Citation Nr: 21075783 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 16-41 092 DATE: December 21, 2021 ORDER Service connection for fibromyalgia, with fatigue and headaches (minor/dull), is granted. Service connection for a disability (separate from the service-connected fibromyalgia) manifesting as fatigue is denied. Service connection for irritable bowel syndrome (IBS) is granted. Service connection for a respiratory condition, currently diagnosed as allergic rhinitis and acute sinusitis, status post septoplasty with inferior turbinate reduction, is granted. REMANDED Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for a heart condition is remanded. FINDINGS OF FACT 1. The Veteran had active service in Southwest Asia and has fibromyalgia manifesting to a degree of 10 percent or more. 2. The Veteran's fatigue is a symptom of his fibromyalgia, and there is no indication that the fatigue is a manifestation of a separate diagnosis. 3. The Veteran had active service in Southwest Asia and has IBS manifesting to a degree of 10 percent or more. 4. The Veteran served in Southwest Asia and has diagnoses of rhinitis and sinusitis that became manifest within 10 years after service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for fibromyalgia are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317, 4.71a. 2. The criteria for service connection for a disability (separate from the service-connected fibromyalgia) manifesting as fatigue are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for IBS are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317, 4.114. 4. The criteria for entitlement to service connection for a respiratory condition, currently diagnosed as allergic rhinitis and acute sinusitis, status post septoplasty with inferior turbinate reduction, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.320. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1988 to September 1991, to include service in Southwest Asia from September 1990 to March 1991. These matters come before the Board of Veterans' Appeals (Board) from a May 2013 rating decision. The Veteran testified at a Board videoconference hearing in August 2019. The Board remanded these matters in October 2019. 1. Service connection for fibromyalgia, with fatigue and headaches (minor/dull), is granted. The Veteran seeks service connection for joint and muscle pain, which he believes is related to hazardous environmental exposure during service in Southwest Asia. At his Board hearing, the Veteran indicated that he had been diagnosed with fibromyalgia. In this regard, VA treatment records show treatment for symptoms that have been deemed consistent with fibromyalgia. In detail, VA notes from March 2013 and August 2014 indicate that the Veteran reported a multi-year history of joint pain in his shoulders, elbows, and knees. These notes indicate that the Veteran did not appear to have an inflammatory arthritis component to his joint discomfort. These notes further indicate that the Veteran had headaches, fatigue, cognitive difficulties, and suboptimal sleep quality, and mood disturbances, symptoms which were suspected to be related in a pattern consistent with fibromyalgia. 05/06/2013, CAPRI, at 38-40; 05/13/2016, CAPRI, at 236. A subsequent November 2015 VA note indicates that the Veteran had developed a contracture of the right elbow and had swelling of both knees, a development that was interpreted as a possible indication that the Veteran had a systemic arthritis problem. 05/13/2016, CAPRI, at 51. Subsequent VA treatment notes (April 2017), however, suggest that fibromyalgia is still suspected. 05/01/2017, CAPRI, at 10. More recently, VA treatment records from 2020 and 2021 reference a history of fibromyalgia and list it as an active problem. 03/23/2021 & 09/13/2021, CAPRI. The Veteran underwent VA examinations, to include a Gulf War general examination, in August 2012. 08/03/2012, VA examination. This examination took place prior to the March 2013 VA rheumatology note that first raised a possible diagnosis of fibromyalgia. Consistent with this timeline, the August 2012 VA examination was silent regarding a diagnosis of fibromyalgia. Rather, the VA examiner diagnosed degenerative joint disease of the bilateral knees and strain of the bilateral elbow. The examiner opined that these conditions were not caused by any specific exposure event secondary to the Veteran's deployment to Southwest Asia. No rationale was provided. 08/03/2012, VA examination, at 81 & 92. As discussed in the Board's October 2019 remand, the August 2012 VA examination does not show adequate consideration of the relevant evidence, to include subsequent VA treatment records that show a suspected diagnosis of fibromyalgia. Further, the opinions regarding the joint pain of the knees and elbow does not include a medical rationale. Pursuant to the Board's October 2019 remand, the Veteran underwent a second VA examination in December 2019. Disability benefits questionnaires (DBQs) for the knees and elbows show diagnoses of degenerative arthritis of both knees and bilateral elbow strain, respectively. A muscle injuries DBQ indicates that there was no subjective or objective evidence of a muscle-related injury. The examiner opined that the knee and elbow diagnoses were less likely than not related to service. The examiner also opined that it is less likely than not that the Veteran's arthritis manifested within one year after separation from service. Regarding the knees, the December 2019 examiner acknowledged that service treatment records show complaints of left leg pain secondary to a 1989 motor vehicle accident (MVA) but explained that this injury was acute, with no further evidence of treatment or complaints noted in the service treatment records. Regarding the elbow, the examiner indicated that there is no evidence of elbow symptoms in service and there is no indication of any in-service event (to include hazardous environmental exposure) that led to the current diagnoses of bilateral elbow strain or degenerative joint disease of the knees, conditions that were first documented in 2012, twenty-one years after separation. The examiner further indicated that the Veteran's joint pain is attributable to known clinical diagnoses, which include bilateral elbow strain and bilateral knee degenerative joint disease. Months later, in September 2020, the Veteran underwent a third VA examination, which focused on the question of whether the Veteran had fibromyalgia. A fibromyalgia DBQ indicates that the examiner initially endorsed a finding that the Veteran had, or had been diagnosed with, fibromyalgia. 09/06/2020, C&P Exam. Nevertheless, in a subsequent addendum opinion, a different examiner indicated that "[i]t is unclear that the Veteran has been diagnosed with fibromyalgia." 09/12/2020, C&P Exam. The examiner explained that fibromyalgia is a diagnosis of exclusion and there is no evidence of the workup confirming a diagnosis of fibromyalgia, adding that any condition caused by exposure of the type encountered in Southwest Asia would almost certainly arise at that time or proximate to it. The examiner opined that, were fibromyalgia to be conceded, it is less likely than not related to service, as it is unlikely that an exposure occurring prior to 1991 would manifest more than 20 years later. The examiner further opined that the Veteran's fibromyalgia is less likely than not secondary to his service-connected PTSD. In this regard, the examiner explained that, by definition, fibromyalgia cannot be caused by any other condition, especially psychological conditions. In other words, according to the examiner, while psychological conditions are known to have psychosomatic complaints, a diagnosis of fibromyalgia cannot be attributed to these complaints. The examiner further indicated that there is no anatomic or pathophysiologic mechanism by which PTSD can cause or aggravate fibromyalgia. Based on the evidence above, the Board resolves doubt in favor of the Veteran on this material issue and finds that he has a current diagnosis of fibromyalgia. The Board acknowledges that there is no clear diagnosis of fibromyalgia. Nevertheless, VA treatment records establish that fibromyalgia has long been suspected and is currently listed as an active problem. The Board further finds that a diagnosis of fibromyalgia is consistent with the Veteran's reported history of symptoms. Significantly, he has competently reported a history of joint pain, headaches, and fatigue since soon after service. The Board acknowledges that the Veteran has specific diagnoses for his knees and elbows. These diagnoses, however, do not account for the totality of the Veteran's symptoms, particularly his headaches and fatigue. Accordingly, it is not surprising that doctors have long suspected a diagnosis of fibromyalgia. To the extent that there is doubt as to whether the Veteran has fibromyalgia, the Board resolves any such doubt in favor of the Veteran and finds that fibromyalgia is shown. 38 U.S.C. § 5107(b). A nexus between active service and a diagnosis of fibromyalgia is presumed when a Persian Gulf Veteran exhibits objective indicators of the disability either during their active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2026. 38 C.F.R. § 3.317. Fibromyalgia is rated under Diagnostic Code 5025. Under this diagnostic code, a disability rating of 10 percent requires widespread musculoskeletal pain and tender points, with or without associated symptoms including fatigue, sleep disturbances, stiffness, paresthesias, headache, depression, anxiety, or Raynaud's like symptoms, requiring continuous medication for control. 38 C.F.R. § 4.71a. As summarize above, the medical evidence indicates that the Veteran has had a multi-year history of joint pain in his shoulders, elbows, and knees. The evidence further indicates that the Veteran has had headaches, fatigue, cognitive difficulties, and suboptimal sleep quality, and mood disturbances, symptoms which were suspected to be related in a pattern consistent with fibromyalgia. Based on the above, the Board finds that the weight of the competent and probative evidence supports a finding that the Veteran has a current diagnosis of fibromyalgia that has manifested to a degree of 10 percent or more. Accordingly, the criteria for entitlement to service connection for fibromyalgia have been met and is hereby granted. The Board further finds that this is a full grant of the benefit sought by the Veteran. As mentioned, he claimed service connection for a disability manifesting a joint and muscle pain. While a recent VA examination shows specific diagnoses for the knees and elbows, there is no argument or indication that these musculoskeletal diagnoses are related to an injury in service. Furthermore, to the extent that these diagnoses manifest as joint pain, they are duplicative of the Veteran's fibromyalgia. 2. Service connection for a disability (separate from the service-connected fibromyalgia) manifesting as fatigue is denied. The Veteran seeks service connection for a disability described as fatigue. The August 2012 VA examination show a diagnosis of fatigue due to limited sleep. It was noted that the Veteran was seeing a psychiatrist for his sleep impairment. It was also noted that the Veteran did not meet the criteria for a diagnosis of chronic fatigue syndrome. 08/03/2012, VA examination, at 69-70. In contrast, VA treatment providers have noted that the Veteran's fatigue is possibly indicative of fibromyalgia. 05/06/2013, CAPRI, at 38-40; 05/13/2016, CAPRI, at 236. Pursuant to the Board's October 2019 remand, the Veteran underwent a second VA examination in December 2019. The Veteran indicated that his fatigue symptoms began in 1993-1994, adding that he was evaluated by a civilian primary care provider, who prescribed testosterone injections. He explained that, when he starts to feel fatigue, the back of his neck aches and he feels as if he has been in an all-out workout. He also reported a dull, background headaches, which are different from the heavy headaches that he reportedly experiences twice a week, and four hours of sleep, per night. The examiner, however, concluded that the Veteran did not meet the criteria for a diagnosis of chronic fatigue syndrome (CFS). The evidence of record tends to show that the Veteran's fatigue is associated with his now service-connected fibromyalgia. In support, the Board notes that the September 2020 DBQ reflects that the Veteran's reports of fatigue, among other difficulties, was noted by the examiner who endorsed a finding that the Veteran had, or had been diagnosed with, fibromyalgia. The competent evidence does not tend to show that it is a manifestation of a separate diagnosis, to include CFS. As mentioned, a VA examiner has concluded that the Veteran does not meet the diagnostic criteria for CFS. The Board finds this evidence to be probative and worthy of weight as the examination was specifically for this purpose, the Veteran was examined in person, and his pertinent medical history was noted. In view of this, and since the Veteran's fatigue is already contemplated and compensated by the above grant of service connection for fibromyalgia, the separate issue of service connection for fatigue is denied. See 38 C.F.R. §§ 4.14, 4.71a, DC 5025 (fibromyalgia). 3. Service connection for IBS is granted. The Veteran seeks service connection for a gastrointestinal disability, characterized as gastroesophageal reflux disease (GERD). At his Board hearing, he described his symptoms as a burning sensation in the back of his throat and upper chest area. He stated that he began to experience gastrointestinal issues within a year after discharge from service. 08/12/2019, Hearing Transcript, at 17-18. An August 2012 VA examination for esophageal disorders shows a diagnosis of GERD. 08/03/2012, VA examination, at 65. The examiner opined that this condition is not caused by any specific exposure event secondary to the Veteran's deployment to Southwest Asia. As discussed in the Board's October 2019 remand, the August 2012 VA opinion does not include a medical rationale and, as such, is inadequate. Pursuant to the Board's October 2019 remand, the Veteran underwent additional VA examinations in December 2019. Theses examination reports shows diagnoses of IBS and GERD. The examiner opined that the Veteran's GERD is less likely than not related to an event or exposure in service. The examiner's rationale was simply that there was no evidence in the available medical records to support the claim that the Veteran's GERD related to service in Southwest Asia or any hazardous environmental exposure and that the first documentation of GERD was from 2012, more than twenty years after service. The opinion from the December 2019 VA examiner is inadequate because it overwhelmingly relies on the absence of documentation to rule out a nexus, does not include a comprehensive medical rationale, and fails to consider the Veteran's report of gastrointestinal symptoms since the 1990s, not long after service. Moreover, the examiner did not comment on the diagnosed IBS. The issue of service connection for GERD is addressed further in the Remand section below. Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term MUCMI refers to 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). Examples of MUCMIs include chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal disabilities). 38 C.F.R. § 3.317(a)(2)(B). As noted in the introduction, the Veteran served in Southwest Asia from September 1990 to March 1991. See DD 214. Therefore, it is established that he is a Persian Gulf veteran. IBS is considered an MUCMI. See 38 C.F.R. § 3.317, Note to paragraph (a)(2)(i)(B)(3). The December 2019 VA examination shows a diagnosis of IBS since 2015. Recent VA treatment records from 2020 and 2021 reference a history of IBS and list it as an active problem. 09/13/2021, CAPRI. Based on this evidence, which appears to satisfy the 6-month chronicity requirement, and resolving any doubt in the Veteran's favor on the question of whether he has an MUCMI, the Board finds that the Veteran has a current diagnosis of IBS. The next questions before the Board are whether the Veteran's IBS meets the chronicity requirement and the requirement that the disorder manifest to a compensable degree at any time after service. With respect to the compensable evaluation requirement, under Diagnostic Code 7319, for irritable colon syndrome (spastic colitis, mucous colitis, etc.), a noncompensable evaluation is warranted for mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent evaluation is warranted for moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. § 4.114. At his August 2019 Board hearing, the Veteran reported episodes of sharp stomach pain soon after eating. 08/12/2019, Hearing Transcript, at 6. In view of the above, the Board finds that the criteria for service connection for an undiagnosed illness manifesting with irritable bowel syndrome have been met, as the evidence supports a finding that the Veteran's diagnosed IBS manifested to a degree of 10 percent or more. 4. Service connection for a respiratory condition, currently diagnosed as allergic rhinitis and acute sinusitis, status post septoplasty with inferior turbinate reduction, is granted. The Veteran seeks service connection for a respiratory disability. At his Board hearing, he described his symptoms as significant congestion with mucus. He believes that his respiratory disability is related to environmental exposure during service in Southwest Asia. In this regard, he reported exposure to burn pits and burned feces. 08/12/2019, Hearing Transcript, at 15-16. An August 2012 VA examination for respiratory disorders shows a diagnosis of allergic rhinitis with sinusitis. 08/03/2012, VA examination, at 39. A veteran who served in Southwest Asia during the Persian Gulf War is presumed to have been exposed to fine, particulate matter during such service. For such veteran, service connection for asthma, rhinitis, or sinusitis may be granted even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within ten years from the date of separation from service. 38 C.F.R. § 3.320 (eff. Aug. 5, 2021). In this case, the Veteran has a qualifying period of service in Southwest Asia and a current diagnosis of allergic rhinitis with sinusitis. The only question is whether this condition became manifest within 10 years of separation from service. As noted in the introduction, the Veteran separated from service in September 1991. The Veteran underwent a VA examination in December 2019. The examination shows diagnoses of allergic rhinitis, and acute sinusitis, status post septoplasty with inferior turbinate reduction. Significantly, the Veteran reported a history of frequent upper respiratory infections and year-round chest congestion, since 1993. The Veteran is competent to report his observable respiratory symptoms. As just mentioned, he has reported an onset of respiratory symptoms in 1993, approximately two years after service. The Board finds no reason to doubt the veracity of the Veteran's reported history. Based on this competent and credible lay evidence, the Board finds that the Veteran's respiratory disability became manifest within 10 years of separation from service. Therefore, entitlement to service connection for the current diagnosis is warranted on a presumptive basis. REASONS FOR REMAND 1. Entitlement to service connection for migraine headaches is remanded. A December 2019 VA examination shows a diagnosis of migraine headaches. The Veteran reported that he began to experience regular headaches in 1993-1994 but then the headaches began to be aggravated by sunlight. The examiner opined that the Veteran's diagnosis of migraine headaches is less likely than not related to service or secondary to a service-connected disability. The examiner's rationale was that migraines were first diagnosed twenty-one years after separation from service, that there was no indication of a headache condition in service, and that migraines are neurological (as opposed to neuropsychological) in nature, a separate entity from the head trauma in service or any hazardous environmental exposure, and medically unrelated to PTSD. The evidence establishes that the Veteran experiences two types of headaches: minor (dull) headaches that are associated with fibromyalgia (see discussion for issue of service connection for fatigue), and major (sharp) headaches that have been diagnosed as migraines. The Board has granted service connection for fibromyalgia. This grant encompasses the minor headaches, but not the migraines. It also raises the question of whether the Veteran's fibromyalgia caused or has aggravated his migraines. This is a medical question and the Board finds a remand is necessary so that it can be addressed by a VA examiner to assist the Board in adjudication of this issue. 2. Entitlement to service connection for GERD is remanded. As discussed above, the Board is granting service connection for IBS. The Veteran, however, also has a diagnosis of GERD. At the December 2019 VA examination, the Veteran described his GERD symptoms as burning in the back of his throat. These symptoms are not encompassed by the grant of service connection for IBS. Accordingly, the Board will treat the issue of service connection for GERD as a separate issue. As discussed above, the opinion from the December 2019 VA examiner is not adequate for adjudicative purposes. To reiterate, it overwhelmingly relies on the absence of documentation to rule out a nexus, does not include a comprehensive medical rationale, and fails to consider the Veteran's report of gastrointestinal symptoms since the 1990s, not long after service. Since an adequate opinion is not of record for this issue, the Board finds a remand is necessary for a new VA opinion before an adjudication on the merits. 3. Entitlement to service connection for a heart condition is remanded. The Veteran seeks service connection for a heart disability. At his Board hearing, he reported having been told by treatment providers that he had a small leakage around his heart. 08/12/2019, Hearing Transcript, at 19. An August 2012 VA examination for heart disorders shows diagnoses of mitral valve regurgitation and tricuspid valve regurgitation. 08/03/2012, VA examination, at 52. The examiner opined that these conditions are not caused by any specific exposure event secondary to the Veteran's deployment to Southwest Asia. As discussed in the Board's October 2019 remand, the August 2012 VA opinion does not include a medical rationale and, as such, is inadequate. Pursuant to the Board's October 2019 remand, the Veteran underwent a another VA examination in December 2019. The Veteran reported a history of heart problems since the 2000s. The examiner opined that the Veteran's diagnosed heart disability is less likely than not related to service. The examiner's rationale was that there was no evidence in the available medical records to indicate that the Veteran's mitral valve regurgitation or tricuspid valve regurgitation or any other cardiac condition is due to an event or exposure in service and that these conditions were diagnosed twenty-one years after service. The opinion from the December 2019 VA examiner is inadequate because it overwhelmingly relies on the absence of documentation to rule out a nexus and does not include a comprehensive medical rationale. For these reasons, the Board finds a remand for a new opinion is necessary to prior to adjudication on the merits. These matters are REMANDED for the following actions: Obtain an addendum opinion from the appropriate clinician(s) for the following issues. For the issue of service connection for migraine headaches, the examiner must address the following: (a.) Is it at least as likely as not (probability of approximately 50 percent) that the Veteran's migraine headaches are related to the Veteran's service in Southwest Asia, to include the January 1990 head trauma or any hazardous environmental exposure? Alternatively, is it at least as likely as not (1) proximately due to service-connected disability, such as PTSD, IBS, or fibromyalgia, or (2) aggravated beyond its natural progression by service-connected disability, such as PTSD, IBS, or fibromyalgia? For the issue of service connection for GERD, the examiner must address the following: Is it at least as likely as not (probability of approximately 50 percent) that the Veteran's GERD is related to his service in Southwest Asia, to include any hazardous environmental exposure? Alternatively, is it at least as likely as not (1) proximately due to service-connected disability, such as PTSD, IBS, or fibromyalgia, or (2) aggravated beyond its natural progression by service-connected disability, such as PTSD, IBS, or fibromyalgia? For the issue of service connection for a heart disability, the examiner must address the following: Is it at least as likely as not (probability of approximately 50 percent) that the Veteran's diagnosed heart disability is related to his service in Southwest Asia, to include any hazardous environmental exposure? A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an 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). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. López, 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.