Citation Nr: 21077132 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-03 238 DATE: December 28, 2021 ORDER Service connection for a right elbow disability, to include under the provisions of 38 C.F.R. § 3.317, is denied. Service connection for a thoracic and/or lumbar spine disability, to include under the provisions of 38 C.F.R. § 3.317, is denied. Service connection for a right knee disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317, is denied. Service connection for a left knee disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317, is denied. Compensation under the provisions of 38 C.F.R. § 3.317 for an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by symptoms involving right hand/finger pain is denied. Compensation under the provisions of 38 C.F.R. § 3.317 for an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by symptoms that include leg swelling is granted. REMANDED Service connection for a left elbow disability, to include under the provisions of 38 C.F.R. § 3.317, is remanded. Service connection for a right foot disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317, is remanded. FINDINGS OF FACT 1. The current diagnoses in the right elbow thoracic and lumbar spine, right knee, left knee, and right hand/finger pain, have a pathophysiology that is either partially or fully understood, and those diagnoses are not related to any event or injury of service. 2. The Veteran's right leg swelling is a condition of unexplained pathophysiology and etiology, and it has manifested to a degree of at least 10 percent for six months. CONCLUSIONS OF LAW 1. The criteria for service connection for a right elbow disability, to include under the provisions of 38 C.F.R. § 3.317, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 2. The criteria for service connection for a thoracic and/or lumbar spine disability, to include under the provisions of 38 C.F.R. § 3.317, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 3. The criteria for service connection for a right knee disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 4. The criteria for service connection for a left knee disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 5. The criteria for compensation under the provisions of 38 C.F.R. § 3.317 for an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by symptoms that include right hand/finger pain have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 6. The criteria for compensation under the provisions of 38 C.F.R. § 3.317 for an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by symptoms that include leg swelling have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1988 to November 1991. These matters are on appeal from a May 2013 rating decision. The Board remanded these issues in July 2019 and March 2021. An August 2020 rating decision granted entitlement to service connection for Osgood-Schlatter's disease of the bilateral knees. Therefore, the issues on appeal pertaining to the bilateral knees are limited to disabilities other than Osgood-Schlatter's disease. Service Connection 1. Service connection for a right elbow disability, to include under the provisions of 38 C.F.R. § 3.317 2. Service connection for a thoracic and/or lumbar spine disability, to include under the provisions of 38 C.F.R. § 3.317 3. Service connection for a right knee disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317 4. Service connection for a left knee disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317 5. Compensation under the provisions of 38 C.F.R. § 3.317 for an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by symptoms involving right hand/finger pain 6. Compensation under the provisions of 38 C.F.R. § 3.317 for an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by symptoms that include leg swelling As issues 1-6 are interrelated, the Board will address them together. The Veteran contends that he injured his knee during service when he jumped off the top of a tank. He sought treatment at the time. Also, as a tank driver for a period of time in service, his back was always in pain when driving for long durations in the small space where he was unable to move very much. He also loaded and unloaded tank rounds, which caused him to often have a sore back. He continued to have issues after service and spoke to his private (non-VA) primary care provider about the issues. See 1/19/2016 VA Form 9. Alternatively, the Veteran contends that his conditions are consistent with a qualifying disability under 38 C.F.R. § 3.317 due to his service in Southwest Asia. A. Applicable Law Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for certain disabilities occurring in Persian Gulf veterans. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Southwest Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). Service connection may be established where a Persian Gulf veteran exhibits objective indications of a qualifying chronic disability, provided that such disability: (i) became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2016; and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (b) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a)(2)(i). The term "medically unexplained chronic multisymptom illness" 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. 38 C.F.R. § 3.317(a)(2)(ii). Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. "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). Non-medical indicators include evidence such as time lost from work, the veteran having sought treatment for his symptoms, and changes in the veteran's appearance, physical abilities, and mental or emotional attitude. Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014). A multisymptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is "medically unexplained," that is, the etiology and pathophysiology of the multisymptom illness, must be particular to the claimant's case. Id. at 291. Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). A qualifying chronic disability referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a)(5). Service connection may not be established under 38 C.F.R. § 3.317 for a chronic disability: (i) if there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or (ii) if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or (iii) if there is affirmative evidence that the disability is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Pain, such as muscle pain or joint pain, may also establish an undiagnosed illness that causes a qualifying chronic disability. Joyner, 766 F.3d at 1395. Presumptive service connection may also be established under 38 C.F.R. § 3.317 for certain infectious diseases, which are listed in 38 C.F.R. § 3.317(c). B. Discussion In this case, the existence of current diagnoses is not in dispute. Regarding the right elbow, the Veteran has been diagnosed with strain. See 4/12/2021 VA examination. Regarding the bilateral knees, the Veteran has been diagnosed with strain and osteoarthritis. He has also been diagnosed with a tear of the left meniscus. 4/12/2021 VA examination. (He is already service-connected for Osgood-Schlatter's disease, right knee, and Osgood-Schlatter's disease, left knee with chondromalacia, so those disabilities are not at issue in this appeal.) Regarding the spine, the Veteran has been diagnosed with lumbar spine strain, degenerative disc disease of the thoracic spine, and postural thoracic scoliosis. 4/12/2021 VA examination. He has been diagnosed with De Quervain's Tenosynovitis associated with right hand/finger pain. See 4/12/2021 VA examination. He has also reported swelling in the lower extremities. See 4/12/2021 VA examination. The service treatment records (STRs) contain some relevant entries. Regarding the knees, in April 1988, the Veteran was seen for complaints of pain in his knees for two days with no history of trauma. He was treated with Tylenol and heating pads. In January 1989, he was treated for complaints of left knee hurting for two days. He gave a history of an old injury to the left knee. The assessment was retropatellar pain syndrome and chondromalacia of the left knee. In August 1989, he was treated for pain in the right knee for one day after falling on it while playing football. The assessment was contusion to the right lateral patella. Regarding the right hand, in August 1988, the Veteran was treated for blunt trauma to the right hand three days prior when wood hit his hand. An X-ray was negative, although it was tender with mild swelling; the assessment was soft tissue trauma. These facts are not in dispute. Finally, the Veteran had active service in Saudi Arabia from December 1990 to May 1991. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The critical question in dispute is whether the current diagnoses are related to service. Although the Veteran points to in-service injuries as the etiology of his conditions, the post-service evidence includes some negative evidence indicating an onset of symptoms well after his service separation in November 1991. With regard to the elbows and knees, the Veteran complained to a private provider in July 2011 of elbows and knees hurting off and on. At a May 2013 VA examination, the Veteran reported a history of pain for 10 years, and the examiner gave a diagnosis of lumbar spine strain, elbow strain, and knee strain beginning from 2003. At VA in May 2015, he reported bilateral knee pain for four to five years and bilateral elbow pain with the same timeframe. He denied a history of trauma. Again in July 2016, he informed a VA provider that he had been having knee pain for the prior eight years without remembering any injury or accident that could have caused the pain. He explained that he was a truck driver, and he had knee pain when climbing into and out of the truck. Again in October 2017, the Veteran complained of left knee pain starting that day. In December 2018, the Veteran complained to a private provider that he had left knee pain for one day after prolonged driving eight days prior. This evidence tends to indicate symptoms starting after the Veteran's service separation in November 1991. This tends to contradict any indication of ongoing or continuity of symptoms after service. In direct connection with the instant claims, the Veteran previously underwent VA examinations in May 2013 and December 2019. The Board previously found these examinations deficient, which was the reason the Board remanded all the issues most recently in March 2021. Upon remand, a VA examiner in April 2021 examined the Veteran and reviewed his case. The examiner separately addressed each of the claimed conditions. Regarding the elbow, the VA examiner classified the pathophysiology of the condition as fully understood. The examiner opined that it was less likely than not that the condition occurred during the Veteran's active service. The VA examiner reasoned that, although the Veteran mentioned bumping his right elbow when he was getting out of a tank, on the day of the examination he did not remember details about the "elbow" bump. The examiner concluded that, due to lack of further evidence from records and from the Veteran's statement, an injury at the time of "the bump" was unlikely. Furthermore, according to the examiner, the Veteran was already evaluated for the elbow in 2013 during which he was diagnosed with bilateral elbow strain since 2003. Based on the records, the examiner found the Veteran's symptoms to have started after working as 19K10 M1 Armor Crewman for 3 years and 5 months (as the tank driver in service) and 12 years as a truck driver. The examiner observed that the steering equipment in tanks is different than in trucks. When considering the much greater time spent driving trucks than tanks and the difference in holding the steering wheel and the timing of first reported symptoms in 2003, the examiner determined that the etiology was more likely due to driving trucks, and it was less likely than not that it occurred during active service. Regarding the knees, the VA examiner opined that the pathophysiology of the bilateral osteoarthritis is partially understood because it is likely a progression from bilateral knee strain, and the pathophysiology of the bilateral knee strain was partially understood. Regarding the torn meniscus, the examiner determined that the etiology was inconclusive because it was impossible to connect it to a specific injury during service. Regarding the knees, the examiner explained that although the Veteran reported previously that he injured his knees while jumping from a tank, he did not on the day of the instant examination remember how he injured his knees; he was unable to provide more details as to the nature of his jump, direction, or fall. The examiner noted that, although an August 1989 medical note indicated right lateral patella contusion from a fall while playing football, it related only to the right knee and since then healed. What was more, according to the VA examiner, a 2013 VA evaluation noted symptoms starting in 2003, which suggested any knee issues (other than left knee chondromalacia) likely started in 2003. Regarding the spine, the April 2021 VA examiner classified the Veteran's condition as fully understood. Regarding etiology, the examiner opined that the condition less likely than not occurred during service. The examiner explained that degenerative disc disease was diagnosed in 2017 which was a progression of the lumbar strain. The examiner defined lumbar strain as resulting from repetitive injuries when stressing a lumbar muscle by doing the same motion over and over. The examiner observed that the Veteran stated that his disabilities were due to being confined to a small area while driving tanks. The examiner pointed out that, at the earlier VA examination, he was diagnosed with lumbar strain since 2003 with no spine injury. The examiner concluded that, based on the Veteran's records, his symptoms started after working as 19K10 M1 Armor Crewman for 3 years and 5 months (as the tank driver in service) and 12 years as a truck driver. The examiner cited MedlinePlus as stating that strains involve muscles, and Mayo Clinic as reporting that chronic muscle strains can result from repetitive injuries by stressing a muscle by doing the same motion over and over. Taking it all into consideration, given that the M1 Abrams tank driver position is different that of a typical truck and the fact that the Veteran spent more time driving trucks than tanks, the examiner determined that the Veteran's chronic lumbar strain (muscle) was more likely due to truck driving and the degenerative disc disease was likely a progression of the chronic lumbar strain. The examiner also concluded that the mild thoracic scoliosis was due to poor posture since 2017 as the Veteran did not have it on his thoracic CT scan in 2017 and "he is too old for a new onset of idiopathic scoliosis." Regarding the right hand condition, the examiner classified the pathophysiology of De Quervain's tenosynovitis as fully understood. The examiner observed that De Quervain's tenosynovitis could be post-traumatic or due to overuse (in this case gripping a steering wheel repetitively for a long time). The examiner again noted that the Veteran did not remember other trauma to the hand/finger other than in August 1988, where there was evidence in the medical records of blunt trauma to the right hand at that time. The examiner observed that, although the Veteran did not remember exactly which finger was involved, the 1988 records indicated that the symptoms involved the right hand, which symptoms were not reproduced at the instant VA examination. The examiner noted that the records were silent for evidence of lateral wrist, distal radius or first metacarpal injury (areas associated with De Quervain's tenosynovitis). Therefore, the VA examiner concluded, the 1988 trauma to right hand/finger was unlikely the cause of the diagnosed De Quervain's tenosynovitis due to different location of the symptoms in 1988. In terms of the overuse, the VA examiner noted that the Veteran was not sure when his symptoms started, but had driven a tank while in service for 3 years and 5 months and a truck for 28 years. The examiner took notice that tank steering equipment differs from the steering wheel in a truck, and the Veteran spent significantly more time driving trucks than tanks. Therefore, the VA examiner opined that the De Quervain's tenosynovitis was more likely than not due to overuse while driving trucks for 28 years and less likely than not due to right blunt trauma to the hand in August 1988. With regard to the leg swelling, the VA examiner classified the pathophysiology as inconclusive. On clinical evaluation, the examiner observed lower extremity swelling at the right leg (shin) with medical records in September 2017 and November 218 indicating right leg and right ankle swelling respectively, but no etiology mentioned. The examiner found no superficial venous disease seen, and the left leg did not have swelling. The examiner also found no shortness of breath or overall fluid overload on examination. Finally, the examiner took notice of a bilateral lower extremity Doppler duplex study dated in September 2017 that was negative for deep vein thrombosis. The examiner found no etiology for this unilateral right leg swelling. Finally, as asked in the Board's prior remand, the VA examiner discussed a May 2013 VA examiner's assessment that the Veteran's joint pains are due to the wear and tear of daily living. The VA examiner explained that the Veteran's "joint pains" refer to the strain in bilateral knee, bilateral elbow, and lumbar joints diagnosed on the May 2013 assessment, and the "wear and tear of daily living" referred to "repetitive injuries by stressing a muscle by doing the same motion over and over." The VA examiner clarified that this means that the Veteran was diagnosed with strain in the bilateral knee, bilateral elbow, and lumbar joints and no other pertinent diagnoses were given on the May 2013 assessment. The examiner pointed out that the 2013 VA examiner mentioned joint pains due to the wear and tear of daily living, diagnosed with strain in bilateral knee, bilateral elbow, and lumbar joints, all since 2003, without history of trauma reported on history with no other pertinent diagnoses given on the evaluation. The VA examiner cited MedlinePlus as stating that strains involve muscles and Mayo Clinic reports that chronic muscle strains can result from repetitive injuries by stressing a muscle by doing the same motion over and over. The VA examiner reiterated that the 2019 evaluation determined that he drove trucks for 28 years and his strain in the bilateral knee, bilateral elbow, and lumbar joints started after he drove trucks for 12 years since leaving service. In a September 2021 addendum the same examiner clarified the opinion as to right leg swelling. The VA examiner explained that, when considering the definition of a medically unexplained chronic multi symptom illness, the medically unexplained multi symptom illness fits closest for the swelling of the right lower extremity. The examiner did not feel the symptoms were out of proportion to physical findings as the physical findings were there of swelling. Finally, the examiner commented that the term "multisymptom" implies other symptoms associated with the swelling, but the Veteran had no other symptoms associated with it. The Board finds this VA examiner's opinion probative because it addresses the pathophysiology of the Veteran's conditions. It also addresses the alternative theories of entitlement raised. It took into consideration the Veteran's contentions, but explained why the conditions were less likely than not due to the events of his service notwithstanding his report of symptoms since service. The examiner explained why the conditions and circumstances of driving a tank were substantively different from those of his post-service work driving a truck, and why that post-service work, but not the "wear and tear" during service, was the likely etiology of the conditions. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). At present, the Board can find no reason to call into question or otherwise discount the probative weight of the VA examiner's opinion. All medical questions were addressed such that the Board can reach an informed decision on the issues. Thus, overall, the VA examiner's opinion is of great probative weight. Overall, as both the etiology and the pathophysiology of the Veteran's right elbow, lumbar spine, right and left knee, and right hand/finger pain conditions are partially or fully understood, they cannot be considered a MUCMI. Presumptive service connection is not warranted under § 3.317. Likewise, the VA examiner's opinion establishes why, as a medical matter, the diagnoses are unlikely related to any other event or injury of service. The Veteran believes his conditions are related to an in-service injury, event, or disease, including Persian Gulf War service. The Veteran in this case is not competent to provide a nexus opinion regarding this question. The question is medically complex, as it requires advanced medical knowledge concerning diagnoses, potential risk factors for the diagnoses, and how the instant Veteran's risk factors correspond with the current diagnoses. It is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiner's opinion. Regarding the left leg swelling, the VA examiner's opinion establishes that the pathophysiology is not partially or fully understood. The examiner excluded all other potential etiologies. Hence, the condition is consistent with a MUCMI. The question thus becomes whether it has manifested to a degree of at least 10 percent. To this end, the most analogous diagnostic code (DC) is 7121 of 38 C.F.R. § 4.104, which sets forth the rating schedule for post-phlebitic syndrome of any etiology. It provides a 10 percent rating for intermittent edema of extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. In this Veteran's case, a private (non-VA) evaluation in September 2017 shows that the Veteran presented for complaints of leg swelling for three days after a recent flight. On follow-up the next week, he returned with complaints of continued swelling in the right leg with no pain, but only improved slightly since the prior week; the Veteran was recommended to elevate the leg and return if no improvement occurred after a week. This evidence is consistent with the minimum 10 percent rating under DC 7121. Moreover, by extending him the benefit of the doubt, his contentions indicate symptoms at least intermittently last six months or more. Hence, this condition is consistent with a qualifying chronic disability under 38 C.F.R. § 3.317. In sum, the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not applicable, and therefore, the claims of service connection are denied, except for right leg swelling, which is granted. REASONS FOR REMAND 1. Service connection for a left elbow disability, to include under the provisions of 38 C.F.R. § 3.317 2. Service connection for a right foot disability other than Osgood-Schlatter's disease, to include under the provisions of 38 C.F.R. § 3.317. These issues are remanded for a new VA examination and medical opinion. Regarding the left elbow, upon the prior remand, a VA examiner in April 2021 diagnosed right elbow strain. The VA examiner noted that the Veteran denied issues with the left elbow. The VA examiner found the left elbow to be less likely than not related to service "because the condition was noted to be resolved and not present on today's exam[ination]." This April 2021 VA examination is incomplete because, even if the Veteran did not have left elbow pain or a diagnosed condition at the time of that VA examination, the May 2013 VA examination diagnosed elbow strain bilaterally. The December 2019 VA examination found no diagnosis, but reported sore left elbow when he bent it. Likewise, with regard to the right foot, the April 2021 VA examiner found no current diagnosis associated with the claimed condition. However, the Veteran complained to the examiner that he sometimes had soreness in the foot. Previously, the December 2019 VA examiner diagnosed metatarsalgia and hallux valgus of the right foot. "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (internal citation omitted). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The standard is whether a disability exists at the time the claim was filed. See Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Furthermore, pain alone can be a service-connectable disability. See Saunders v. Wilkie, 886 F.3d 1356, 1362 (Fed. Cir. 2018); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 398 (2020). Plus, in the context of 38 C.F.R. § 3.317, joint pain can be a sign of a qualifying chronic disability. Here, the Veteran filed his claim in February 2011. This claim was pending when the diagnosis of elbow strain was made in May 2013 and the report of left elbow pain was reported at the time of the December 2019 VA examination. There was also the diagnosis of metatarsalgia and hallux valgus of the right foot in December 2019. These diagnoses were made during the pending appeal period. Hence, there is an indication of a potential condition in the left elbow and right foot during the appeal period. An opinion was needed as to the left elbow, even though the condition was fully resolved by the time of the April 2021 VA examination. Remand for a new opinion is therefore needed. The matters are REMANDED for the following action: Schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the claimed left elbow and right foot. (a.) Does the Veteran have a current diagnosis in the left elbow or right foot? The examiner must provide a diagnosis for any conditions found extant. In doing so, the examiner must conduct all necessary diagnostic testing, unless it can be explained why such testing is not medically necessary. The examiner should consider all prior diagnoses of record. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (b.) Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis (c.) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern consistent with options (3) or (4) above, (i.e., either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis), then please provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. (CONTINUED ON NEXT PAGE) (d.) If no, is it at least as likely as not that any condition of the left elbow or right foot had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? JOHN G. SETTER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Bosely, 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.