Citation Nr: 21074959 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 18-53 114A DATE: December 16, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for a right ankle sprain is dismissed. New and material evidence having not been received, the application to reopen the claim of entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. New and material evidence having not been received, the application to reopen the claim of entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected PTSD, is denied. New and material evidence having not been received, the application to reopen the claim of entitlement to service connection for a left knee condition is denied. New and material evidence having not been received, the application to reopen the claim of entitlement to service connection for a right knee condition is denied. Entitlement to an effective date prior to August 26, 2018 for a 20 percent disability rating for a right ankle sprain is denied. Service connection for irritable bowel syndrome (IBS) is granted. Service connection for fibromyalgia is denied. A 20 percent rating, but no higher, for a left ankle disability is granted. REMANDED Entitlement to service connection for degenerative arthritis of the spine is remanded. Entitlement to service connection for sciatic nerve condition of the left lower extremity is remanded. Entitlement to service connection for a sciatic nerve condition of the right lower extremity is remanded. Entitlement to service connection for numbness is remanded. Entitlement to service connection for a condition characterized as muscle and joint pain with spasms is remanded. Entitlement to service connection for migraines is remanded. Entitlement to service connection for fatigue is remanded. Entitlement to service connection for memory loss is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. FINDINGS OF FACT 1. The claim of entitlement to a disability rating in excess of 10 percent for a right ankle sprain was withdrawn on the record during a hearing held in August 2021. 2. In a final rating decision issued in November 2016, service connection for hypertension and for ED, to each include as secondary to service-connected PTSD, was denied. 3. Evidence added to the record since the final November 2016 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claims of entitlement to service connection for hypertension or ED. 4. In a final rating decision issued in December 2016, service connection for a left knee condition and right knee condition was denied. 5. Evidence added to the record since the final December 2016 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claims of entitlement to service connection for a left knee or right knee condition. 6. The evidence does not show that the Veteran filed a claim for an increased disability rating for his service-connected right ankle disability prior to August 26, 2018; and it is not factually ascertainable that any increase in disability occurred in the year prior to that date. 7. The Veteran had service in the Southwest Asia Theater of operations during the Persian Gulf War and has a diagnosis of IBS. 8. The preponderance of the evidence of record is against finding that the Veteran has had fibromyalgia at any time during or approximate to the pendency of the claim. 9. Resolving all doubt in favor of the Veteran, for the entire appeal period, his left ankle disability is manifested by marked limitation of motion, to include in consideration of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis of the ankle or subastragalar or tarsal joint, malunion of os calcis or astragalus, or an astragalectomy. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the issue of entitlement to a disability rating in excess of 10 percent for a right ankle sprain are met. 38 C.F.R. § 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 2. The November 2016 rating decision that denied service connection for hypertension, to include as secondary to service-connected PTSD, is final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 3. New and material evidence has not been received to reopen a claim of entitlement to service connection for hypertension, to include as secondary to service-connected PTSD. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 4. The November 2016 rating decision that denied service connection for ED, to include as secondary to service-connected PTSD, is final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 5. New and material evidence has not been received to reopen a claim of entitlement to service connection for ED, to include as secondary to service-connected PTSD. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 6. The December 2016 rating decision that denied service connection for a left knee condition is final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 7. New and material evidence has not been received to reopen a claim of entitlement to service connection for a left knee condition. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 8. The December 2016 rating decision that denied service connection for a right knee condition is final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 9. New and material evidence has not been received to reopen a claim of entitlement to service connection for a right knee condition. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 10. The criteria for an effective date prior to August 26, 2018, for a 20 percent disability rating for a right ankle disability have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.159, 3.400. 11. The criteria for service connection for IBS have been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. § 3.317. 12. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 13. For the entire appeal period, the criteria for a rating of 20 percent, but no higher, for a left ankle disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 1987 to June 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in January 2016, November 2016, May 2018, October 2018 and December 2018 by Department of Veterans Affairs (VA) Regional Offices. In August 2021, the Veteran testified before the undersigned at a Board hearing. A transcript of that hearing has been associated with the record. PTSD claim At the August 2021 hearing, the Veteran's attorney indicated a belief that in October 2017 he had filed a request for reconsideration of November 2016 rating decision which denied a disability rating in excess of 50 percent for PTSD. However, review of the record shows that no such request was filed. Rather, as explained in detail below, in September 2017 the Veteran filed claims for service connection for multiple disorders which had been previously denied by the RO; in October 2017, he contacted VA via telephone and indicated that his claims were, in fact, requests for reconsideration of those previously-denied service connection claims. Unfortunately, the Veteran's claim for an increased disability rating for PTSD was not part of the September 2017 filing or October 2017 telephone call, and review of the record shows no further request or filing for an increased disability rating for PTSD after the November 2016 decision. Should he feel such a rating is warranted, the Veteran is welcome to file a claim for an increased disability rating with the RO. Characterization of claims At the outset, the Board notes that the Veteran's claims of entitlement to service connection for numbness, muscle and joint pain, migraines, memory loss, and a lower back condition were initially denied in a January 2016 rating decision. In August 2016, the Veteran filed a new claim for the conditions, which was interpreted as a request to reconsider the January 2016 rating decision. In a November 2016 rating decision, the claims were again denied, except for the lower back condition claim, which was deferred and ultimately denied in a December 2016 rating decision. In a September 2017 application for compensation and an October 2017 phone call with VA, the Veteran again requested reconsideration of the denial of the claims of entitlement to service connection for muscle and joint pain, migraines, numbness, memory loss, and a lower back condition. In an October 2017 rating decision, the RO found that no new and material evidence had been submitted to reopen the denied claims. Similarly, the Veteran's claims of entitlement to service connection for IBS, fibromyalgia, and fatigue were denied in the November 2016 rating decision. In the September 2017 application for compensation and October 2017 phone call with VA, referenced above, the Veteran requested reconsideration of each of these claims, other than hypertension and ED. They were denied in the November 2017 rating decision, with a finding that no new and material evidence had been submitted to warrant reopening the denied claims. The Board finds that, when reviewed wholistically, the Veteran clearly intended to disagree with the initial January 2016 rating decision, but was unfamiliar with the appeals process and acting pro se. The Board has a special obligation to read pro se filings liberally. See Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); Comer v. Peake, 552 F.3d 1362, 1368 (Fed. Cir. 2009) ("A liberal and sympathetic reading of appeal submissions is necessary because a pro se veteran may lack a complete understanding of the subtle differences in various forms of VA disability benefits and of the sometimes arcane terminology used to describe those benefits."); Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004) (emphasizing that pro se filings must be read liberally). It is clear from a sympathetic reading of the Veteran's submissions that he was expressing disagreement with the rating decisions but, lacking familiarity with the appeals process, continued to refile his claims rather than a formal notice of disagreement. This reading is supported by the fact that, in July 2018, the Veteran appointed an attorney to assist him in the pursuit of his claims and that same month, the attorney filed a proper Notice of Disagreement with the October 2017 rating decision. See e.g. Andrews v. Nicholson, 421 F.3d 1278, 1282 (Fed. Cir. 2005) (pro se pleadings, not those of counsel, are entitled to a sympathetic reading). Thus, the Board finds that the claims filed by the Veteran in August 2016 and September 2017 shall be interpreted as Notices of Disagreement, not as new claims requiring new and material evidence. Although the RO adjudicated these claims under such a framework, this action is not binding on the Board. It was clearly the Veteran's intention to move the claims of entitlement to service connection for IBS, fibromyalgia, a lower back condition, numbness, muscle and joint pain, migraines, fatigue, memory loss and IBS forward by timely and consistently opposing the denials issued via the initial rating decisions. Therefore, his claims do not require new and material evidence before being considered by the Board on a de novo basis and have been recharacterized accordingly as shown on the title page. Dismissed claim Under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn by the appellant or their representative so long as the Veteran and/or claimant is identified, the file number is included, and there is a clear statement of withdrawal identifying the issue(s) withdrawn. 38 C.F.R. §§ 19.55, 20.205. During the August 2021 hearing, the issue of entitlement to a disability rating in excess of 10 percent for a right ankle sprain was withdrawn on the record by the Veteran through his attorney; the requirements for withdrawal are met. As the Veteran has withdrawn his appeal on this issue, there remains no allegation of error of fact or law for appellate consideration. Accordingly, the Board has no further jurisdiction in this matter, and the appeal is dismissed. New and Material Evidence The Veteran's claims of entitlement to service connection for hypertension and ED, to each include as secondary to service-connected PTSD, were previously denied in a final rating decision issued in November 2016 on the basis of a lack of nexus to service, or to service-connected PTSD. The claims of entitlement to service connection for left and right knee conditions were initially denied in a final rating decision issued in December 2016 due to a lack of nexus. Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104 (b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 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 sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Since the issuance of the November 2016 rating decision, updated VA treatment records, statements from the Veteran, to include his August 2021 testimony, and copies of private treatment records have been received; however, such only reflect ongoing treatment for hypertension, ED, and left and right knee conditions, without any discussion of a link between these conditions and service or a service-connected disability. Similarly, while the Veteran has provided additional statements regarding his belief that his hypertension and ED are related to his PTSD, such are duplicative of those he previously provided in connection with his prior claim and were of record at the time of the November 2016 rating decision. In addition, the Veteran has submitted various internet articles which purport to show a link between hypertension and PTSD. Included with those articles is one which addresses chondromalacia, a knee disability. Normally, medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222 (1999); Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). Here, however, the suggestion of a link between hypertension and PTSD was already addressed by the medical evidence considered in the November 2016 rating decision, and the article regarding chondromalacia provides speculative generic statements that the Board finds are not relevant to the Veteran's claim. Wallin at 514. Therefore, as the Veteran's claims for service connection for hypertension, ED, a left knee condition and a right knee condition were previously denied based on the lack of a nexus to service, or a service-connected disability, and the newly received evidence likewise fails to address such missing element, the Board finds the evidence added to the record since the final November 2016 and December 2016 denials is cumulative or redundant of the evidence of record at the time of those decisions and does not raise a reasonable possibility of substantiating the Veteran's claims for service connection. Consequently, as new and material evidence has not been received, reopening the claims is not warranted. In making its decision, the Board acknowledges that the RO reopened the Veteran's knee claims in its May 2018 rating decision; however, the Board is not bound by the RO's decisions and reiterates its finding that the evidence does not raise a reasonable possibility of substantiating the Veteran's claims for service connection for left and right knee conditions. 38 C.F.R. § 3.156 (a); Butler v. Brown, 9 Vet. App. 167, 171 (1996); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). For all of these reasons, the application to reopen these claims is denied. Earlier Effective Date The Veteran seeks an earlier effective date for a 20 percent disability rating for his service-connected right ankle disability. By way of history, the Veteran was initially granted service connection for a right ankle disability, characterized as residuals of right ankle sprains, in a December 1993 rating decision. At that time, the disability was assigned a noncompensable rating. In August 2016, he filed a claim for an increased disability rating, and, in a November 2016 rating decision, a 10 percent rating was granted. On August 26, 2018, the Veteran submitted an intent to file and a claim for an increased disability rating, concurrently. After undergoing a VA examination in September 2018, his claim was granted and a disability rating of 20 percent was assigned, effective as of the date the Veteran submitted his claim for an increased rating. He now generally asserts, without explanation, that an earlier effective date is warranted. Because the November 2016 rating decision became final, the effective date for an increased rating is the earliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability occurred if a claim is received within one year from such date; otherwise, the effective date for increased rating is the date of receipt of the claim for increase. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2); Gaston v. Shinseki, 605 F. 3d 979, 984 (Fed. Cir. 2010). Thus, the two questions before the Board are whether there is evidence of an unaddressed claim for increase submitted prior to August 26, 2018, or whether it is factually ascertainable that the Veteran met the criteria for the 20 percent rating in the year prior to filing his claim. As to the first question, the window that the Board must scan to determine if there was an earlier claim is limited. As previously noted, the Veteran was granted a 10 percent rating in a November 2016 rating decision. From that date until the date he submitted his claim for an increased rating, there is no evidence that the Veteran filed another claim. Importantly, given the timeframe in question here, claims must be initiated with specific forms prescribed by the Secretary. 38 C.F.R. § 3.155. There is no evidence, and the Veteran does not specifically contend, that he filed a claim for an increased rating subsequent to the November 2016 decision and prior to his August 2018 claim. Thus, entitlement to an earlier effective date on this basis is not warranted. As to the second question, worsening of the ankle disability during this period, the Veteran's right ankle disability is evaluated under Diagnostic Code 5271 for limitation of motion of the ankle joint. Under that code, a 20 percent disability rating is assigned where there is evidence of marked loss of ankle motion. However, the only medical evidence that speaks to the severity of the Veteran's service-connected right ankle disability was the September 2018 VA examination that formed the basis of the 20 percent rating granted in October 2018. Treatment for right ankle pain is noted in the Veteran's VA treatment records in the year preceding the filing of his claim, but such records do not include specific information regarding the Veteran's ankle disability so as to establish that the criteria for an increased rating were met at any point. There exists no medical evidence outside of these VA treatment records regarding his right ankle for this period, and there are no lay statements that establish evidence regarding increased severity or frequency of the disability, prior to the August 2018 claim. The Board therefore finds that it is not factually ascertainable that the Veteran experienced an increase in his disability in the year prior to filing his claim, and an earlier effective date is not warranted on that basis. Thus, because there is no evidence of a claim or an intent to file earlier than August 26, 2018, and as it is not factually ascertainable that an increase in disability occurred in the year prior to the Veteran's claim, an earlier effective date for the grant of an increased rating for the Veteran's right ankle disability is not warranted. The claim is denied. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) 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). Service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. For purposes of section 3.317, there are two types of qualifying chronic disabilities: (1) an undiagnosed illness, and (2) a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. There must also be objective indications of chronic disability, which 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). A MUCMI is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome, (2) fibromyalgia, and (3) functional gastrointestinal disorders (excluding structural gastrointestinal disease). The term MUCMI means 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. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). Along with the three examples of a MUCMI provided by section 1117(a)(2)(B), Congress has provided a list of signs or symptoms that may be a manifestation of a MUCMI that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory system symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b). A layperson is generally incapable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson, supra. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Irritable Bowel Syndrome The Veteran seeks service connection for IBS, based on his service in Southwest Asia. A review of his service personnel records confirms that he served in the Southwest Asia theater of operations during the Persian Gulf War. Thus, he is considered a Persian Gulf Veteran. 38 C.F.R. § 3.317 (a)(1)(i). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). IBS is considered a qualifying chronic disability under 38 C.F.R. § 3.317, the Board finds that the criteria for service connection for IBS are met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Review of the Veteran's VA treatment records shows the Veteran sought treatment in September 2018 for an intestinal condition, to include diarrhea, occasional episodes of bowel disturbance with abdominal distress to include pain, and frequent episodes of exacerbations or attacks of the intestinal condition. Although at the time, the Veteran was given a provisional diagnosis of IBS, he was prescribed medication for its treatment. Later records show he continued to take the medication. Thus, when resolving all reasonable doubt in his favor, the Board finds that the Veteran has a diagnosis of IBS. Therefore, when taking into consideration the evidence showing his symptomology, the Veteran has had IBS manifesting to at least a degree of 10 percent under 38 C.F.R. § 4.114, Diagnostic Code 7319 during the pendency of the claim and prior to December 31, 2021. In sum, the Veteran had the requisite service in the Southwest Asia Theater of Operations during the Persian Gulf War, and he now has current diagnoses of IBS which manifested to a compensable degree prior to December 31, 2021. Therefore, absent evidence to the contrary, service connection for these disabilities is presumed. See 38 C.F.R. § 3.317. The claim is granted. Fibromyalgia The Veteran seeks to establish service connection for fibromyalgia. The Veteran's service treatment records do not reflect any complaints, findings, or treatment for fibromyalgia. VA outpatient treatment reports and private treatment reports from various providers do not reflect any complaints of, treatment for, or a diagnosis of fibromyalgia. The Veteran has not been treated for fibromyalgia and does not take any medication for fibromyalgia. At an October 2016 VA Gulf War examination, the examiner stated that there was no diagnosis of fibromyalgia, to include undiagnosed illness. In the absence of proof of present disability there can be no successful claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (also interpreting 38 U.S.C. § 1131 as requiring the existence of a present disability for VA compensation purposes). To be present as a current disability, there must be evidence of the condition at some time during the claim period. Gilpin v. West, 155 F. 3d 1353, 1356 (Fed. Cir. 1998); see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (the Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves). The question for the Board is whether the Veteran has a current disability of fibromyalgia. After considering the evidence in its entirety, the Board finds that the preponderance of the evidence is against finding that the Veteran has or has had such disability at any time since filing his claim for service connection or prior thereto. Cf. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency); McClain, at 321. As noted above, fibromyalgia is not shown in the Veteran's service treatment records or in post service treatment records. Moreover, a diagnosis was not rendered at the October 2016 VA Gulf War examination, with the examiner finding that the Veteran did not meet the diagnostic criteria for fibromyalgia or an undiagnosed illness. The examiner based her opinions on her examination of the Veteran and on her review of the Veteran's claims file, and her opinions constitute probative evidence. Moreover, there is no medical evidence to the contrary. In short, the only evidence supporting current diagnoses of fibromyalgia is the Veteran's lay statements. These lay statements have evidentiary value inasmuch as the Veteran is competent to report observable symptomatology. Jandreau, supra. However, the claimed disability is medically complex and requires specialized medical education, and knowledge of the interaction between multiple systems in the body. Id. In short, the Board finds that the Veteran is not competent to self-diagnose this disability. Accordingly, the Board finds that the preponderance of the evidence is against the claim and service connection for fibromyalgia is not warranted. 38 U.S.C. § 5107; Gilbert, supra. The claim is denied. Increased Disability Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts founda practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the diagnostic code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). For the entire appeal period, the Veteran's left ankle disability is rated as 10 percent disabling pursuant to Diagnostic Code 5271, which, as in effect for the entire appeal period, provides for a 10 percent rating where there is moderate limitation of ankle motion and a 20 percent rating where there is marked limitation of ankle motion. 38 C.F.R. § 4.71. Normal plantar flexion ranges from zero to 45 degrees and normal dorsiflexion ranges from zero to 20 degrees. Based upon a review of the evidence and after resolving all doubt in favor of the Veteran, the Board finds that his left ankle disability more nearly approximates marked limitation of motion, which results in the award of a 20 percent rating under Diagnostic Code 5271. During the appeal period, in September 2018, the Veteran underwent a VA examination of his left ankle in September 2018. At that time, he reported instability, flare-ups, pain and swelling which were aggravated by activities such as prolonged standing, walking and climbing. Flare-ups were found to result in weakened movement, instability, stiffness and swelling. Range of motion testing showed dorsiflexion and plantar flexion to 10 degrees. The range of motion contributed to a functional loss, in that there was less range of motion and increased pain. This pain was noted on both dorsiflexion and plantar flexion, as was pain with weight bearing. There was less movement than normal due to swelling and disturbance of motion. Weakened movement interfered with sitting, standing and caused instability. The examiner determined that the Veteran's left ankle disability would interfere with his ability to run, jump, climb, lift or carry weight, and with prolonged positioning, squatting and kneeling. It was noted that the Veteran used a brace constantly. Ankylosis was absent. A remote history of shin splints was noted, without stress fractures, achilles tendonitis, achilles tendon rupture, malunion of os calcis or astragalus, or an astragalectomy. There were otherwise no other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran's left ankle disability. In addition, VA treatment notes from the appeal period show that the Veteran continuously experienced left ankle pain and instability. Further, at his August 2021 hearing, the Veteran testified that he experienced constant pain, and the instability had gotten to a point where he used a cane to walk. Based on the foregoing, Board resolves all doubt in favor of the Veteran and finds that his left ankle disability more nearly approximated marked limitation of motion for the entire appeal period. Specifically, as noted previously, at the September 2018 VA examination, he had plantar flexion limited to 10 degrees. In addition, his testimony described symptomology such as pain which resulted a limitation of motion. In this regard, while "marked" and "moderate" are not described in the rating criteria pertinent to this appeal, guidance can be found in the VA Adjudication Procedures Manual, M21-1 (Manual). The Manual states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees of plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See M21-1, III.iv.4.A.3.k. The Manual is not binding on the Board; however, the Board must address relevant provisions of the Manual and conduct an independent analysis before determining whether the provisions may be relied upon as a factor to supports is decision. Overton v. Wilkie, 30 Vet. App. 257 (2018). The Board has also considered VA's proposed changed to Diagnostic Code 5271, in August 2017. See 82 Fed. Reg. 35719. There, VA noted that the criteria set forth in Diagnostic Code 5271 are "subjective and the terminology is vague, resulting in inconsistent evaluations." VA proposed to define "marked" as less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion, and "moderate" as less than 15 degrees of dorsiflexion or less than 30 degrees of plantar flexion. Id. at 35723. VA noted that, "[a]s VA currently uses these standards to define marked and moderate, this change is intended as clarification of current policy and would ensure consistent application of these criteria among rating personnel." Id. The Board, again, finds the explanation of the proposed regulation to be persuasive as VA is expressing its intent to codify a policy that was employed to ensure more uniformity among its rating personnel. The Board does not consider the Manual's provision to be binding, but finds the reasoning employed in the 2017 proposed rules to be highly persuasive in support of a finding that the ranges of motion listed in the Manual are appropriate. Moreover, in the most recent revision to Diagnostic Code 5271, effective February 7, 2021, VA codified the foregoing definitions of marked and moderate, defining the former as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion, and the latter as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. The Board finds that the Veteran's September 2018 plantar flexion of 10 degrees, in combination with his reported flare-ups and symptoms of pain, laxity, and instability, more nearly approximates marked limitation of ankle motion. However, as there is no evidence of ankylosis of the ankle, to include in consideration of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, or subastragalar or tarsal joint, malunion of os calcis or astragalus, or an astragalectomy at any point during the appeal period, higher or separate ratings under Diagnostic Codes 5270, 5272, 5273, and 5274, respectively, are not warranted. Thus, the Board finds that a rating of 20 percent, but no higher, under Diagnostic Code 5271 for the Veteran's left ankle disability is warranted for the entire appeal period. In reaching such determination, it has resolved all doubt in the Veteran's favor, which resulted in this award. To this extent, the claim is granted. However, to the extent that the Board has denied higher or separate ratings, the preponderance of the evidence is against such aspect of his claim and it is otherwise denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Degenerative arthritis of the spine The Veteran asserts that, as a result of an in-service back injury, he developed chronic back pain and degenerative arthritis of the spine. His service treatment records show that, in January 1990, he was seen with complaints of back pain after moving heavy gear on a truck. A March 1990 treatment note shows the Veteran continued to experience back pain on and off. In January 2016, the Veteran underwent a VA examination in relation to his claim. At that time, a diagnosis of degenerative disc disease was noted. On the question of etiology, the examiner noted that he was unable to review the Veteran's service treatment records, as they had not yet been associated with the record. However, he acknowledged the Veteran's description of the in-service injury to his back and determined it was less likely than not that the degenerative disc disease was due to service. He explained that the injury occurred 22 years prior, and the Veteran did not report a continuity of symptoms since that time. In a November 2016 addendum report, the examiner indicated that he was able to review the Veteran's service treatment records, and noted the March 1990 treatment for back pain and spasm. However, concurrent x-ray imaging showed no bony injury and the back was otherwise within normal limits. The examiner noted that the Veteran was treated for other conditions, post-service, and did not report back problems. He again noted that the injury occurred over 20 years prior, and that any associated pain or spasm had resolved by the time that the Veteran had separated from service, as evidenced by a denial at that time of any back problems or pain. The examiner did acknowledge a notation by the examiner at separation, who noted a history of mechanical low back, non-chronic disease, in support of his conclusion. The record also contains private treatment records which show the Veteran sought treatment in 2017 for longstanding lower back pain, which he indicated at that time had an in-service onset. Based on this evidence, the Board must find that further examination is warranted. The January 2016 examination report, combined with the November 2016 addendum, are inadequate to adjudicate the claim. Specifically, the examiner based his conclusions on the fact that the Veteran's post-service medical records were silent as to treatment and did not comment on the Veteran's reports of symptoms. The sole basis for rejecting lay statements cannot be the fact that there are no corroborating records. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, supra ("the Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). Once VA provides an examination, it must ensure that it is adequate. Id. Here, that has not happened and thus the Board finds that a remand is warranted. Sciatic nerve condition of the left and right lower extremities, numbness As for the Veteran's claims of entitlement to service connection for a sciatic nerve condition of the left and right lower extremities, and numbness, he testified at the August 2021 hearing that he believed he experienced such symptoms as a result of his degenerative arthritis of the spine. Therefore, upon remand, the examiner assigned to perform his back examination will be asked to opine as to the presence and etiology of such conditions. Muscle and joint pain, migraines, fatigue, memory loss As noted above, service connection may be established for a chronic disability resulting from an undiagnosed illness which manifested either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Throughout the appeal period, the Veteran has been diagnosed with migraine headaches. He has also reported muscle and joint pain, fatigue and memory loss. He asserts these disabilities are due to environmental exposures in Southwest Asia. At a November 2016 VA Gulf War examination, it was determined without explanation that the Veteran's headaches, muscle tension, and non-respiratory sleep disturbances were also due to PTSD. In contrast, an October 2016 Chronic Fatigue Syndrome examination determined that the Veteran did not have a diagnosis of such; rather, his symptoms of exhaustion and fatigue were due to his service-connected PTSD. Further, an October 2016 PTSD examination shows that memory loss was a symptom of the condition. After a review of the evidence, the Board finds that the examinations of record are insufficient to determine the present claims. In this regard, there has been no opinion regarding whether the Veteran's fatigue and muscle and joint pain are manifestations of an undiagnosed illness pursuant to 38 C.F.R. § 3.317. Moreover, as the findings of the November 2016 examination were conclusory and without explanation, there has been no opinion to address whether or how the Veteran's conditions are secondary to his service-connected PTSD. Accordingly, the Board finds that a remand is warranted for VA examinations to be performed to determine the nature and etiology of any muscle and joint pain, migraines, fatigue and memory loss, including whether they are manifestations of an undiagnosed illness or due to PTSD. Obstructive Sleep Apnea The Veteran contends that his currently diagnosed OSA is due to his military service. Review of the record shows a diagnosis of sleep apnea. Furthermore, while the Veteran's service treatment records are negative for any complaints, treatment, or diagnosis referable to OSA, he testified in August 2021 that VA doctors told him he developed the condition as a result of his exposure to oil and soot from burn pits while serving. Thus, the Board finds that VA's duty to assist had been triggered, requiring VA to obtain a medical opinion to determine the etiology of the Veteran's currently diagnosed OSA. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (holding that an examination is necessary if, inter alia, evidence indicates that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or service-connected disability). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the etiology of his arthritis of the spine. a. The selected examiner is asked to identify all lumbar spine conditions present during the appeal period. Then, for each identified condition, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that such disorder had its onset in, or is otherwise related to, the Veteran's service. In offering such opinion, the examiner must consider and discuss the January 1990 and March 1990 reports of medical history, in which the Veteran was treated in service for a back injury and subsequent back pain. b. The examiner is also asked to determine all diagnoses related to the Veteran's lower extremities, to include any sciatic nerve impairment or numbness. Then, the examiner should provide an opinion as to whether any diagnosis is due to, or otherwise causally or etiologically related to, the Veteran's military service. The examiner should also opine as to whether any nerve diagnosis is due to, caused by, or aggravated by the lumbar spine conditions identified above. A detailed rationale for any opinion offered should be provided. 2. Schedule the Veteran for appropriate VA examination(s) to determine the nature and etiology of his muscle and joint pain, migraines, fatigue, and memory loss. The examiner(s) should review the claims file, including a copy of this remand, and respond to the following: a. Please state whether the symptoms such as muscle and joint pain, migraines, fatigue and memory loss are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had such disability, when did that disability resolve? b. For any diagnosed disability, including migraine, is it at least as likely as not (probability of at least 50 percent) that any diagnosed disorder had its onset during and/or is otherwise related to the Veteran's period of active service, including Gulf War environmental exposures? c. With regard to muscle and joint pain, migraines, fatigue, and memory loss, if not directly related to service, is it at least as likely as not (probability of at least 50 percent) that these conditions were caused by his service-connected PTSD? d. If any of the above symptoms (such as muscle and joint pain and fatigue) are not attributable to a known clinical diagnosis, then is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? e. With regard to muscle and joint pain or fatigue, if there is no diagnosed disability, it is at least as likely as not that any pain reaches the level of a functional impairment of earning capacity? Describe the impairment caused. If so, is it at least as likely as not (50 percent probability or more) that this pain or fatigue had its onset in and/or is otherwise etiologically related to the Veteran's period of active service? If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. A detailed rationale for any opinion offered should be provided. 3. Obtain a medical opinion from an appropriate VA clinician addressing the etiology of the Veteran's OSA. Specifically, after reviewing the Veteran's record, the clinician is asked to opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's OSA had its onset during, or is otherwise related to, the Veteran's military service, to include exposure to burning oil and soot. A rationale for any opinion offered should be provided. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeremy J. Olsen, 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.