Citation Nr: 21066047 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 20-05 557 DATE: October 28, 2021 ORDER Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with associated depression and anxiety also claimed as sleep disturbance, insomnia, and anxiety, is denied. Entitlement to total disability rating based on individual unemployability (TDIU) is denied. REMANDED Entitlement to service connection for fibromyalgia (claimed undiagnosed illness due to Gulf War Syndrome) is remanded. Entitlement to service connection for right shoulder pain is remanded. Entitlement to service connection for left shoulder pain is remanded. Entitlement to service connection for trochanteric pain syndrome of the right hip is remanded. Entitlement to service connection for trochanteric pain syndrome of the left hip is remanded. Entitlement to service connection for degenerative arthritis of the right knee is remanded. Entitlement to service connection for degenerative arthritis of the left knee is remanded. Entitlement to service connection for degenerative arthritis of the right ankle with ankle strain and calcaneal spur is remanded. Entitlement to service connection for left ankle strain is remanded. Entitlement to service connection for cervical spondylosis is remanded. Entitlement to service connection for lumbosacral strain is remanded. Entitlement to service connection for erectile dysfunction (claimed undiagnosed illness due to Gulf War Syndrome) is remanded. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's PTSD with associated depression and anxiety has not resulted in disability which more closely approximated occupational and social impairment with deficiencies in most areas. 2. For the entire appeal period, the Veteran's service-connected disabilities did not render her unable to secure and follow a substantially gainful occupation consistent with her educational and occupational background. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD with associated depression and anxiety are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1989 to February 2000 with service in South West Asia during the Persian Gulf War. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2017, January 2018, July 2018, and December 2019 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In an April 2017 statement, the Veteran contended that he was unable to maintain stable employment due to his service-connected disabilities. As such, a claim for TDIU is before the Board. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In August 2020, the Board remanded claims for entitlement to service connection for disabilities of the right and left hips, right and left knees, right and left ankles, lumbar spine, and cervical spine, erectile dysfunction, and TDIU for additional development. These issues are again before the Board for further appellate review. In addition, the Board denied entitlement to service connection for fibromyalgia and a higher rating for PTSD and the Veteran appealed these denials. In June 2021, the United States Court of Appeals for Veterans Claims (Court) issued an Order granting a May 2021 joint motion for partial remand (JMPR) submitted on behalf of the Veteran and VA vacating the decisions as to the issues listed above and remanding the appeal consistent with the parties' terms. Initial Rating PTSD with Depression and Anxiety The Veteran contends that his service-connected psychiatric disability warrants a higher rating. His service-connected PTSD with depression and anxiety has been rated under Diagnostic Code 9411 for PTSD. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a holistic analysis that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. A March 2017 VA medical record shows that the Veteran reported that he had had suicidal thoughts in 2014-2015, when he was in the process of getting a divorce and his father died. He had no intent or plan and "adamantly" denied suicidal thoughts, intent, or plan at the time of the treatment provided. Notably, the period on appeal begins in January 2017, when the Veteran filed his first claim for service connection. Because the report of suicidal thoughts was more than one year, at a minimum, before the date of claim, the Board finds the March 2017 medical record is a more accurate representation of the Veteran's symptoms as of the beginning of the appeal period. The Veteran was provided with a VA examination in April 2017. The examiner opined that the Veteran's service-connected psychiatric disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran experienced diminished interest or participation in significant activities, a persistent inability to experience positive emotions, including the inability to experience happiness, satisfaction, or loving feelings, hypervigilance, depressed mood, chronic sleep impairment, and disturbances of motivation and mood. The Veteran was casually dressed, calm, cooperative, and had a congruent affect and denied suicidal or homicidal ideation. The Veteran was provided with another VA examination in May 2018. The examiner opined that the Veteran's service-connected disability resulted in occupational and social impairment with reduced reliability and productivity. The Veteran reported that he lived with his girlfriend of 10 years and their 2-year-old son. With regards to his romantic relationship, he stated, "It's good. That's my support. I don't know how I'd make it without her." The Veteran also had a 28-year-old daughter from a previous relationship with whom he had a good relationship. They tend to communicate once a week. His father was deceased, but he maintained a positive rapport with his mother. He was not particularly close to his four siblings, he denied having any close friends, and he rarely participated in social activities. Since his last exam in April of 2017, Veteran had continued to work full-time in customer service for a child support agency, a position he has held since September 2016. He was considering leaving this position due to his difficulties coping with the stress, as well as his poor concentration and problems completing tasks. He reported that he often missed work due to his significant depressive symptoms. The Veteran indicated that he had held approximately 16 different jobs since he left the military in 2000. He stated that when things became difficult, he always thought it was time for a new job. The Veteran's symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, frequent irritability, poor concentration with forgetfulness, social isolation, markedly diminished interest or participation in significant activities, difficulty in establishing and maintaining effective work, and difficulty in adapting to stressful circumstances, including work or a worklike setting. He additionally reported a lack of motivation, low energy, intrusive thoughts of traumatic military experiences with psychological distress, hypervigilance, low libido, and low self-esteem. While the Veteran denied overt suicidal ideation, he reported that he sometimes thought about how it would be if he was not around. He stated that he did not want to be a burden to anyone. The Veteran was provided with another VA examination in October 2019. The examiner opined that the Veteran's service-connected disability resulted in occupational and social impairment with reduced reliability and productivity. He is in a relationship that was going well, and they have been living together for eleven years. He had two children, ages 30 from his prior marriage and a three-year-old with his girlfriend. He reported a fair relationship with the 30-year-old. He indicated that he had no friends, and that his leisure activities were reading, going on the computer, and going to the park. At the time of the examination, he had been working for the Social Security Administration for two weeks. Prior to his position, he had been working full time for Child Support Agency since September 2016. He missed about five days per month and was on intermittent Family and Medical Leave Act (FMLA) because of the missing time. Symptoms included markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, persistent inability to experience positive emotions, irritable behavior, and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects, hypervigilance, sleep disturbance, depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The Veteran denied suicidal or homicidal ideation. VA medical records show ongoing treatment for medication management. These records reflect mental status examinations reflected that the Veteran was oriented in all spheres and was neatly dressed and groomed. His speech was within normal limits and he was polite and cooperative. His thought content and process were within normal limits. He denied hallucinations and delusions and his judgment and insight were adequate. He denied suicidal and homicidal ideation. VA medical records and examination reports show that the Veteran's service-connected psychiatric disorder was manifested by symptoms associated with a 50 percent rating and symptoms that were not listed with a specific rating, such as lack of motivation, low energy, intrusive thoughts of traumatic military experiences with psychological distress, hypervigilance, low libido, and low self-esteem. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. These symptoms are similar to those contemplated by the assigned 50 percent rating. While the Veteran did experience symptoms contemplated by a 70 percent rating impaired impulse control, including such as unprovoked irritability with periods of violence and difficulty in adapting to stressful circumstances including work or a worklike setting the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. Turning reported suicidal ideations, suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The March 2017 VA medical record reflected the Veteran's report that he had suicidal ideation in 2014 to 2015, while going through a divorce and the loss of his father. At his May 2018 VA examination, the Veteran denied overt suicidal ideation, but he did report sometimes thinking about how it would be if he was not around. However, VA medical records show that the Veteran consistently denied suicidal ideation for the entire appeal period, notwithstanding the reports of suicidal ideation three to four years prior to the start of the current appeal period. The Veteran has otherwise affirmatively denied having suicidal ideation or thoughts. Moreover, the presence of a single symptom is not dispositive of the particular disability level. Bankhead, 29 Vet. App. at 22. The Veteran's suicidal ideation is rare in the record before the Board and has not been tied to any specific impairment in occupational or social functioning. The Board finds that the presence of this symptom has not resulted in total occupational and social functioning or such functioning with deficiencies in most areas. Significantly, the Veteran did not present any of the remainder of the listed symptoms in the 70 percent rating criteria. The record does not reflect that the Veteran reported suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, spatial disorientation, neglect of personal appearance and hygiene, or an inability to establish and maintain effective relationships. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating. The May 2018 and October 2019 examination reports reflect the examiners' assessment that the Veteran symptoms associated with his service-connected psychiatric disability resulted in occupational and social impairment with reduced reliability and productivity, commensurate with a 50 percent disability rating. The evidence does not show that the Veteran's psychiatric disability resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. As such, the Board finds that a higher rating for the Veteran's service-connected psychiatric disorder is not warranted. As the preponderance of evidence is not in support of a higher rating, the benefit of the doubt doctrine is not for application. Entitlement to a TDIU The Board concludes first that the TDIU issue is not inextricably intertwined with the service connection issues remanded below. TDIU is a downstream element of service connection, a component of the disability rating assigned after service connection is awarded. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). In the event that a service connection issue is granted, the Agency of Original Jurisdiction will be able to revisit entitlement to a TDIU based on the enlarged number of service-connected disabilities and based on the effective date or dates assigned for the newly service-connected disability or disabilities. Delrio v. Wilkie, 32 Vet. App. 232 (2019) (holding a TDIU cannot be awarded earlier than the effective date of service connection for a disability causing unemployability). Should a TDIU be denied at that time, the Veteran will have his procedural and appeal rights available. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that a notice of disagreement creates subject matter jurisdiction in those matters actually decided and does not create jurisdiction in matters not yet addressed). Moreover, as the development required for the service connection issue does not pertain to the functional impairment caused by his currently service-connected disabilities, remand of the TDIU issue is not needed. Thus, the Veteran is not prejudiced by the Board's consideration of this issue at this time. Turning to the merits of a TDIU, VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). Throughout the appeals period, the Veteran has been service-connected for PTSD at a 50 percent disability rating effective January 16, 2017, for obstructive sleep apnea at a 50 percent rating effective October 10, 2017 for headaches at a 30 percent rating effective January 16, 2017, for cherry hemangiomas at a noncompensable rating prior to March 16, 2021 and at a 10 percent thereafter, and for chronic sinusitis, nonallergic vasomotor rhinitis, and residuals of tonsillitis all at noncompensable ratings throughout the appeals period. The Veteran's combined rating was 70 percent effective January 16, 2017, 80 percent effective October 10, 2017, and 90 percent effective March 16, 2021. The Veteran meets the criteria for a TDIU under 38 C.F.R. § 4.16(a) throughout the appeals period. The Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected condition and advancing age, which would justify a total rating based on individual unemployability due solely to the service-connected conditions. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Entitlement to a TDIU is based on an individual's particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). The term unable to secure and follow a substantially gainful occupation as having two components: one economic and one noneconomic. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The non-economic component includes consideration of the following: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Id. Marginal employment shall not be considered substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). In August 2020, the Veteran was asked to complete and return a form VA 21-8940 to provide the VA with his education and training background and employment history; however, he did not return the form. As such, there is very little evidence upon which to assess his education and work history. In an April 2017 statement, the Veteran contended that he was unable to maintain stable employment since leaving the military. He reported that his career goals had long faded and his fatigue, headaches, constant body aches and joint pain, and low tolerance for stress had negatively affected him in the workplace. He indicated that he had fifteen different employers and periods of unemployment since leaving the military. He had not taken vacation since leaving the military because he had to use his vacation and sick leave at each employer for those times when his symptoms prevented him from working. Inasmuch as the Veteran has reported difficulty maintaining stable employment, the evidence of record reflects his statements throughout the appeals period that he has been employed full time. Moreover, the evidence fails to show that his employment has been marginal or in a protected environment. At a May 2017 VA headaches examination, the Veteran reported that he had missed two days of work since September 2016 because of headaches. At his October 2019 VA examination for PTSD, the Veteran reported that he had recently begun working for the Social Security Administration and that, prior to this employment, he was working full time for a child support agency since September 2016. He indicated that he missed about five days of work per month because he felt tired due to his sleep problems and that he was on intermittent FMLA because of the missing time. The Veteran has reported that he has changed jobs several times since discharge from service and has had periods of employment since discharge from service in February 2000. However, the evidence of record shows that the Veteran has been employed full time throughout the appeal period, which began in January 2017, and no evidence has been proffered to show that his earned annual income fell below the poverty threshold during this time. The evidence also does not show that the Veteran's employment has been in a protected environment. While VA has not defined the term "protected environment" in the regulations governing TDIU claims, the applicable VA regulations suggest that a protected environment includes a family business or sheltered workshop. Factors to consider may also include the "magnitude of the veteran's job responsibilities and the degree of accommodation necessary for successful, full-time work." Cantrell v. Shulkin, 28 Vet. App. 382, 392 (2017). Where a veteran's disabilities do not result in lost income or where legally required accommodations permit a veteran to maintain gainful employment, an award of TDIU does not serve its intended purpose. Cantrell v. Shulkin, 28 Vet. App. 382, 396 (2017) (Lance, J., concurring) ("Where a claimant's employer is required by law to provide reasonable accommodations pursuant to the [Americans with Disabilities Act (ADA)] and those accommodations allow the claimant to engage in a substantially gainful occupation, a TDIU award would, in effect, constitute a second paycheck on the back of the taxpayer."). The Veteran's employment has not been with a family business during the relevant period on appeal. There has been no evidence to show that the Veteran has been provided with accommodations in order to support his continued employment. While the Veteran has used leave when he has felt his symptoms warranted it, this is a benefit provided by his employer and not an accomodation. The Veteran has also reported being on FMLA intermittently. Leave under the FMLA is a protection provided to all employees by law, and there is no evidence that his use of FMLA on an as needed basis was an accommodation that was extraordinary or beyond that which would be required by the ADA; therefore, the use of FMLA is not an accommodation in itself which would warrant an award of a TDIU. As such, the evidence does not show that the Veteran's employment during the appeals period has been marginal. With regard to the second component under Ray, the evidence of record shows that the Veteran appears to have the education level to maintain his employment. He reported that he was a high school graduate and was one course shy of obtaining his bachelor's degree in business administration. See October 2019 VA PTSD examination While the Veteran's service-connected disabilities, indeed, affected his employability to some extent in that he may have experienced trouble holding a job due to conflicts related to his psychiatric disorders, or other service-connected physical limitations, the medical evidence does not show that the Veteran's service-connected disabilities precluded him from securing or maintaining substantially gainful employment at any time during the pendency of the appeal. At an April 2017 VA PTSD examination, the examiner noted that the Veteran's service-connected psychiatric disability caused clinically significant distress or impairment in an occupation. He additionally experienced depressed mood, chronic sleep impairment, and disturbance of motivation and mood. However, the examiner determined that the Veteran's PTSD resulted in occupational and social impairment with only an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although he generally functioned satisfactorily, with normal routine behavior, self-care, and conversation. At an April 2017 VA headaches examination, the Veteran reported daily headaches with sensitivity to light and sounds and changes in vision, but no characteristically prostrating attacks of headache pain. The Veteran reported missing only two days of work since September 2016 because of headaches. The Veteran provided a private Disability Benefits Questionnaire (DBQ) dated in November 2017, assessing his service-connected sleep apnea. The examiner noted that his sleep apnea caused daytime hypersomnolence which would decrease his work performance and make driving especially dangerous. The Veteran was provided with a VA headaches examination in December 2017. He reported that he had daily headaches, with light and noise sensitivity and had prostrating attacks once per month; however, he did not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. The examiner opined that the Veteran's service-connected headaches did not impact his ability to work. In February 2018, the Veteran was provided with a VA examination to assess his service-connected sleep apnea. He was issued a continuous positive airway pressure (CPAP) machine in December 2017 and did not snore or choke while using it but continued to wake due to insomnia attributable to PTSD. The examiner opined that the Veteran's sleep apnea did not impact his ability to work. In May 2018, the Veteran was provided with a VA examination to assess his service-connected PTSD. The examiner opined that the Veteran's service-connected PTSD had resulted in occupational and social impairment with reduced reliability and productivity. He reported that he would misses work due to his significant depressive symptoms. The Veteran's symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in establishing and maintaining effective work and relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran underwent an October 2019 VA examination to assess his PTSD. The examiner found that his service-connected psychiatric disability resulted in occupational and social impairment with reduced reliability and productivity. Symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. In the context of a TDIU, "applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner." Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). In this case, while it is clear that the Veteran's service-connected disabilities have caused some occupational impairment and have resulted in symptoms including daytime sleepiness, headaches, and substantial psychiatric symptoms, the Board finds that the evidence does not support a conclusion that his service-connected disabilities have precluded employment or profoundly affected his ability to maintain his current employment. Significantly, none of the examiners have found that the Veteran's service-connected disabilities prevent the Veteran from maintaining employment. In light of the foregoing, the Board finds the preponderance of the evidence demonstrates that the Veteran is able to secure and maintain substantially gainful employment despite his many service-connected disabilities. As a result, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Entitlement to a TDIU must be denied. 38 C.F.R. § 4.16. REASONS FOR REMAND Service Connection Fibromyalgia In the JMPR, the parties agreed that the Board relied upon an inadequate medical opinion to deny service connection for fibromyalgia. The Board found that the Veteran did not have a current diagnosis fibromyalgia, based on the findings of a May 2017 VA examination. According to the findings in the JMPR, the May 2017 examiner did not clearly address whether Veteran's condition warranted a current diagnosis of the fibromyalgia. While the examiner found that the Veteran did not have, and never previously had, a diagnosis of fibromyalgia in the diagnosis section of the report, in the "Medical History" and "Remarks" sections, the examiner explained that Veteran had never been previously diagnosed with fibromyalgia but did not appear to consider whether a current diagnosis was warranted at the time of the examination. Thus, the parties agreed that the examiner's opinion was unclear as to whether the Veteran had a current diagnosis of the condition. Service Connection - Disabilities of the Right and Left Hips, Right and Left Knees, Right and Left Ankles, Lumbar Spine, and Cervical Spine In March 2017, a VA examiner diagnosed the Veteran with trochanteric pain syndrome of both hips, degenerative arthritis of the right and left knees, degenerative arthritis of the right ankle and bilateral ankle strain, degenerative arthritis of the cervical spine, and lumbosacral strain. In each instance, the examiner stated that the Veteran had a diagnosed disability with a clear and specific etiology but opined that none of the diagnosed disabilities was related to service since there was no evidence of in-service treatment in his service treatment records. In its August 2020 remand, the Board found these opinions to be inadequate as the examiner did not address the Veteran's statements that his joint, back, and neck pain began during service. The issues were remanded for additional examinations and opinions in which the examiner would address the Veteran's contentions. The Veteran was provided with VA examinations in March 2021. For each disability, the examiner opined that there was no evidence to support the specific disability was incurred in or caused by service and noted that service treatment records did not contain complaints, treatment, or diagnosis for the specific disability during service. However, while this examiner noted the Veteran's reports that he began experiencing he began experiencing pain in these joints due to physical labor while in service, she did not address these contentions in rendering her opinions, only noting that there was no evidence in service treatment records of complaints, treatment, or diagnoses. With regard to arthritis, the examiner opined that the Veteran's arthritis manifested within one year of discharge from service but did not specify the joints to which she was referring. As such, these opinions are inadequate, and new opinions are necessary, with VA examination if needed to assess the Veteran. Service Connection Erectile Dysfunction In its prior remand, the Board found that an April 2017 VA examination was inadequate, as the examiner noted that the etiology of erectile dysfunction was multifactorial including organic and inorganic etiologies but did not provide a rationale as to why the Veteran's erectile dysfunction was not related to service. This was of particular importance given the fact that the veteran reported that his erectile dysfunction symptoms developed in the year 2000, soon after separation from the service, and continued to the present. Pursuant to the Board's August 2020 remand instructions, the Veteran was provided with another VA examination in March 2021. The examiner was specifically asked to address the Veteran's contentions that he began having erectile dysfunction shortly after leaving service in 2000. However, the March 2021 VA examiner opined that the Veteran's erectile dysfunction was not related to service and merely noted the Veteran's contentions, without providing any discussion. As such, the opinion is inadequate. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for fibromyalgia. The examiner must review the claims file. The examiner is asked to determine if the Veteran now or at any point during the appeal period (since January 2017) has met the criteria for a diagnosis of fibromyalgia. Provide a rationale to support the opinion(s). 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right and left hip disability, to include trochanteric pain syndrome. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In the case of arthritis, the examiner must opine whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right and left knee disability, to include degenerative arthritis. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In the case of arthritis, the examiner must opine whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right and left ankle disability, to include degenerative arthritis. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In the case of arthritis, the examiner must opine whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right and left shoulder disability. The examiner must determine whether the Veteran has a diagnosed disability of the right or left shoulders and, if so, much opine whether it is at least as likely as not related to an in-service injury, event, or disease. If arthritis is diagnosed, the examiner must opine whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If it is determined that there is no diagnosis of a shoulder disability, the examiner must opine as to whether the objective signs and symptoms of left or right problems are manifestations of an undiagnosed illness or a medically unexplained chronic multi-symptom illness. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any lumbar spine disability, to include degenerative arthritis. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In the case of arthritis, the examiner must opine whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any cervical spine disability, to include degenerative arthritis. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In the case of arthritis, the examiner must opine whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of erectile dysfunction. The examiner must opine whether it is at least as likely as not that his contentions that he began having erectile dysfunction shortly after leaving service in 2000 would indicate that erectile dysfunction (Continued on the next page) was due to an in-service event or is etiologically related to service. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Harrigan Smith 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.