to service connection for a left arm disability is remanded. Entitlement to service connection for fibromyalgia, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness, is remanded. Entitlement to service connection for a neurological disorder, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness, is remanded. Entitlement to service connection for a respiratory disorder, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1973 to May 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2018, the Veteran and his son testified at a Travel Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, the Board initially remanded the Veteran's claims for entitlement to service connection for fibromyalgia and neurological symptoms in April 2015. See April 2015 BVA Decision. In a subsequent August 2018 decision, the Board reopened the Veteran's claims for entitlement to service connection for upper respiratory problems and left arm pain and arthritis in the joints and remanded all four service connection claims for additional development. See August 2018 BVA Decision. Thereafter, in a February 2020 decision, the Board denied the Veteran's claims for entitlement to service connection for a left arm disability, fibromyalgia, neurological symptoms, and a respiratory disability, and the Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). See February 2020 BVA Decision. To this end, in July 2021, the Court granted the parties' Joint Motion for Remand (JMR), which vacated the Board's February 2020 decision and remanded the matters for readjudication. Specifically, the parties agreed that remand was warranted because the Board failed to provide adequate reasons and bases in denying the Veteran's claims. See July 2021 CAVC Decision. 1. Entitlement to service connection for a left arm disability is remanded. During the May 2018 Board hearing, the Veteran testified that his left arm pain manifested while he was serving on active duty and indicated that he has continued to experience such symptoms since service. To this end, the Veteran acknowledged that he could not remember whether he sustained a left arm injury in service but reported that his symptoms may have been caused by wear and tear sustained while carrying two 80 pound radios upstairs on multiple occasions while he was serving on active duty. The Veteran further testified that he sought treatment for whole body aches during service but noted that he had not reported symptoms specific to his left arm on that occasion. See May 2018 Hearing Transcript, pages 34-37. The Veteran's service treatment records (STRs) are silent as to any complaints or treatment for a left arm injury. In this regard, the Board notes that the Veteran's January 1993 separation report of medical examination shows his upper extremities, back, and other musculoskeletal system to be normal. In addition, although the Veteran denied arthritis, rheumatism and bursitis, bone, joint or other deformity, and painful or "trick" shoulder on the corresponding report of medical history, he endorsed swollen or painful joints at that time. Notably, however, the examiner explained that the Veteran's report referred to right wrist pain associated with push-ups and right foot pain that occurred when he performed physical training exercises. See May 2015 STR Medical. A review of the post-service treatment records shows that the Veteran endorsed left arm pain and arthritis in the joints during a May 1999 VA general medical examination. In this regard, the Veteran reported that he occasionally experienced pain in his joints, which worsened with overuse, but denied any specific injury to any of his joints. Following the examination, the examiner diagnosed the Veteran with left arm arthritis. Notably, the examiner indicated that the Veteran's claims file was not available for review at the time of the examination and x-rays of the Veteran's forearms and shoulders obtained in connection therewith were normal bilaterally. See May 1999 VA examination; April 2013 CAPRI. The Veteran was diagnosed with left arm pain in February 2010. Thereafter, a January 2012 private treatment record shows that the Veteran reported numbness and tingling in both of his hands with certain positions, to include when sitting in a recliner and lying in bed. He further explained that his left hand numbness occurred at rest and radiated up his forearm to below his elbow. The private physician diagnosed the Veteran with carpal tunnel syndrome. See March 2013 Medical Treatment Record Non-Government Facility. The Veteran underwent a VA examination for elbow and forearm conditions in August 2012. During the examination, the Veteran endorsed progressive bilateral elbow pain that manifested gradually over time. The examiner noted that the Veteran had been diagnosed with arthritis in both of his elbows and forearms, but an x-ray obtained in connection with the examination did not reveal any joint effusion, fractures, or other joint abnormalities. See August 2012 VA examination. Thereafter, a September 2013 x-ray revealed mild left shoulder osteoarthritis. See March 2019 Medical Treatment Record Non-Government Facility. After a review of the evidence of record, the Board finds a remand for a VA opinion is necessary. 2. Entitlement to service connection for fibromyalgia, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness, is remanded. During his May 2018 Board hearing, the Veteran testified that his fibromyalgia was caused by exposure to environmental hazards in the Persian Gulf. Specifically, he indicated that he was exposed to toxic smoke from burning oil well fires, drinking water contaminated with diesel fuel, sandflea and sandfly bites, and particles of depleted uranium ammunition, during Operations Desert Storm and Desert Shield and indicated that his symptoms manifested 25 to 30 years prior to the date of the hearing. Alternatively, the Veteran states that his fibromyalgia symptoms may have been caused by an undiagnosed illness or by a medically unexplained chronic multi-system illness (MUCMI). See January 1999 VA Form 21-4138 Statement in Support of Claim; November 2009 VA Form 21-4138 Statement in Support of Claim; May 2018 Hearing Transcript, pages 3-6. A review of the Veteran's DD-214 shows that his military occupational specialty (MOS) was tactical communication chief, and he received the Southwest Asia Service Medal with two bronze stars and Saudi Kuwait Liberation Medal. See May 2015 Certificate of Release or Discharge from Active Duty (e.g., DD 214, NOAA 56-16, PHS 1867). In addition, a November 2018 Information Report shows that the Veteran served in the Gulf War theater from October 1990 to April 1991. See November 2018 Military Personnel Record. The Veteran initially underwent a VA general medical examination in May 1999. During the examination, the Veteran endorsed pain in his joints, which worsened with overuse, but did not report a specific injury to any of his joints. Following the examination, the examiner found that the Veteran's symptoms were most likely consistent with a fibromyalgia-like syndrome. See May 1999 VA examination. Private treatment records dated in September 2009 and October 2009 show that the Veteran had been diagnosed with fibromyalgia/myofascial pain syndrome with an estimated onset of March 2009. In this regard, private physical therapy records indicate that the Veteran's functional deficits included upper and lower extremity weakness, decreased range of motion, radicular symptoms, muscle spasms, pain affecting activities of daily living, and decreased tolerance to standing, sitting, sleeping, ambulation, and prolonged positioning. See October 2010 Medical Treatment Record Non-Government Facility. In April 2010, the Veteran endorsed diffuse pain with sensation of pins and needles all over his body and low back pain that radiated to both of his lower extremities. In this regard, a private physician indicated that the Veteran might have fibromyalgia. See December 2010 Medical Treatment Record Non-Government Facility. The Veteran was afforded a VA examination for fibromyalgia in August 2019. The examiner found that the Veteran did not have, and had never been diagnosed with, fibromyalgia. During the examination, the Veteran reported that a private physician stated that he had fibromyalgia years prior but indicated that he was not receiving any treatment at the time of the examination. In this regard, the examiner noted that the most recent private treatment note of record did not show any treatment for fibromyalgia and that the Veteran stated that he had not undergone a rheumatology evaluation in the past. Following the examination, the examiner found that the Veteran's fibromyalgia was not related to environmental exposure in Southwest Asia as he did not have a current diagnosis. After performing an examination and reviewing the evidence of record, the examiner opined that the Veteran's claimed fibromyalgia was not incurred in or caused by his service in the Persian Gulf. In support of the opinion, the examiner noted that the Veteran did not have fibromyalgia, but rather indicated that his diagnoses included cervical spondylosis, lumbar spondylosis, bilateral knee osteoarthritis, right wrist osteoarthritis, right foot osteoarthritis, idiopathic peripheral neuropathy, and other disorders, which most likely caused his complaints of multiple joint pain and all over body pain. In this regard, the examiner noted that fibromyalgia was a diagnosis of exclusion and found that the likely cause of the Veteran's complaints was the normal aging progress or post-service overuse or injury. See August 2019 C&P examination. Following a review of the evidence of record, the Board finds that a remand is warranted to obtain an addendum medical opinion to reconcile and/or address the conflicting medical evidence of record regarding the Veteran's claimed fibromyalgia. In this regard, the Board finds that the evidence of record is unclear as to whether there is a diagnosis associated with the Veteran's claimed disability. Specifically, the Board notes that the August 2019 VA examination report shows that the Veteran did not have, and had never been diagnosed with, fibromyalgia. See August 2019 C&P examination. Notably, however, the VA examiner did not address the May 1999 VA examination report, which indicates that the Veteran's joint pain symptoms were most likely consistent with a fibromyalgia-like syndrome, September 2009 and October 2009 private physical therapy records, which show diagnoses for fibromyalgia/myofascial pain syndrome, or the April 2010 medical record indicating that the Veteran might have fibromyalgia, or proffer an opinion as to whether these diagnoses were made in error. See May 1999 VA examination; October 2010 Medical Treatment Record Non-Government Facility; December 2010 Medical Treatment Record Non-Government Facility. Based on the foregoing, the Board finds that a remand is warranted to obtain an addendum medical opinion to determine whether the Veteran currently has or, at any time during the period on appeal, had fibromyalgia, and whether such disability is etiologically related to the Veteran's active duty service, to include as due to exposure to environmental hazards in the Persian Gulf. 3. Entitlement to service connection for a neurological disorder, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness, is remanded. As noted above, the Veteran states that his neurological symptoms were caused by exposure to environmental hazards in the Persian Gulf during Operations Desert Storm and Desert Shield. In February 2010, the Veteran endorsed light headedness and dizziness, and he reported "prickly pins" all over his body when he was exposed to outdoor sunlight in January 2011. In addition, a September 2011 letter indicates that the Veteran was denied a change in insurance coverage due, in pertinent part, to his history of weakness and dizziness. See April 2012 Medical Treatment Record Non-Government Facility. The Veteran underwent a Gulf War general medical examination in August 2012. The examiner did not note any findings or diagnoses pertinent to the Veteran's neurologic system during the examination. See August 2012 VA examination. Private treatment records dated in February 2013 show that the Veteran endorsed diffuse pain and neurological symptoms and was subsequently diagnosed with unspecified polyarthropathy or polyarthritis involving multiple sites and unspecified neuralgia, neuritis, and radiculitis. See March 2013 Medical Treatment Record Non-Government Facility. In October 2017, the Veteran was diagnosed with idiopathic peripheral neuropathy, and he continued to report dizziness when he stood too quickly in June 2019. See March 2019 Medical Treatment Non-Government Facility; September 2019 CAPRI. Following a review of the evidence of record, the Board finds that a remand is warranted to obtain an addendum medical opinion to reconcile and/or address the conflicting medical evidence of record regarding the Veteran's claimed neurological disorder. In this regard, the Board finds that the evidence of record is unclear as to whether there is a diagnosis associated with the Veteran's claimed disability. Specifically, the August 2012 VA examination report shows that the Veteran did not have a neurological disorder. See August 2012 VA examination. However, the medical evidence of record shows that he endorsed diffuse pain, dizziness, pins and needles sensations, and itchiness exacerbated by sunlight multiple times during the period on appeal and subsequent treatment records show that the Veteran has been diagnosed with unspecified polyarthropathy or polyarthritis involving multiple sites and unspecified neuralgia, neuritis, and radiculitis, idiopathic peripheral neuropathy. See March 2013 Medical Treatment Record Non-Government Facility; March 2019 Medical Treatment Record Non-Government Facility. The Board further notes that the August 2012 VA examiner did not proffer an opinion as to the etiology of the Veteran's claimed neurological disorder and that there are no other medical opinions of record as to whether the Veteran's claimed neurological disorder is related to his service. Based on the foregoing, the Board finds that a remand is warranted to obtain a VA examination to determine whether the Veteran currently has or, at any time during the period on appeal, had a neurological disorder and whether such is etiologically related to the Veteran's active duty service, to include as due to exposure to environmental hazards in the Persian Gulf. 4. Entitlement to service connection for a respiratory disorder, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness, is remanded. During his May 2018 Board hearing, the Veteran testified that his chronic upper respiratory symptoms, to include a chronic cough and difficulty breathing, manifested while he was serving in the Persian Gulf during Operation Desert Storm. The Veteran underwent a VA examination for respiratory conditions in August 2012. The examiner noted that the Veteran had been diagnosed with dyspnea. During the examination, the Veteran reported that his symptoms manifested in 1985, but the examiner noted that the Veteran was a master fitness trainer during service. Following the examination, the examiner noted that no pulmonary function tests or chest films were ordered because being a master fitness trainer made the possibility of any significant functional problem virtually untenable. See August 2012 VA examination. The Veteran was next afforded a VA examination for respiratory conditions in August 2019. The examiner noted that the Veteran had been diagnosed with chronic obstructive pulmonary disease (COPD), resolved bronchitis with pleurodynia, and multiple resolved upper respiratory infections. During the examination, the Veteran reported that he had worsening shortness of breath over time especially with exertional activity such as stair climbing and denied smoking. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed respiratory disorder was incurred in or caused by the claimed in-service injury, event, or illness. In support of the opinion, the examiner explained that there was no medical evidence that the Veteran had a diagnosis of a respiratory disorder that was incurred in or caused by an undiagnosed illness due to Gulf War Syndrome during service. In this regard, the examiner noted that the Veteran's January 1993 separation examination was negative for any pulmonary complaints or diagnoses and that he had been diagnosed with COPD in October 2017. As such, the examiner found that COPD, which was most likely due to genetics or the normal aging process in older adults, was the most likely etiology of the Veteran's pulmonary condition. However, in support of the opinion, the examiner also cited an UpToDate article, which indicates that environmental exposure to particulate matter, dusts, gases, vapors, fumes should be avoided or reduced whenever possible and explains that progressive changes associated with increased susceptibility to many diseases, to include COPD, was influenced, in relevant part, by environmental exposures. See August 2019 C&P examination. Notably, although the VA examiner cited an article indicating that susceptibility to COPD was influenced by environmental exposure, they did not proffer an opinion as to whether the Veteran's diagnosed COPD is etiologically related to exposure to environmental hazards while he was serving in the Persian Gulf. Thus, the Board finds that a remand is warranted to obtain an addendum medical opinion to determine whether the Veteran's diagnosed COPD is etiologically related to his active duty service, to include as due to exposure to environmental hazards in the Persian Gulf. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. After completion of the above development, obtain an opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's claimed left arm disability. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinions: (a) Identify all diagnoses pertaining to his claim for left arm disability. The examiner should address the prior findings and diagnoses of left arm arthritis (May 1999 VA general medical examination), left arm pain (February 2010 VA record), carpal tunnel syndrome (January 2012 private treatment record), arthritis in elbow and forearm (August 2012 VA examination), and mild left shoulder osteoarthritis (September 2013 VA x-ray). If the examiner determines that any prior diagnoses are incorrect, he or she should provide an explanation for why the diagnosis was in error. (b) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed disorders were caused by, or are otherwise etiologically related to, the Veteran's 20 year active duty service, to include as due to wear and tear sustained, to include while carrying two 80 pound radios upstairs on multiple occasions. Please explain why or why not. (c) The examiner must also provide an opinion as to whether there are any symptoms of the Veteran's claimed left arm disability that are not attributable to a known clinical diagnosis. If so, the examiner must then provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the symptoms are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness due to service in Southwest Asia during the Gulf War. The examiner should review the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified 3. After completion of the development in #1, obtain an addendum opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's claimed fibromyalgia. It is up to the discretion of the examiner as to whether an in-person examination is necessary. If the examiner concludes that a rheumatology evaluation should be provided, such should be scheduled. The examiner should provide the following opinions: (a.) Identify any symptoms that the Veteran relates to "fibromyalgia," to include diffuse joint pain. (b.) The examiner should determine whether such symptomatology can be attributed to a known clinical diagnosis and identify, with specificity, all current diagnoses pertinent to the Veteran's claimed fibromyalgia. The examiner is advised that by "current disability" the Board means: (1) any disability diagnosed by the examiner; (2) any relevant diagnosis during the appeal period (beginning in November 2009); and/or (3) symptoms resulting in functional impairment but not otherwise warranting a specific diagnosis. The examiner should specifically consider the diagnoses of fibromyalgia and myofascial pain syndrome noted in the Veteran's VA and private treatment records to include, pain in joints found to be most likely consistent with fibromyalgia-like syndrome (May 1999 VA examination), notations of diagnosis of fibromyalgia/myofascial pain syndrome with estimated onset of March 2009 (September and October 2009 private treatment records), no diagnosis of fibromyalgia (August 2019 VA examination). If the examiner determines that any prior diagnoses are incorrect, he or she should provide an explanation for why the diagnosis was in error. (c.) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed disorders (to include fibromyalgia and myofascial pain syndrome) were caused by, or are otherwise etiologically related to, the Veteran's active duty service, to include as due to exposure to environmental hazards including toxic smoke from burning oil well fires, drinking water contaminated with diesel fuel, sandflea and sandfly bites, and particles of depleted uranium ammunition, in the Persian Gulf during Operations Desert Storm and Desert Shield. Please explain why or why not. (d.) The examiner must also provide an opinion as to whether there are any symptoms of the Veteran's claimed fibromyalgia that are not attributable to a known clinical diagnosis. If so, the examiner must then provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the symptoms are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness due to service in Southwest Asia during the Gulf War. (e.) During the August 2019 VA examination, the Veteran was noted to have cervical spondylosis, lumbar spondylosis, bilateral knee osteoarthritis, right wrist osteoarthritis, right foot osteoarthritis, which most likely caused his complaints of multiple joint pain and all over body pain. The examiner should opine as to whether it is at least as likely as not that any of these diagnoses is etiologically related to his 20 year military service, to include as due to wear and tear on his body. Please explain why or why not. The examiner should review the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 4. After completion of the development in #1, obtain an addendum opinion by an appropriately qualified examiner to determine the nature and etiology of the Veteran's claimed neurological disorder. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinions: (a) Identify any symptoms that the Veteran relates to a "neurological disorder," to include diffuse pain, dizziness, and pins and needles and burning sensations exacerbated by sunlight. (b) Determine whether such symptomatology can be attributed to a known clinical diagnosis. The examiner should specifically consider the diagnoses of unspecified polyarthropathy or polyarthritis involving multiple sites, unspecified neuralgia, neuritis and radiculitis, and idiopathic peripheral neuropathy identified in the Veteran's private treatment records and during the April 2019 VA examination. See March 2013 Medical Treatment Record Non-Government Facility; March 2019 Medical Treatment Record Non-Government Facility. (c) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed neurological disorder was caused by, or is otherwise etiologically related to, the Veteran's active duty service, to include as due to exposure to environmental hazards including toxic smoke from burning oil well fires, drinking water contaminated with diesel fuel, sandflea and sandfly bites, and particles of depleted uranium ammunition, in the Persian Gulf during Operations Desert Storm and Desert Shield. Please explain why or why not. (d) The examiner must also provide an opinion as to whether there are any symptoms of a neurological disorder that are not attributable to a known clinical diagnosis. If so, the examiner must then provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the symptoms are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness due to service in Southwest Asia during the Gulf War. The examiner should review the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 5. After completion of the development in #1, obtain an addendum opinion by an appropriately qualified examiner to determine the nature and etiology of the Veteran's claimed respiratory disorder. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinion: Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed respiratory disorder (to include COPD) was caused by, or is otherwise etiologically related to, the Veteran's active duty service, to include as due to exposure to environmental hazards including toxic smoke from burning oil well fires, drinking water contaminated with diesel fuel, sandflea and sandfly bites, and particles of depleted uranium ammunition, in the Persian Gulf during Operations Desert Storm and Desert Shield? Please explain why or why not. The examiner should review the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.