Citation Nr: 21066106 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 14-08 754 DATE: October 28, 2021 REMANDED Entitlement to service connection for a chronic multi-symptom disability under 38 C.F.R. § 3.317, to include symptoms of pain and numbness affecting the bilateral upper and lower extremities, and cervical and lumbar spine, claimed as Gulf War Syndrome, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2006 to October 2010, with additional service in the Army Reserve. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision by a Department of Veterans Affairs Regional Office (RO). In May 2018, the Veteran testified at a Travel Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. This case was remanded in October 2018. The Board remanded this case again in August 2020 and instructed the Agency of Original Jurisdiction (AOJ) to obtain a VA examination. During the pendency of the appeal, a July 2021 rating decision granted service connection for posttraumatic stress disorder. Therefore, as the AOJ granted the benefit sought on appeal, that issue is no longer before the Board. Chronic Multi-Symptom Disability Under 38 C.F.R. § 3.317 As noted above, this claim was remanded in August 2020 to obtain a VA examination. The Board notes that a series of VA examinations including a Gulf War Illness examination were obtained in March 2021. As noted in the Remand, VA medical records and prior VA examinations evidenced reports of bilateral knee and foot pain, and the Board noted that a March 2020 VA examination did not address those records. The March 2021 VA Gulf War examination noted that VA medical records showing complaints of bilateral foot and knee pain were reviewed. However, with regard to any muscle, fibromyalgia, neuropathy, foot, ankle, knee, hip, hand or wrist condition, the examiner noted that there were no signs, symptoms, evaluations, therapies (including medication), or diagnosis for any such conditions. Physical examinations were also noted as normal. The examiner found no diagnosed illness for which no etiology had been established. The examiner also found no signs or symptoms that might represent an "undiagnosed illness" or a "diagnosed medically unexplained chronic multi-symptom illness. Separate VA examinations were also obtained evaluating the Veteran for fibromyalgia, muscle and peripheral nerve conditions, as well as musculoskeletal examinations for the neck, back, shoulders, elbows, wrists, hips, knees, ankles and feet. For each of these conditions, the examiner provided negative nexus opinions supported by a statement that there were no signs, symptoms, evaluations, therapies, medications or other diagnoses. As noted in the prior Remand, VA medical records do note signs, symptoms and treatment for chronic bilateral knee and foot pain. More specifically, VA medical records show that beginning in June 2011, the Veteran reported joint and back pain, and tingling/numbness which were reported as combat related injuries. The Veteran specifically reported numbness in his feet when running, and joint pain in his knees, shoulders and low back. Neck pain was reported in September 2011. In November 2015, he reported intermittent problems with his knees and feet since service, and that those conditions had recently worsened. Pain medication reportedly did not help. He was treated with an injection of Toradol. A February 2016 VA medical record noted knee pain treated with Naproxen and topical analgesics. The Veteran also reported experiencing pain in his bilateral knee and foot described as aching and throbbing and which interfered with physical activity. He reported experiencing right arm pain with symptoms worsening with activity in July 2017. He also reported ongoing knee pain in June 2019, and the physician noted a 5 year history for chronic knee pain. See VA Medical Records Received August 2020. More recently, in June 2020, the Veteran reported continued bilateral knee and back pain. The examiner noted he was morbidly obese and that his body mass index was over 40 percent, which he explained contributed to the pain symptoms. The examiner also noted a diagnosis for bilateral knee osteoarthritis and back pain, however, the Veteran declined undergoing an imaging study. He was also prescribed pain medication. See VA Medical Records Received August 2020. Therefore, VA medical records are replete with evidence of signs, symptoms, evaluations, therapies, medications and/or other diagnoses related to knee, foot, back, neck and shoulder pain. As noted above, the examiner was instructed to address these VA medical records. While, the examiner did indicate that these records were reviewed, he further indicated that there were no relevant VA medical records. For reasons cited above, the Board finds the March 2021 VA examinations inadequate, and the matter must be remanded. The matter is 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 not already associated with the file. 2. Then, schedule the Veteran for an appropriate VA examination to determine the nature, extent, and etiology of any medically undiagnosed symptoms, including those involving the bilateral upper and lower extremity, and cervical and lumbar spine (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). Current VA Gulf War Examination Guidelines must be followed. All indicated tests should be performed, and all findings reported in detail. Specifically, the VA examiner's opinion should address the following: (a) State whether the Veteran's cervical and lumbar spine and bilateral upper and lower extremity complaints are attributable to known clinical diagnoses, or whether those reported problems are manifestations of an undiagnosed illness. The examiner is asked to consider VA medical records showing complaints and treatment related to knee, foot, back, neck and shoulder pain. See VA Medical Records dated June and September 2011, July 2013, November 2015, February 2016, July 2017, June 2019 and June 2020. The examiner should also consider the June 2020 VA medical record noting a diagnosis for bilateral knee osteoarthritis. (b) For any symptoms attributable to a known clinical diagnosis, state whether it is at least as likely as not (50 percent probability or greater) that the condition(s) had clinical onset during active service or is related to any in-service disease, event, or injury. (c) If any of the symptoms have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. If a diagnosable condition is not appropriate to account for any of the distinct groupings of symptoms detailed by the Veteran, please note whether he has a medically unexplained chronic multi-symptom illness corresponding to each distinct grouping of symptoms detailed by the Veteran for which there is no diagnosable condition that accounts for that symptomatology. (Continued on the next page) The examiner should review pertinent documents in 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 C. Lamb, 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.