Citation Nr: 21072983 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 16-45 353 DATE: December 7, 2021 ORDER The claim for an initial compensable disability rating for service-connected vertigo is dismissed. The claim for an effective date earlier than May 1, 2015, for service-connected tinnitus is denied. New and material evidence has been received; the petition to reopen the claim for service connection for asthma is granted. New and material evidence has been received; the petition to reopen the claim for service connection for joint pain is granted. New and material evidence has not been received; the petition to reopen the claim for service connection for headaches is denied. Service connection for chronic fatigue syndrome as due to service in Southwest Asia during the Persian Gulf War is granted. Service connection for a respiratory condition, to include asthma, is granted. Service connection for bilateral pes planus (flatfeet) is granted. Service connection for a right shoulder disability is granted. Service connection for a left shoulder disability is granted. Service connection for erectile dysfunction as secondary to service-connected left varicocele is granted. Service connection for right varicocele is granted. Service connection for tuberculosis and residuals thereof is denied. REMANDED Service connection for joint pain is remanded. Service connection for a throat condition, to include a swollen throat, is remanded. Service connection for a right knee disability, to include patellofemoral pain syndrome and arthritis, is remanded. Service connection for a left knee disability, to include patellofemoral pain syndrome and arthritis, is remanded. Service connection for a sinus disability, to include sinusitis and allergic rhinitis, to include as to due to service in the Southwest Asia Theater of Operations during the Persian Gulf War, is remanded. Service connection for a hernia is remanded. Service connection for a back disability is remanded. Service connection for a left hip disability is remanded. Service connection for left eye retinal hole without detachment (claimed as left eye/tear in retina) is remanded. Service connection for irritable bowel syndrome is remanded. The claim for an increased initial disability rating in excess of 30 percent from January 22, 2015, to March 14, 2017, and in excess of 50 percent thereafter, for service-connected posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo is remanded. The claim for an initial compensable disability rating for service-connected left varicocele disability (claimed as left testicular condition) is remanded. The claim for special monthly compensation based on loss of use of creative organ is remanded. The claim for a total disability rating based on individual unemployability is remanded. FINDINGS OF FACT 1. The Veteran's vertigo is subsumed within his rating for service-connected posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo; thus, there is no claim on which to grant a separate rating for vertigo. 2. The earliest date on which service connection for tinnitus may be effective is May 1, 2015, the date the Veteran filed his claim for service connection for tinnitus. 3. Since the final August 2004 decision, new and material evidence has been received that raises a reasonable possibility of substantiating the Veteran's claim for service connection for asthma. 4. Since the final August 2004 decision, new and material evidence has been received that raises a reasonable possibility of substantiating the Veteran's claim for service connection for joint pain. 5. Since the final August 2004 decision, new and material evidence has not been received that raises a reasonable possibility of substantiating the Veteran's claim for service connection for headaches. 6. The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, and he is diagnosed with chronic fatigue syndrome, a medically unexplained chronic multi-symptom illness, which manifested in service and has existed for more than six months. 7. The Veteran's respiratory condition, to include asthma, began during active service. 8. The Veteran's bilateral pes planus (flatfeet) began during active service. 9. The Veteran's right shoulder disability began during active service. 10. The Veteran's left shoulder disability began during active service. 11. The Veteran's erectile dysfunction is proximately due his service-connected left varicocele. 12. The Veteran's right varicocele began during active service. 13. The preponderance of the evidence of record is against finding that the Veteran has had tuberculosis or accompanying residuals thereof at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The claim for an initial compensable disability rating for vertigo as a separate and distinct disability is moot. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 4.14, 20.104. 2. The criteria for an effective date earlier than May 1, 2015, for the award of service connection for tinnitus have not been met. 38 U.S.C. §§ 5101, 5107, 5110; 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.159, 3.400. 3. The August 2004 rating decision that denied service connection for asthma is final; however, new and material evidence raising a reasonable possibility of substantiating that claim has been received. Thus, the claim is reopened. 38 U.S.C. §§ 5103A, 5108, 7105; 38 C.F.R. §§ 3.156, 19.52, 20.1103. 4. The August 2004 rating decision that denied service connection for joint pain is final; however, new and material evidence raising a reasonable possibility of substantiating that claim has been received. Thus, the claim is reopened. 38 U.S.C. §§ 5103A, 5108, 7105; 38 C.F.R. §§ 3.156, 19.52, 20.1103. 5. The August 2004 rating decision that denied service connection for headaches is final; and new and material evidence raising a reasonable possibility of substantiating that claim has not been received. Thus, the claim is not reopened. 38 U.S.C. §§ 5103A, 5108, 7105; 38 C.F.R. §§ 3.156, 19.52, 20.1103. 6. The criteria for entitlement to service connection for chronic fatigue syndrome are met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 7. The criteria for service connection for a respiratory condition, to include asthma, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for bilateral pes planus (flatfeet) are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for a right shoulder disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for service connection for a left shoulder disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for service connection for erectile dysfunction as secondary to left varicocele are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 12. The criteria for service connection for right varicocele are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for service connection for tuberculosis and residuals thereof are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1978 until his honorable discharge in July 1981; he served again from September 1981 until his honorable retirement in June 1998. His active service included a tour of duty in Southwest Asia Theater of Operations from December 1990 to May 1991. He was awarded numerous medals, badges, and other accolades for his service. This case comes before the Board of Veterans' Appeals (Board) on appeal from July 2015, August 2015, and July 2016 decisions by the Nashville, Tennessee, Regional Office of the United States Department of Veterans Affairs (VA). In April 2021, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. Since transfer of the case to the Board, VA and the Veteran have associated numerous new and relevant medical documents with the Veteran's claims file. Pursuant to 38 C.F.R. § 20.1305(c), this evidence "must be referred to the agency of original jurisdiction for review, unless this procedural right is waived by the appellant or representative, or unless the Board determines that the benefit or benefits to which the evidence relates may be fully allowed on appeal without such referral." In August 2021, the Board sent the Veteran and his representative a letter regarding this new and relevant evidence informing him of his right to waive initial consideration of these documents by the VA Regional Office. In a September 22, 2021, correspondence, the Veteran opted to waive his right to have his appeal remanded to the VA Regional Office for consideration of the evidence in the first instance. As such, the Board will adjudicate his claims. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits and when rating disabilities. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (service connection); 38 C.F.R. § 4.3 (disability rating). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analyses below focus on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. Dismissal of Appeal The Board has an obligation to ensure that a case or controversy exists. 38 U.S.C. §§ 7104, 7105. A case or controversy ceases to exist, and a case becomes moot, "when the issues presented are no longer 'live' or the parties lack a legally cognizable interest in the outcome." Godsey v. Wilkie, 31 Vet. App. 207, 218 (2019). When the relief sought by an appeal has been accomplished, the appropriate course of action is for the Court to dismiss the matter as moot. Long v. Principi, 17 Vet. App. 555, 557 (2004). 1. The appeal for an initial compensable disability rating for service-connected vertigo is dismissed. The Veteran filed a claim for service connection for vertigo in February 2016. The VA Regional Office granted service connection in a July 2016 decision and assigned an initial noncompensable disability rating effective January 19, 2016. Following the Veteran's timely appeal to the Board of the initial rating assignment for vertigo, the VA Regional Office granted service connection for traumatic brain injury in a February 2020 decision. As part of the Veteran's traumatic brain injury, a VA-contracted examiner documented that his residual symptoms included tension headaches and vertigo. Accordingly, the VA Regional Office determined that the Veteran's traumatic brain injury subsumed his service-connected vertigo as it was an associated residual. In addition, at that time, the Veteran was also service connected for posttraumatic stress disorder. A VA-contracted examiner opined that it was not possible to differentiate the overlap and concurrent nature of symptoms attributable to the Veteran's psychiatric disability and traumatic brain injury. Consequently, the VA Regional Office rated the Veteran's posttraumatic stress disorder and traumatic brain injury and residual symptoms as one entity, assigning the disability the title, "posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo." The VA Regional Office assigned the Veteran an initial 30 percent disability rating effective January 22, 2015, and a 50 percent disability rating as of March 14, 2017. Consequently, there is no longer a separate service connection for vertigo. The initial grant of service connection for vertigo was subsumed by the Veteran's service-connected traumatic brain injury because vertigo is a symptom of that disability. The Veteran's psychiatric disability and traumatic brain injury were rated as one disability under 38 C.F.R. § 4.130, Diagnostic Code 8045-9411 because their symptomatology overlapped and could not be separated. See 38 C.F.R. § 4.14 (rule against "pyramiding"); see generally Boggs v. Peake, 520 F.3d 1330, 1337 (Fed. Cir. 2008) ("[A] veteran cannot be compensated more than once for the same disability."). Accordingly, the Veteran's claim for an initial compensable disability rating for service-connected vertigo is moot because the VA Regional Office assigned an initial 30 percent disability rating for the Veteran's posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo effective January 22, 2015, which is prior to the initial effective date of January 19, 2016, for the initial grant of service connection for vertigo on its own. The Board recognizes that the Veteran's claim for an initial disability rating for vertigo naturally equates to a claim for an increased disability rating for posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo. The Veteran currently has a separate claim within this appeal pending for an increased disability rating for posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo, which covers the entire period of the original claim for a compensable disability rating for vertigo. Therefore, no prejudice results from dismissal of the claim for a compensable disability rating for vertigo on its own. See generally Norvell v. Peake, 22 Vet. App. 194, 20001 (2008) (discussing mootness). Earlier Effective Date The general rule under 38 U.S.C. § 5110(a) and 38 C.F.R. § 3.400 is that the effective date of a veteran's disability compensation shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefor. See Sutton v. Nicholson, 20 Vet. App. 419, 422 (2006). 2. The claim for an effective date earlier than May 1, 2015, for service-connected tinnitus is denied. The Veteran filed a claim for service connection for tinnitus on May 1, 2015. The VA Regional Office granted service connection for tinnitus in an August 2015 decision, assigning a 10 percent disability rating effective May 1, 2015. The Veteran filed a notice of disagreement in which he asserted he was entitled to an earlier effective date. During his April 2021 Board hearing, rather than offering testimony or argument at that time, the Veteran's representative stated he would file a post-hearing brief addressing entitlement of an earlier effective date. The Board received a post-hearing brief in May 2021. On review of the brief, the Board finds no argument as to why the Veteran believes he is entitled to an earlier effective date for his service-connected tinnitus. Following complete review of the record, the Board also finds no legal or factual bases on which to award an earlier effective date. The first claim for service connection for tinnitusor any claim that may be reasonably construed as including tinnituswas not filed until May 1, 2015. Accordingly, pursuant to 38 U.S.C. § 5110(a) and 38 C.F.R. § 3.400, the earliest date for which the Veteran's disability benefits for tinnitus may become effective is May 1, 2015. Therefore, an entitlement to an earlier effective date is not warranted. New and Material Evidence To appeal a rating decision, the appellant must file a "notice of disagreement" "within one year from the date of the mailing of notice of the decision of the agency of original jurisdiction." 38 U.S.C. § 7105(b)(1)(A); 38 C.F.R. § 19.2(c). A notice of disagreement must be submitted in writing and identify the specific determination with which the claimant disagrees. 38 U.S.C. § 7105(b)(2)(A). If no notice of disagreement is filed within the prescribed period, the action or decision of the agency of original jurisdiction becomes final from the date notice was mailed. 38 U.S.C. § 7105(c). For the purposes of reopening claims decided by the agency of original jurisdiction (AOJ) before February 19, 2019 (the effective date of the Veterans Appeals Improvement and Modernization Act of 2017), such claims are still considered "Legacy Appeals" and are to be analyzed under VA's traditional "Legacy" process. See 38 C.F.R. § 3.156(a); 38 C.F.R. § 3.2400(b). Under the Legacy process, a veteran "may reopen a finally adjudicated legacy claim by submitting new and material evidence." 38 C.F.R. § 31.56(a). Regardless of the AOJ's determination as to whether new and material evidence was received, the Board must address the issue in the first instance because it ultimately affects the Board's jurisdiction to adjudicate the underlying claims. See Woehlaert v. Nicholson, 21 Vet. App. 456, 46061 (2007) (citation omitted). The Board must perform a two-step analysis when a veteran seeks to reopen a final decision based on new and material evidence. See Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). First, it must determine whether the evidence presented or secured since the last final disallowance is "new and material." Id. If it is, the Board must then reopen the claim and "evaluate the merits of the veteran's claim in light of all the evidence, both new and old." Id. "New evidence" "is evidence not previously part of the actual record before agency adjudicators." 38 C.F.R. § 3.156(a). VA is required to presume the credibility of newly submitted evidence for the purposes of determining whether that evidence is material and sufficient to reopen a previously denied claim. Justus v. Principi, 3 Vet. App. 510, 513 (1992). "Material evidence" means "evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim." 38 C.F.R. § 3.156(a). "New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim and must raise a reasonable possibility of substantiating the claim." 38 C.F.R. § 3.156(a). The language of section 3.156(a) "does not require new and material evidence as to each previously unproven element of a claim"; instead, it compels reopening whenever a claimant submits new and material evidence "as to an unestablished fact from the previously denied claim." Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). In Shade, the Court held that the language of section 3.156(a), requiring the new evidence raise a reasonable possibility of substantiating the claim, is an analytical guide that creates a low threshold rather than a separate element. Id. at 117. In determining whether the low threshold is met, however, VA should consider whether the new and material evidence could, if the claim were reopened, reasonably substantiate the claim, to include triggering VA's duty to assist or through consideration of an alternative theory of entitlement not previously established by the evidence, id. at 11719, but not including "presentation of new arguments based on evidence already of record at the time of the previous decision," Untalan v. Nicholson, 20 Vet. App. 467, 470 (2006) (emphasis added). 3. New and material evidence has been received, the petition to reopen the claim for service connection for asthma is granted. 4. New and material evidence has been received, the petition to reopen the claim for service connection for joint pain is granted. The Board addresses the Veteran's petitions to reopen his claims for service connection for asthma and joint pain together as they involve substantially similar legal and factual analyses. The VA Regional Office issued an August 2004 decision denying service connection for asthma and joint pain. The Veteran did not file a timely notice of disagreement with that decision, new and material evidence was not received within one year of notification of the decision that was not already considered by the VA Regional Office as part of its decision, and no appeal was otherwise taken. Therefore, the August 2004 decision is final. The Veteran filed a petition to reopen his claims for service connection for asthma and joint pain in January 2015. Since the August 2004 decision, numerous documents have been submitted, including medical records and lay statements, and testimony has occurred related to these claims. In particular, multiple VA-contracted examinations, each dated March 22, 2019, addressing the Veteran's asthma, biliteral knee disabilities and back disability (which the Board reasonably construes as related to "joint pain") are new and material evidence. There is also a December 2019 chronic fatigue syndrome disability benefits questionnaire and opinion completed by a private physician and submitted by the Veteran, which the Board finds is new and material evidence. This evidence raises a reasonable possibility of substantiating the claims for service connection. Accordingly, the Board finds that new and material evidence has been received warranting reopening of his claims for service connection for asthma and joint pain. 5. New and material evidence has not been received, the petition to reopen the claim for service connection for headaches is denied. The VA Regional Office issued an August 2004 decision denying service connection for headaches. The Veteran did not file a timely notice of disagreement with that decision, new and material evidence was not received within one year of notification of the decision that was not already considered by the VA Regional Office as part of its decision, and no appeal was otherwise taken. Therefore, the August 2004 decision is final. Since the August 2004 decision, the Veteran became service connected for posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo. He received an initial 30 percent disability rating effective January 22, 2015, the date he filed a claim to reopen his claim for service connection for headaches. Within this decision, the Board has granted service connection for chronic fatigue syndrome based in part on symptoms of headaches. The evidence that has been received, to include statements, testimony, VA-contracted and private medical examinations, does not raise a reasonable possibility of substantiating a claim for service connection for headaches that is separate and distinct from the current service-connected residual headaches associated with the Veteran's traumatic brain injury or his chronic fatigue syndrome. The Board acknowledges that an October 2019 VA-contracted examiner diagnosed the Veteran with tension headaches and a March 2019 VA-contracted examiner diagnosed him with migraine headaches. There is no indication in the record, based on competent medical evidence, that the Veteran's headaches, tension or migraine, are separate and distinct disabilities apart from his traumatic brain injury residuals or chronic fatigue syndrome. The Veteran seems to acknowledge as much, stating in his May 2021 post-hearing brief, "many if not all of the claimed conditions represented on this appeal can be considered as symptoms of one illness, . . . chronic fatigue syndrome." For these reasons, the Board concludes the evidence is not new and material as it does not raise a reasonable possibility of substantiating a separate and distinct claim for service connection for headaches because the Veteran's headaches are symptoms of currently service-connected disabilities. Accordingly, the Board finds the Veteran has not submitted new and material evidence warranting reopening of his claim for service connection for headaches. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 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). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. In addition to direct service connection, presumptive service connection is available for Persian Gulf War veterans who exhibit objective indications of "qualifying chronic disabilities," provided that any such disability manifests "during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War" or to a degree of 10 percent or more no later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117(a); 38 C.F.R. § 3.317(a)(1)(i). This presumption alleviates the need for the Veteran to establish a direct causal link between service and his or her disability. A "chronic disability" is defined "as disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period." 38 C.F.R. § 3.317(a)(4). A "qualifying" chronic disability is one that results from either an undiagnosed illness or a medically unexplained chronic multi-symptom illness, such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder. 38 U.S.C. § 1117(a)(2)(A); 38 C.F.R. § 3.317(a)(2)(i). The term "medically unexplained chronic multi-symptom illness (MUCMI)" is "a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." 38 C.F.R. § 3.317(a)(2)(ii); see Stewart v. Wilkie, 30 Vet. App. 383, 390 (2018) ("Under the proper interpretation of the law, an illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Conversely, a multi-symptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood."); 38 C.F.R. § 3.317(a)(2)(ii). The determination of whether an illness is "medically unexplained" or without a conclusive etiology is particular to the claimant in each case and requires a medical opinion. Stewart, 30 Vet. App. at 391 (noting that a MUCMI determination is "to be based on a claimant's unique symptoms and the evidence of record"). Therefore, an illness cannot, as a general matter, be excluded from being a MUCMI on the basis of definitional materials or treatises alone. Id. ("[G]eneric information in a medical journal or treatise that certain factors could cause a medical condition does not, as a general matter, establish nexus absent additional evidence that those factors did cause a veteran's condition." Rather, there must be an examination of "all the facts of record and the claimant's unique symptoms." Id. Significantly, there must be objective indications of qualifying chronic disabilities. 38 C.F.R. § 3.317(a)(1). "Objective indications of chronic disability" include both "signs," in the medical sense of 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); see also 38 U.S.C. § 1117(g) (listing examples of signs and symptoms that may be manifestations of undiagnosed illnesses or a MUCMI); 38 C.F.R. § 3.317(b) (same). Additional legal theories of service connection will be addressed within this decision where appropriate. 6. Service connection for chronic fatigue syndrome as due to service in Southwest Asia during the Persian Gulf War is granted. The Veteran filed a general claim for service connection for fatigue in February 2016. Although no VA examiner diagnosed him with chronic fatigue syndrome, the Veteran submitted a private December 2019 medical examination and opinion addressing chronic fatigue syndrome. That physician diagnosed the Veteran with chronic fatigue syndrome as of 1991. The physician recorded that following the Veteran's military service in Southwest Asia during the Gulf War in 1991, he experienced a sudden onset of abnormal fatigue, headaches, pulmonary, sleeping, and mental issues, muscle pain, and throat issues. Following consideration of the Veteran's VA claims file, medical history, and lay statements, the physician concluded that the Veteran's chronic fatigue syndrome was at least as likely as not incurred in or caused by his military service in Southwest Asia during the Gulf War. He also provided a detailed rationale in support of his conclusion. The Board finds this opinion and accompanying rationale is the most probative evidence of record addressing the etiology of the Veteran's chronic fatigue syndrome. The Veteran is considered a Gulf War veteran due to his service in Southwest Asia during the Gulf War. His diagnosed chronic fatigue syndrome, which has existed for more than six months, is a qualifying chronic disability as it constitutes an unexplained chronic multi-symptom illness. 38 C.F.R. § 3.117(a)(2)(i)(B)(1). Accordingly, the Veteran is entitled to presumptive service connection for his chronic fatigue syndrome. 38 U.S.C. § 1117(a); 38 C.F.R. § 3.317(a)(1)(i). The Board acknowledges that the Veteran has submitted a post-hearing brief in which he asks the Board to address the appropriate rating for his chronic fatigue syndrome. The Board concludes that the VA Regional Office must address the appropriate rating in the first instance, particularly because the rating may be influenced by the Veteran's other service-connected disabilities and the potential for overlapping symptoms. 7. Service connection for a respiratory condition, to include asthma, is granted. First element: A current disability According to a March 2019 VA-contracted examination, the Veteran has a diagnosis of asthma. Therefore, the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof The Veteran asserts that he had an onset of asthma in service and that the disability has continued since service. He stated that he began having breathing problems in 1991, which resulted in struggles with physical training. The Board finds a June 1992 in-service medical record documented that the Veteran sought treatment for difficulty breathing, coughing, and weakness. The medical professional diagnosed him with an upper respiratory infection, "probably bronchitis." April 1993 and May 1993 in-service medical records documented shortness of breath. He also received an inhaler for his breathing issues while in service. During his June 1998 retirement examination, the Veteran reported chronic breathing issues, including asthma, since 1991. The examining medical professional recorded the Veteran's breathing issues but noted that the Veteran did not need an inhaler during the retirement examination. The Board finds that the evidence sufficiently establishes an in-service onset of respiratory conditions. Therefore, the second element is satisfied. Third element: A causal link No medical opinion has been obtained addressing the etiology of the Veteran's asthma on a direct basis. Nevertheless, the Board finds one is not necessary because there is competent, credible, and probative lay evidence in the record that sufficiently establishes a link between the Veteran's military service and respiratory condition. First, the Veteran's June 1978 entrance examination, April 1981 exit examination, and October 1981 entrance examination did not document respiratory issues. Therefore, at each point of his entrance into the military, the Veteran was sound. 38 U.S.C. § 1111 ("[E]very veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment."); see also 38 C.F.R. § 3.304(b). Second, the Veteran testified that his asthma has continued since service. He continues to receive treatment for his asthma. The Veteran also testified that his breathing issues did not begin until he returned from service in Southwest Asia in 1991. The Board finds the Veteran's testimony credible. Furthermore, his testimony is probative as to the continuous nature of his respiratory conditions. Although he did not seek continuous treatment for this disability, that is of no consequence. A Veteran is capable of explaining continuous symptoms that are readily observable by a lay person. Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms). Significantly, there is no evidence of record indicating that the Veteran's respiratory conditions stem from some other non-service event. When viewing the evidence as a whole, the Board finds that the evidence sufficiently establishes that the Veteran's current respiratory conditions are reasonably related to the onset of breathing difficulties that began while in military service. The Veteran's lay statements and testimony are enough for the Board to conclude that he has continuously experienced respiratory issues since the initial onset in service in 1991. See Savage v. Gober, 10 Vet. App. 488, 497 (1997) (holding that lay evidence of continuing symptoms of a disability following service can be sufficient to demonstrate a medical nexus between a current disability and an in-service event or injury, even where there is no medical opinion establishing that nexus). Therefore, the third element is satisfied. Accordingly, service connection for a respiratory condition, to include asthma is warranted. 8. Service connection for bilateral pes planus (flatfeet) is granted. First element: A current disability According to a March 2019 VA-contracted examination, the Veteran has a diagnosis of bilateral pes planus. Therefore, the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof The Veteran asserts that he experienced an onset of bilateral pes planus in service and that the disability has continued since service. The Board finds a November 1984 in-service treatment record documented that the Veteran sought treatment for pain in his feet, which he had for the preceding three weeks. The treating medical professional diagnosed him with bilateral pes planus. He also testified that his feet issues developed due to his physical training during his active service, to include running in military boots for the first four years of his military service. The Board finds that the evidence sufficiently establishes an in-service onset of bilateral pes planus. In addition, the Board finds the Veteran's testimony about his physical training and subsequent feet issues credible and probative such that it establishes an in-service event. Therefore, the second element is satisfied. Third element: A causal link A medical opinion has not been obtained addressing the etiology of the Veteran's bilateral pes planus. Nevertheless, the Board finds one is not necessary because there is competent, credible, and probative lay evidence in the record that sufficiently establishes a link between the Veteran's military service and bilateral pes planus. First, the Veteran's June 1978 entrance examination, April 1981 exit examination, and October 1981 entrance examination did not document bilateral pes planus other similar feet issues. Therefore, at each point of his entrance into the military, the Veteran was sound. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Second, the Veteran testified that his bilateral pes planus has continued and worsened since service. Recently, he received additional shoe inserts to use to accommodate his feet. The Board finds the Veteran's testimony credible. Furthermore, his testimony is probative as to the continuous nature of his bilateral pes planus. Although he did not seek continuous treatment for this disability, that is of no consequence. A Veteran is capable of explaining continuous symptoms that are readily observable by a lay person. Jandreau, 493 F.3d at 1377. Significantly, there is no evidence of record indicating that the Veteran's bilateral pes planus stems from some other non-service event. When viewing the evidence as a whole, the Board finds that the evidence sufficiently establishes that the Veteran's current bilateral pes planus is reasonably related to the onset of pes planus that began while in military service. The Veteran's lay statements and testimony are enough for the Board to conclude that he has continuously experienced bilateral pes planus since its initial onset in service. See Savage, 10 Vet. App. at 497. Therefore, the third element is satisfied. Accordingly, service connection for bilateral pes planus is warranted. 9. Service connection for a right shoulder disability is granted. 10. Service connection for a left shoulder disability is granted. The Board addresses the Veteran's claims for service connection for his right and left shoulders together as they involve substantially similar legal and factual analyses. First element: A current disability According to a March 2019 VA-contracted examination, the Veteran is diagnosed with a rotator cuff tear in each shoulder as of 1990. As a result of those tears, the Veteran currently reports limited mobility in each shoulder. The March 2019 examiner documented limited range of motion in each shoulder on passive testing and noted pain throughout the examination. The Veteran also testified that his right shoulder is now "dead" and he "cannot do anything with it." April 2021 Board Hearing Transcript, at 23. Although there is no specifically diagnosed disability at this time, the Veteran's pain and limitation of mobility are sufficient to constitute a current disability. Saunders v. Wilkie, 886 F.3d 1356 (2018) (pain alone can qualify as a disability where it diminishes the body's ability to function under the ordinary conditions of daily life including employment, even where it is not diagnosed as connected to a current underlying condition). Therefore, the first element is satisfied with respect to each shoulder. Second element: An in-service event, injury, or illness, or aggravation thereof The Veteran asserts that he experienced an onset of bilateral shoulder disabilities in service and that these disabilities, primarily pain, have continued since service. The Board finds multiple in-service medical records, primarily from 1992 to 1995, documenting the Veteran's bilateral shoulder treatment. His in-service medical records documented bilateral rotator cuff injuries, bilateral shoulder impingement, and chronic bilateral shoulder pain. He provided lay statements about the onset of pain and stiffness in each of his shoulders. His lay statements are consistent with his in-service medical records documenting his bilateral shoulder conditions. In addition, it was noted by a medical professional during his June 1998 separation examination that he had bilateral shoulder pain in service for five to six years. The Board finds that the evidence establishes an in-service onset of bilateral shoulder conditions that have resulted in residual disabilities. Therefore, the second element is satisfied as to each shoulder. Third element: A causal link No medical opinion has been obtained addressing the etiology of the Veteran's bilateral shoulder disabilities. Nevertheless, the Board finds one is not necessary because there is competent, credible, and probative lay evidence in the record that sufficiently establishes a link between the Veteran's military service and bilateral shoulder disabilities. First, the Veteran's June 1978 entrance examination, April 1981 exit examination, and October 1981 entrance examination did not document bilateral shoulder disabilities other similar shoulder issues. Therefore, at each point of his entrance into the military, the Veteran was sound. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Second, the Veteran testified that his bilateral shoulder disabilities have continued and worsened since service. He has participated in physical therapy, received injections, and was contemplating surgery at the time of his testimony. April 2021 Board Hearing Transcript, at 23. The Board finds the Veteran's testimony credible. Furthermore, his testimony is probative as to the continuous nature of his bilateral shoulder disabilities. A Veteran is capable of explaining continuous symptoms that are readily observable by a lay person. Jandreau, 493 F.3d at 1377. Significantly, there is no evidence of record indicating that the Veteran's bilateral shoulder disabilities stem from some other non-service event. Finally, when viewing the evidence as a whole, the Board finds that the evidence sufficiently establishes that the Veteran's current bilateral shoulder disabilities are reasonably related to the onset of those disabilities that began while in military service. The Veteran's lay statements and testimony in conjunction with his in-service medical records are enough for the Board to conclude that he has continuously experienced bilateral shoulder disabilities since their respective onsets in service. See Savage, 10 Vet. App. at 497. Therefore, the third element is satisfied. Accordingly, service connection for right and left shoulder disabilities is warranted. 11. Service connection for erectile dysfunction as secondary to service-connected left varicocele is granted. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability exists, (2) the veteran has a service-connected disability; and (3) the current disability was either (a) proximately due to or the result of; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where aggravation is the relied upon theory, compensation may only be provided to that degree over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448. As part of the Veteran's claim for a compensable initial disability rating for his service-connected left varicocele conditiondiscussed in detail laterhe was afforded a March 2019 VA-contracted examination. The examiner diagnosed the Veteran with erectile dysfunction at that time. The examiner concluded that the Veteran's erectile dysfunction began in 2017 and was caused by his service-connected (bilateral) varicocele. Although the Veteran never filed a claim for service connection erectile dysfunction, according to Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021), "VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for the proper evaluation level for the primary service-connected disability." Citing 38 C.F.R. §§ 3.155(d)(2), 3.160. Accordingly, the Board finds the claim for service-connection for erectile dysfunction as secondary (causation) to service-connected left varicocele is reasonably raised by the record and service connection is warranted as each necessary element is satisfied. 12. Service connection for right varicocele condition is granted. Initially, the Veteran only sought service connection for left varicocele (claimed as left testicular condition). After receiving an award of service connection and an initial noncompensable disability rating, he appealed to the Board. He was afforded a VA-contracted examination in March 2019 to address the severity of his left varicocele. The examiner corrected the prior diagnosis and determined that the Veteran had bilateral varicocele based on examination and review of the Veteran's medical records. He opined that the Veteran's right and left varicoceles started together. The Board finds no reason to doubt the March 2019 examiner's medical conclusion. Therefore, as the medical diagnosis has been corrected, the Board concludes the Veteran is entitled to service connection for right varicocele in addition to his currently service-connected left varicocele. As will be discussed later, this will affect the Veteran's disability rating for his left varicocele. 13. Service connection for tuberculosis is denied. To be entitled to service connection under any legal theory, a veteran must have a current disability. The requirement for a veteran to have a "current disability" is satisfied when he or she has a disability (1) at the time a claim for VA disability compensation is filed or (2) has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran's in-service medical records document that in July 1978 he tested positive for tuberculosis. He received Isoniazid (INH) medication as treatment, which he continuously took during his active until his self-discontinuance. See May 1981 In-Service Medical Record. At the time of his retirement examination in June 1998, the medical professional did not document a then-existing diagnosis of tuberculosis or residuals associated with the disease. As of this date, the Board is unable to locate a diagnosis of tuberculosis, or residuals thereof, while the claim has been pending in any of the Veteran's medical records. There is no competent or credible lay evidence that he has had tuberculosis during the claim period. Accordingly, absent a current disability, service connection for tuberculosis is not warranted. REASONS FOR REMAND 1. Service connection for generalized joint pain is remanded. 2. Service connection for a throat condition, to include a swollen throat, is remanded. 3. Service connection for a right knee disability is remanded. 4. Service connection for a left knee disability is remanded. 5. Service connection for a sinus disability, to include sinusitis and allergic rhinitis, to include as to due to service in the Southwest Asia Theater of Operations during the Persian Gulf War, is remanded. 6. Service connection for a hernia is remanded. 7. Service connection for a back disability is remanded. 8. Service connection for a left hip disability is remanded. 9. Service connection for left eye retinal hole without detachment (claimed as left eye/tear in retina) is remanded. 10. Service connection for irritable bowel syndrome is remanded. The Board addresses these claims (#s 1 through 10) together. The Board finds remand is required to obtain VA examinations and opinions for these claimed disabilities. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran seeks presumptive service connection for each claimed disability as due to his service in the Southwest Asia Theater of Operations during the Persian Gulf War. In addition, the Board notes that effective August 5, 2021, VA has issued an interim rule that presumptive service connection for sinusitis and rhinitis (as well as asthma) may be available to veterans who served in the Southwest Theater of Operations during the Person Gulf War and whose disabilities manifested within ten years from separation from service. Presumptive Service Connection for Respiratory Condition Due to Exposure to Particulate Matter, 86 Fed. Reg. 42,72442,733 (August 5, 2021). Unfortunately, the medical opinions of record addressing the etiology of these claimed disabilities, to include in relation to the Veteran's service in Southwest Asia during the Persian Gulf War, are insufficient. Particularly, there are no sufficient opinions addressing whether the Veteran's claimed disabilities may nonetheless be directly service connected despite a lack of presumptive service connection. Thus, remand is required. 11. The claim for an increased initial disability rating in excess of 30 percent from January 22, 2015, to March 14, 2017, and in excess of 50 percent thereafter, for service-connected posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo is remanded. The Board finds that an updated VA examination is required to address the severity of the Veteran's posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo. During his April 2021 Board hearing, he testified his disability has worsened, testifying that he has panic attacks nearly every day and has regressed socially. April 2021 Board Hearing Transcript, at 34. In addition, the Board finds an examination is required to address any overlap of symptoms between the Veteran's service-connected psychiatric disability and his now service-connected chronic fatigue syndrome. 12. The claim for an initial compensable disability rating for service-connected left varicocele disability (claimed as left testicular condition) is remanded. As the Board has now granted service connection for right varicocele, this affects the rating associated with the Veteran's left varicocele disability. The Veteran's service-connected left varicocele disability is rated under 38 C.F.R. § 4.115, Diagnostic Code 7523 (complete atrophy of testis). This diagnostic code provides that a noncompensable rating is assigned when there is atrophy of one testis, and a 20 percent rating for the loss of both testes. As a rating has not yet been assigned based on the grant of service connection for right varicocele, remand is appropriate for the VA Regional Office to address the rating in the first instance, which will also include addressing the rating for the Veteran's service-connected left varicocele. 13. The claim for special monthly compensation based on loss of use of creative organ is remanded. VA has a duty to maximize benefits and consider claims properly raised by the record, even if the claim is not raised by the veteran. As the Board has granted service connection for erectile dysfunction and right varicocele, the Veteran will potentially be entitled to special monthly compensation. 38 U.S.C. § 1114(k) (providing special monthly compensation "if the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organ"); 38 C.F.R. § 3.350 (implementing regulation). As the VA Regional Office has not yet had the opportunity to rate the Veteran's service-connected erectile dysfunction of right varicocele, it also has not had the opportunity to consider entitlement to special monthly compensation. Remand is appropriate for the VA Regional Office to consider special monthly compensation in the first instance. 14. The claim for a total disability rating based on individual unemployability is remanded. Throughout his April 2021 Board hearing testimony as well as his statements submitted in connection with his claims on appeal, the Board find a claim for entitlement to a total disability rating based on individual unemployability (TDIU) is raised by the record. Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record). Of particular note, the Veteran asserted in his May 2021 post-hearing brief that his then-current employment was a protected environment. When entitlement to TDIU is raised during the adjudicatory process of the underlying disability or during the administrative appeal of the initial rating assigned for that disability, it is "part and parcel" of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 45355 (2009). Consequently, a separate formal claim for TDIU is unnecessary in the context of an appeal from an initial rating. Id. at 454; Comer v. Peake, 552 F.3d 1362, 1367 (Fed. Cir. 2009) (TDIU is implicitly raised whenever a veteran, who presents cogent evidence of unemployability, seeks to obtain a higher disability rating). Because the Veteran is challenging the initial disability ratings assigned for his service-connected psychiatric disability and left varicocele, the determination of whether he is entitled to TDIU is part and parcel of the determination of these ratings. Rice, 22 Vet. App. at 45455. Therefore, as development has not occurred on the claim for TDIU, nor has the VA Regional Office rendered an initial decision on the claim of TDIU, remand is required. Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding VA medical records and associate them with the claims file. 2. After any additional records are associated with the claims file, obtain medical examinations and opinions from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's claimed disabilities to include: (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, and (ix) irritable bowel syndrome. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this DECISION and REMAND order. The examiner is asked to provide opinions regarding the following: (a.) Please identify and explain whether the Veteran has a current disability, or has had a disability during the pendency of the claim, in relation to his claims of: (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, and (ix) irritable bowel syndrome. The examiner is advised that a functional impairment due to pain is a current disability for VA purposes even in the absence of diagnosed pathology. Thus, if a diagnosis cannot be provided but the Veteran's condition(s) manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. (b.) Please identify and explain whether any of the Veteran's claims of (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, and (ix) irritable bowel syndrome are separate and distinct disabilities apart from any of his currently service-connected disabilities, or are they symptoms of his currently service-connected disabilities, to include obstructive sleep apnea, posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo, and chronic fatigue syndrome. Please explain. (c.) If the Veteran's (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, or (ix) irritable bowel syndrome are symptoms of one or more service-connected disabilities, is it possible to differentiate to which disabilities the symptoms are attributable and to what degree? Please explain. (d.) Whether it is at least as likely as not (50 percent probability or higher) that the Veteran exhibited signs or symptoms associated with his claimed disabilities: (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, or (ix) irritable bowel syndrome, during the claim period that constitute: a. An undiagnosed illness; b. A medically unexplained chronic multi-symptom illness; or c. if the claimed symptoms can be attributed to any specific pathology or diagnosed disorder? The examiner should provide reasons for all of his or her conclusions with respect to the foregoing questions. (e.) Is the etiology of the claimed (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, or (ix) irritable bowel syndrome inconclusive? For legal purposes, this discussion must take into consideration this Veteran's unique symptoms. If the etiology is partially understood, this should be explained. (f.) Is the pathophysiology of any claimed (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, or (ix) irritable bowel syndrome inconclusive? For legal purposes, this discussion must take into consideration this Veteran's unique symptoms. If the pathophysiology is partially understood, this should be explained. (g.) If the examiner finds the Veteran's claimed (i) joint pain, (ii) right knee disability, (iii) left knee disability, (iv) left hip disability, (v) back disability, (iv) sinus disability, (vi) throat disability, (vii) left eye disability, (viii) hernia, or (ix) irritable bowel syndrome can be attributed to a known diagnosis, please opine whether it is at least as likely as not (50 percent probability or higher) that such disability, to include associated symptoms, had their onset during active duty service, or are related to his active duty service, to include as due to exposure environmental hazards in the Southwest Asia Theater of Operations. In rendering his or her foregoing opinions, the examiner should consider and, if deemed relevant, address the following evidence where appropriate, in addition to any other relevant evidence: As to all claims The Veteran's June 17, 1998, retirement examination and report of medical history documenting numerous medical conditions/reports. The Veteran's June 12, 1978 (enlistment examination) April 21, 1981 (exit examination); October 28, 1981 (entrance examination); and November 20, 1991 (annual examination). A December 2019 chronic fatigue syndrome disability benefits questionnaire and accompanying medical opinion (received by VA on January 6, 2020). Correspondences dated May 20, 2017 (received by VA June 15, 2017), and April 14, 2021 (received by VA May 7, 2021) from the Veteran's representative addressing the claimed disabilities. Undated correspondence from the Veteran received by VA on January 22, 2019, addressing his claims for Gulf War illnesses. Joint Pain; Right and Left Knee Disability; Left Hip Disability; & Back Disability The Veteran's April 2021 Board hearing testimony (pages 19 to 32, specifically) in which he testifies about his joint pain, bilateral knee disabilities, and left hip disability. Two separate correspondences from the Veteran dated February 1, 2016 (received by VA June 2, 2016) reporting on his joint, knee, hip, and back disabilities. Two separate undated correspondences from the Veteran received by VA on December 3, 2016, reporting on his joint, knee, hip, and back disabilities. A May 5, 1997, in-service medical record documenting treatment for joint pain in the Veteran's right knee, and the Veteran's report he has had the pain for seven years. In-service medical records dated: January 22, 1986; February 2, 1990; July 2, 1990; July 19, 1990; and August 27, 1991; documenting treatment for back pain. March 22, 2019, VA-contracted examinations (received by VA on July 1, 2019) addressing the Veteran's back and bilateral knee conditions. Note, at that time, a low back disability examination was not conducted, only a cervical spine examination. Sinus Disability & Throat Disability In-service medical records dated: October 17, 1983; June 6, 1986; October 2, 1986; April 18, 1981; October 17, 1983; October 2, 1986; February 18, 1987; and March 20, 1987; documenting treatment for tonsil conditions, sinus infections, and throat conditions. March 22, 2019, VA-contracted examination addressing Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx (received by VA July 1, 2019). Left Eye Disability The Veteran's April 2021 Board hearing testimony (pages 15 to 19, specifically) in which he testifies about his left eye condition. An April 8, 2015 VA examination addressing the Veteran's left eye condition. Correspondence from the Veteran dated February 1, 2016, (received by VA June 2, 2016) reporting on his left eye condition. Correspondence from the Veteran received by VA on December 3, 2016, reporting on his left eye condition. An August 3, 1994, in-service optometry medical record. Hernia & Irritable Bowel Syndrome In-service medical records dated: May 6, 1980; and April 3, 1982; documenting abdominal pain and a potential hernia. VA/VA-contracted examinations dated: June 10, 2015 (received by VA June 30, 2015); July 29, 2015 (received by VA August 4, 2015); May 12, 2016 (received by VA same day); November 21, 2016 (received by VA December 7, 2016); March 22, 2019 (received by VA July 1, 2019); addressing the Veteran's hernia/stomach/IBS/Gulf War illness conditions. The Veteran's April 2021 Board hearing testimony (pages 3 to 8, specifically) in which he testifies about his hernia/stomach/IBS/Gulf War illness conditions. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his claimed disabilities, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of any claimed disabilities in service or the assertion that an in-service event, injury, or illness led to a claimed disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). 3. After any additional records are associated with the claims file, obtain a new VA examination from an appropriately qualified clinician as to the Veteran's service-connected posttraumatic stress disorder with traumatic brain injury residuals of tension headaches and vertigo. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. In addition to the general evaluation of the severity of this disability, the examiner is asked to address whether it is possible to differentiate to which disabilities the Veteran's symptoms are attributable? In particular, the Veteran claims headaches due to his left eye condition, chronic fatigue syndrome, and psychiatric disability. Are his headaches, and any other common symptom, attributable to a single condition or not? The examiner is reminded to consider the Veteran's lay statements as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertions. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. The VA Regional Office should undertake any necessary development to adjudicate whether the Veteran is entitled to presumptive service connection for his sinus disabilities based on VA's interim rule, effective August 5, 2021, providing for presumptive service connection for veterans who served in the Southwest Theater of Operations during the Persian Gulf War and developed sinusitis and/or rhinitis within ten years of separation from service. See Presumptive Service Connection for Respiratory Condition Due to Exposure to Particulate Matter, 86 Fed. Reg. 42,72442,733 (August 5, 2021). 5. Provide the Veteran with a notice regarding what is necessary to substantiate a claim for entitlement to a total disability rating based on individual unemployability (TDIU) and request that he complete and return a formal application for entitlement to TDIU and an authorization to obtain information from his previous employers. If the Veteran returns any form which is incomplete or contains insufficient information, he must be informed of such and be given the opportunity to provide a complete one. The RO should take any additional, reasonable, and necessary developmental action. 6. Conduct any necessary and reasonable development to adjudicate entitlement to special monthly compensation based on the Veteran's service-connected erectile dysfunction and bilateral varicoceles. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.