Citation Nr: 21072251 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-59 619 DATE: December 2, 2021 ORDER Entitlement to service connection for lumbar spine disability is denied. Entitlement to service connection for cervical spine disability is denied. Entitlement to service connection for left knee disability is granted. REMANDED Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for right ankle disability is remanded. Entitlement to service connection for left ankle disability is remanded. Entitlement to service connection for obstructive sleep apnea, including secondary to service-connected disabilities, is remanded. Entitlement to service connection for migraine headaches, including secondary to service-connected disabilities, is remanded. Entitlement to service connection for benign paroxysmal positional vertigo (claimed as dizziness), to include as due to an undiagnosed illness and/or medically unexplained chronic multisymptom illness (MUCMI) as a result of exposure to environmental hazards during the Persian Gulf War, and to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness and/or MUCMI as a result of exposure to environmental hazards during the Persian Gulf War, and to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for fibromyalgia, to include as due to an undiagnosed illness and/or MUCMI as a result of exposure to environmental hazards during the Persian Gulf War, and to include as secondary to service-connected disabilities, is remanded. FINDINGS OF FACT 1. The Veteran's lumbar spine disability, diagnosed as lumbosacral strain, lumbar spondylosis, degenerative arthritis of the spine, intervertebral disc syndrome, and left-sided lumbar radiculopathy, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran's cervical spine disability, diagnosed as segmental dysfunction, degenerative disc disease, and degenerative joint disease of the cervical spine, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 3. The Veteran's left knee disability, diagnosed as chondromalacia patellae and tear of articular cartilage, status post arthroscopic surgery, left knee, is related to his active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for lumbar spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for cervical spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for left knee disability are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1982 to August 1985 and from October 1987 to March 1991. The Veteran also served on active duty in the United States Air Force from March 2003 to January 2004, from February 2004 to June 2004, and August 2004 to March 2005, with additional serve in the Air Force Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2015 and January 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. A transcript of this hearing has been added to the record. The claim seeking entitlement to service connection for lumbar spine disability was first denied in a September 2012 rating decision, which concluded that there was no evidence of a lumbar spine disability both during his military service and also currently. Although the Veteran did not submit a notice of disagreement or otherwise perfect an appeal of that rating decision, new and material evidence was received within one year of the rating decision indicating that the Veteran had a current lumbar spine disability. As new and material evidence was received within one year of the September 2012 rating decision regarding the claim of entitlement to service connection for lumbar spine disability, that rating decision never became final, and the issue is recharacterized to reflect that it will be considered on the merits. See 38 C.F.R. § 3.156(b). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Moreover, where a veteran served continuously for 90 days or more during active service, and arthritis and other/or other organic diseases of the nervous system manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for lumbar spine disability. The Veteran contends that his lumbar spine disability began during his military service. At his July 2021 Board hearing, the Veteran testified that he was removing concertina wire off of his tank when he was struck by the rotating turret knocking him off the tank and injuring his low back. Through statements and testimony, the Veteran has claimed that he continued to have low back pain ever since. The Veteran has a current lumbar spine disability, diagnosed as lumbosacral strain, lumbar spondylosis, degenerative arthritis of the spine, intervertebral disc syndrome, and left-sided lumbar radiculopathy. Arthritis and radiculopathy are enumerated conditions under 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed.Cir. 2013). However, a lumbar spine disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. A review of the Veteran's service treatment records reveals that he sought treatment for a headache and dizziness two days after having been struck by a turret in January 1988. No complaints of back pain were noted, and the report concluded with an assessment of tension headache. Subsequent physical examinations performed in May 1991, June 1996, and January 2001 found his spine to be normal. On medical history reports completed pursuant to these examinations, dated in May 1991, June 1996, and January 2001, the Veteran denied any history of recurrent back pain. On a March 2003 pre-mobilization health survey, the Veteran denied ever having had pain or problems with his back. On an October 2003 post-deployment health assessment, the Veteran denied having experienced any symptoms of back pain. On an August 2004 pre-mobilization health survey, the Veteran denied ever having pain or problems with his back. On an October 2004 post deployment examination, the Veteran denied having any symptoms of back pain during the deployment. A December 2009 VA treatment report noted findings of no arthralgia, myalgia, or back pain. The first post service complaints of or treatment for a lumbar spine disability was not shown for more than seven years after the Veteran's discharge from the service, well outside the applicable presumptive period. A February 2011 VA treatment report noted the Veteran's complaints of pain in the left shoulder following a motor vehicle accident. The report concluded with an assessment of status post motor vehicle accident with left shoulder pain. An April 2011 VA treatment report noted that the Veteran has had mild back and neck pain ever since the motor vehicle accident. A June 2011 MRI examination of the lumbar spine revealed disc bulge and herniation at L5-S1. While the Veteran is competent to report experiencing symptoms of low back pain during the presumptive period and consistently since, the Board finds the Veteran's contentions of continuity of low back symptomatology not credible. His contentions are inconsistent with multiple contemporaneous treatment records reflecting normal physical findings concerning his lumbar spine. Moreover, the Veteran is shown to have repeatedly denied having any back problems during his military service and for several years thereafter. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Veteran is also not competent to provide a diagnosis in this case or determine that his current lumbar spine symptoms were manifestations of a spine injury during service as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of complicated diagnostic medical testing and pathology. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board gives more probative weight to competent medical evidence, which is silent as to any chronic lumbar spine disability until many years after his miliary service and presumptive service connection period have ended. Thus, service connection on a presumptive basis must be denied. Service connection for lumbar spine disability may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran's current lumbar spine disability and an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The July 2021 VA examiner opined that the Veteran's lumbar spine disability is not at least as likely as not related to an in-service injury, event, or disease, including his reported tank turret injury. In rendering this opinion, the VA examiner considered the evidence of record, including the Veteran's statements, prior to forming this opinion. The examiner physically examined the Veteran and also supported the opinion provided with a sufficient rationale. Specifically, the VA examiner noted that the Veteran's service treatment records are silent as to any complaints concerning his low back, silent as to any injuries to the low back, and silent as to any diagnosis or treatment for a low back disability. The VA examiner also noted that the Veteran's post service treatment records are also silent as to any complaints of or treatment for a low back disability until many years after the Veteran's military service. Thus, neither chronicity of an inservice condition, nor continuity of symptoms between service and now are established. In support of his claim, the Veteran has submitted a February 2021 opinion letter from J.E., M.D. In the letter, Dr. E. opined that the Veteran's current lumbar spine disability was related to his "occurrence of symptoms" during service. The rationale provided in support of this opinion relies exclusively on the Veteran's own narrative history of low back symptomatology, which the Board concludes is not credible. No reference is made to any of his available service treatment reports, or post service treatment reports prior to June 2011. Under these circumstances, the Board finds this opinion lacking any probative value. The Veteran has also submitted an November 2014 opinion letter from M.H., D.C. It states that the Veteran's neck and back "damage is of the approximate age which agrees with the [Veteran's] claim of injury that, more likely than not, occurred while on active duty." No supporting rationale is offered in support of this opinion. Moreover, the letter does not actually state the manner in which the Veteran claims to have been injured. Nor is there any reference to any inservice or post service treatment records which may support this opinion. Accordingly, the Board finds this opinion to be lacking probative value. Instead, the Board finds the VA examination and opinion of record to be both adequate and probative as to the question of whether the Veteran's current disability is related to his active service. The VA examiner reviewed and commented on the entire record, performed an examination and provided specific diagnoses, and supported the opinion with references to the record. Based upon a longitudinal review of the evidence of record, the Board concludes that the preponderance of the evidence is against finding that a medical nexus exists between the Veteran's current lumbar spine disability and any in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. Thus, service connection for a lumbar spine disability must be denied. Accordingly, the preponderance of the evidence is against the Veteran's claim seeking service connection for lumbar spine disability. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for cervical spine disability. The Veteran contends that his cervical spine disability began during his military service. At his July 2021 Board hearing, the Veteran testified that the physical demands of his in-service duties, including carrying a 182-pound .50 caliber machine gun, led to his cervical spine disability. Through statements and testimony, the Veteran has claimed that his cervical spine disability continued to bother him ever since. The Veteran has a current cervical spine disability, including diagnoses of segmental dysfunction, degenerative disc disease, and degenerative joint disease of the cervical spine. Arthritis and radiculopathy are enumerated conditions under 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed.Cir. 2013). However, a cervical spine disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. A review of the Veteran's service treatment records revealed no complaints of or treatment for a cervical spine disability. Physical examinations performed in May 1991, June 1996, and January 2001 listed his spine as normal. On medical history reports completed pursuant to these examinations in May 1991, June 1996, and January 2001, the Veteran denied any history of recurrent back pain. On a March 2003 pre-mobilization health survey, the Veteran denied ever having had pain or problems with his back. On an October 2003 post-deployment health assessment, the Veteran denied having experienced any symptoms of back pain. On an August 2004 pre-mobilization health survey, the Veteran denied ever having pain or problems with his back. On an October 2004 post deployment examination, the Veteran denied having any symptoms of back pain during the deployment. A December 2009 VA treatment report noted findings of no arthralgia, myalgia, or back pain. The first post service complaints of or treatment for a cervical spine disability was not shown for more than seven years after the Veteran's discharge from the service, well outside the applicable presumptive period. A February 2011 VA treatment report noted that the Veteran's complaints of pain in the left shoulder following a motor vehicle accident. The report concluded with an assessment of status post motor vehicle accident with left shoulder pain. An April 2011 VA treatment report noted that the Veteran has had mild back and neck pain since the motor vehicle accident. An April 2013 VA treatment report noted an assessment of segmental dysfunction, degenerative disc disease, and degenerative joint disease of the cervical spine. While the Veteran is competent to report experiencing symptoms of cervical spine pain during the presumptive period and consistently since, the Board finds the reports of continuity of symptomatology not credible. The Veteran's contentions are internally inconsistent with multiple reports in contemporaneous service treatment records reflecting normal physical findings concerning his spine. Moreover, the Veteran is shown to have repeatedly denied having any back problems during his military service and for several years thereafter. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Veteran is also not competent to provide a diagnosis in this case or determine that his current cervical spine symptoms were manifestations of an injury during service as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of complicated diagnostic medical testing and pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Board gives more probative weight to competent medical evidence, which is silent as to any chronic cervical spine disability until many years after his miliary service and the applicable presumptive service connection period have ended. The Board also concludes that, while the Veteran has a diagnosis of a cervical spine disability, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The Veteran's service treatment records are silent as to any complaints of or treatment for a cervical spine disability. Moreover, repeated inservice physical examinations found his spine to be normal. Post service treatment records are also silent as to any complaints of or treatment for a cervical spine disability for more than seven years after his discharge from the service. The Veteran has submitted a November 2014 opinion letter from M.H., D.C., which states that the Veteran's neck and back "damage is of the approximate age which agrees with the [Veteran's] claim of injury that, more likely than not, occurred while on active duty." No supporting rationale is offered in support of this opinion. The letter does not address the manner in which the Veteran claims to have been injured. Nor is there any reference to any inservice or post service treatment records which may support this opinion. At best, the opinion is based entirely upon the Veteran's contentions, which the Board has found not to be credible. Accordingly, the Board finds this opinion to be lacking any probative value. Based upon a longitudinal review of the evidence of record, the Board concludes that the preponderance of the evidence is against finding that a medical nexus exists between the Veteran's current cervical spine disability and any in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. Thus, service connection for a cervical spine disability must be denied. 3. Entitlement to service connection for left knee disability. The Veteran contends that he has a left knee disability related to his military service. At his July 2021 Board hearing, the Veteran testified that he injured his left knee while repairing a tank tire in 1988. He further reported having ongoing problems with his left knee ever since that injury. A review of the Veteran's service medical records reveal that he injured his left knee while taking off a road wheel in March 1989. The report noted that the resulting left knee pain prevented weight bearing or normal motion by the Veteran. A March 2003 medical assessment noted the Veteran's history of a left knee injury and pain. Thus, Veteran is shown to have had an in-service injury to his left knee. A review of the Veteran's claims file reveals a current left knee disability, diagnosed as chondromalacia patellae, medical compartmental degenerative joint disease, and tear of articular cartilage, left knee, status post arthroscopic surgery. A June 2011 x-ray examination of the left knee revealed mild medial compartmental degenerative joint disease. A May 2020 private treatment report noted diagnoses of chondromalacia patellae and tear of articular cartilage of the left knee. A June 2021 VA examination of the knee noted that the Veteran underwent arthroscopic ligament repair in July 2019. Thus, the Board's decision shall focus on whether his left knee disability is related to the Veteran's in service injury to the left knee. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current left knee disability arose during service. In support of his claim, the Veteran submitted a February 2021 opinion letter from J.E., M.D. In the letter, Dr. E. opined that the Veteran's left knee disability was more likely than not related to his inservice injury to his left knee. In support of this opinion, Dr. E. noted the Veteran's documented in-service history of injuring his left knee while removing a tank tire. Dr. E. also noted that this type of knee injury to the cartilage and menisci results in instability in the ligaments leading to arthritis and an unstable knee. Finally, Dr. E. noted the Veteran's ongoing complaints of and treatment for left knee pain ever since his inservice injury. Standing in contrast to the February 2021 opinion letter, is the June 2021 VA examiner's opinion that the Veteran's current left knee disability was less likely as not incurred in or caused by his left knee pain during service. In support of this opinion, the VA examiner concluded that the Veteran's inservice left knee injury was acute in nature, as shown by the 16-year gap from post service treatment and service separation. Contrary the VA examiner supporting rationale, the Veteran is shown to have reported ongoing left knee problems during service as late as March 2003. Moreover, a June 2011 x-ray examination of the left knee revealed mild medial compartmental degenerative joint disease. Thus, the stated rationale, a 16-year period without treatment, appears to be at least partially incorrect. Resolving all doubt in favor of the Veteran, the Board finds that service connection for left knee disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for right knee disability is remanded. 2. Entitlement to service connection for right ankle disability is remanded. 3. Entitlement to service connection for left ankle disability is remanded. The Board cannot make a fully-informed decision on the issues of service connection for right knee, right ankle, and left ankle disabilities because no VA examiner has opined whether these disabilities were caused by and/or aggravated by his now service-connected left knee disability. Moreover, no VA examiner has opined as to whether the Veteran's current bilateral ankle disabilities are related to his multiple inservice ankle injuries. Accordingly, a new examination shall be scheduled to obtain the necessary opinions to adjudicate these issues. 4. Entitlement to service connection for obstructive sleep apnea, including secondary to service-connected disabilities. The Board cannot make a fully-informed decision on the issue of obstructive sleep apnea because no VA examiner has adequately addressed the issue of whether this condition has been aggravated beyond its natural progression by the Veteran's service-connected disabilities, including PTSD. The VA examiner in January 2016 opined that the Veteran's obstructive sleep spnea was not due to or the result of the Veteran's service-connected disabilities. This opinion, however, does not address whether the Veteran's obstructive sleep apnea has been aggravated beyond its normal course by his service-connected disabilities. To this point, a July 2015 private treatment report noted an assessment of history of obstructive sleep apnea with very poor CPAP compliance due to insomnia and anxiety. Accordingly, a supplemental opinion should be obtained to adjudicate this issue. 5. Entitlement to service connection for migraine disability, including secondary to service-connected disabilities. The Board cannot make a fully informed decision on the issue of migraine disability because no VA examiner has adequately addressed the issue of whether this condition was incurred in or aggravated during his military service; or whether this condition was aggravated beyond its natural progression by the Veteran's service-connected disabilities, including PTSD. A review of the Veteran's service treatment records reveals that he was treated for headaches. Specifically, complaints of headaches are noted in January 1988 and October 2003. Moreover, the January 1988 complaints of headaches are related to a head injury. Under these circumstances, a medical opinion should be obtained addressing whether the Veteran's migraines are related to his military service. As for service connection on a secondary basis, the VA examiner in January 2016 opined that the Veteran's migraine disability was not due to or the result of his service-connected disabilities. This opinion, however, does not address or otherwise provide an adequate rationale regarding whether the Veteran's obstructive sleep apnea has been aggravated beyond its normal course by the Veteran's service-connected disabilities. In this regard, a July 2015 private treatment report noted an assessment of frequent migraines very likely due to cervicogenic headaches refracting migraine compounded by PTSD. Accordingly, a new examination shall be scheduled to obtain the necessary opinions to adjudicate this issue. 6. Entitlement to service connection for benign paroxysmal positional vertigo (claimed as dizziness), to include as due to an undiagnosed illness and/or MUCMI as a result of exposure to environmental hazards during the Persian Gulf War, and to include as secondary to service-connected disabilities, is remanded. 7. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness and/or MUCMI as a result of exposure to environmental hazards during the Persian Gulf War, and to include as secondary to service-connected disabilities, is remanded. 8. Entitlement to service connection for fibromyalgia, to include as due to an undiagnosed illness and/or MUCMI as a result of exposure to environmental hazards during the Persian Gulf War, and to include as secondary to service-connected disabilities, is remanded. The Veteran contends that he has dizziness, nausea, chronic fatigue, joint and muscle pain throughout his body, as a result of his service exposure to environmental hazards during the Persian Gulf War. Alternatively, he contends that these conditions are secondary to his service-connected PTSD. Regrettably, the Board concludes that it cannot make a fully informed decision in this matter without additional development. A January 2016 VA examination for ear conditions concluded with a diagnosis of benign paroxysmal positional vertigo. The Veteran contends that this disability began after he was injured by a tank turret in January 1988. A review of his service treatment records reveals that he sought treatment for a headache and dizziness two days after having been struck by a turret in January 1988. An October 2003 treatment report also noted his complaints of vomiting, nausea, and dizziness. Under these circumstances, an examination should be scheduled to address whether the Veteran's current benign paroxysmal positional vertigo was caused or aggravated by his military service, including inservice environmental exposures while service in the Persian Gulf. The evidence of record also does not adequately address whether the Veteran's claimed remaining symptomatology, including nausea, chronic fatigue, joint and muscle pain throughout his body, are attributable to a known clinical diagnosis or whether it is an objective indication of a chronic disability (a disability that existed 6 months or more) resulting from an undiagnosed illness related to the Veteran's service in the Persian Gulf. Although a VA Gulf War examination was conducted in January 2020, it fails to fully identify and address the Veteran's contentions concerning his claimed symptomatology. Under these circumstances, the Board concludes that new examinations should be scheduled to ascertain the nature of the Veteran's present symptoms/disabilities, and also obtain medical opinions addressing whether any condition identified is related to the Veteran's military service, including whether each is due to an undiagnosed illness or other qualifying chronic disability from Persian Gulf War service and/or secondary to service-connected disabilities. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Schedule the Veteran for a VA examination for his right knee and bilateral ankle disabilities. The examiner must review the claims file. The examiner is asked to identify all current disabilities found involving the Veteran's right knee and bilateral ankles. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinions below. For each disability or condition manifested by functional impairment identified, the examiner is asked to provide a response to the following: (a) Is the disability at least as likely as not related to service, including the Veteran's inservice treatment for right and left ankle injuries? This should include consideration of inservice treatment for his right ankle in December 1988, January 1989, December 1998; and his left ankle in December 1988, April 1990, and an April 1990 left ankle sprain profile. (b) If a disability is not shown to be related to service, is it at least as likely as not: (a) proximately due to, or (b) aggravated, i.e., worsened beyond its natural progression, by his service-connected disabilities? Provide a rationale to support the opinions. In providing the requested opinion, consider the Veteran's description of his 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 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. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's obstructive sleep apnea is at least as likely as not related to, proximately due to, or aggravated beyond its natural progression by his service-connected disabilities. 4. Schedule the Veteran for a VA examination for his migraine headache disability. The examiner must review the claims file. Thereafter, the VA examiner must provide an opinion on the following: (a) Is the Veteran's migraine headache disability at least as likely as not related to service, including consideration of the Veteran's inservice treatment for headaches following a head injury in January 1988 and subsequent inservice complaints of headaches in October 2003? (b) If the Veteran's migraine headache disability is not shown to be related to service, is it at least as likely as not: (a) proximately due to, or (b) aggravated, i.e., worsened beyond its natural progression, by his service-connected disabilities? This should include consideration of an October 2015 private treatment report noting as assessment of frequent migraines compounded by PTSD and insomnia. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his 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 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 appropriate examination to determine the nature and etiology of his claimed dizziness, nausea, chronic fatigue, joint and muscle pain throughout his body. The examiner must review the entire claims file, including a copy of this remand. The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if possible. The examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a disability, considering the Veteran's claims of dizziness, nausea, chronic fatigue, joint and muscle pain throughout his body. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for her symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis? This should include consideration of his diagnosis of benign paroxysmal positional vertigo. If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. E) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. F) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition was incurred in, or is otherwise related to, her active service? G) The examiner should also address if any of the Veteran's claimed symptoms of dizziness, nausea, chronic fatigue, joint and muscle pain throughout his body are at least as likely as not proximately due to or aggravated beyond its natural progression by her service-connected disabilities. A complete rationale must be provided for all opinions expressed. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board W. Yates, 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.