Citation Nr: A21019166 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 191129-51308 DATE: December 2, 2021 ORDER Service connection for fibromyalgia is denied. Service connection for costochondritis is denied. Service connection for a prostate condition is denied. A rating in excess of 30 percent for degenerative joint disease of the left knee is denied. REMANDED The claim for service connection for a low back condition is remanded. The claim for service connection for obstructive sleep apnea (OSA) is remanded. The claim for service connection for a skin condition is remanded. The claim for service connection for a undiagnosed illness manifested by joint pain or a medically unexplained chronic multi-symptom illness. FINDINGS OF FACT 1. The weight of the evidence is against finding that the Veteran has had a diagnosis for fibromyalgia at any time during the period on appeal, or that any chronic pain he experiences is otherwise related to his active-duty service. 2. The weight of the evidence is against finding that the Veteran's costochondritis had its onset during his active-duty service, or is otherwise related to his active-duty service. 3. The weight of the evidence is against finding that the Veteran's prostatitis had its onset during his active-duty service, or is otherwise related to his active-duty service. 4. The Veteran's left knee disability has not resulted in ankylosis; recurrent subluxation or lateral instability; dislocated or removed meniscus; flexion functionally limited to 60 degrees or less; extension functionally limited to 5 degrees or more; or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 2. The criteria for service connection for costochondritis have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 3. The criteria for service connection for a prostate condition have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 4. The criteria for a rating in excess of 30 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5055, 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active-duty from May 1987 to October 1987 and from February 1989 to July 1996. The Veteran testified before Veterans Law Judge (VLJ), K. Millikin at a December 2017 Board hearing. A complete transcript is of record. The Veteran then testified before the undersigned VLJ in May 2021. A complete transcript is of record. This appeal was previously before the Board in November 2018. The Board decision remanded the issues on appeal for further development, to include obtaining outstanding VA and private treatment records and VA examinations. Since the November 2018 remand, numerous VA treatment records have been associated with the claims file. The Veteran was sent correspondence in April 2019 asking him to authorize VA to obtain his private treatment records, or to obtain them himself and to provide them to VA. The Veteran provided about 650 pages of medical evidence, and reported that he submitted all the medical records VA was requesting for his claims. As such, the Board finds that there has been substantial compliance with the November 2018 Board remand directives, as they pertain to the obtaining of outstanding treatment records. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board will discuss whether there was substantial compliance regarding the requested VA examinations in their respective sections. After the requested development took place, an October 2019 supplemental statement of the case (SSOC) denied the service connection claims for a skin disorder, a low back disorder, costochondritis, OSA, a gastrointestinal disorder, a prostate disorder, fibromyalgia, and the increased rating claim for a left knee disability. The Veteran then filed a VA Form 10182 Notice of Disagreement and selected the AMA review hearing lane. Accordingly, in adjudicating the issues on the merits, the Board is required to consider the evidence of record at the time of the RO's October 2019 SSOC, evidence submitted by the Veteran at the hearing, as well as evidence submitted within 90 days following the hearing. 38 C.F.R. § 20.302 (b). The Board notes that the Veteran has submitted additional evidence, to include both lay statements and medical records, within 90 days following the hearing. As such, the Board will proceed with adjudication. The Board does acknowledge that the November 2018 Board decision also remanded the service connection claim for a gastrointestinal condition. However, service connection was granted by an August 2020 rating decision and therefore is no longer before the Board. Additionally, while this decision finds that the Veteran does not have fibromyalgia, the examinations that have been provided have yet to assess whether the Veteran has either an undiagnosed illness or a medically unexplained chronic multi-symptom illness manifested by joint pain. As an initial matter, the Board acknowledges that the Veteran has had two separate Board hearing, before two separate VLJs. This would ordinarily entitle the Veteran for an opportunity to have a third Board hearing. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). However, the Board notes that VLJ Millikan resigned as a VLJ, and returned as a decision writing attorney. Moreover, once the Veteran opted out of the legacy appeal framework and into the AMA framework, the hearing in the legacy system no longer bound the case to the hearing VLJ. As such, the Board finds that a third Board hearing is not required. Id. Service Connection 1. Service connection for fibromyalgia is denied. The Veteran asserts that he did not have chronic pain prior to entering the service, but after being deployed to the Gulf War, his arms would get numb and experienced unexplained joint pains. A review of the Veteran's service treatment records (STRs) does not appear to show any complaints for chronic generalized joint pain. His separation examination showed a normal clinical evaluation of the neurologic system, as well as the upper and lower extremities. The separation "Report of Medical History" showed specific complaints of left knee, back spasms, a foot problem, and shoulder and elbow pain. However, there was no indication that the Veteran was diagnosed with fibromyalgia, or any other generalized joint condition. A review of the Veteran's post-service treatment records, to include both VA and private treatment records does not reveal any diagnosis for fibromyalgia. He was seen in October 2004 for knee symptoms, but he otherwise reported that he had no numbness of weakness in his lower extremities. The first instance of numbness was in June 2011, when he reported a long history numbness in his arms and fingers. A July 2011 treatment note shows that a VA medical professional suspected carpal tunnel syndrome, based on his upper extremity symptoms. A nerve conduction test was performed and was negative for carpal tunnel syndrome. See VA Treatment Record dated September 21, 2011. The Veteran was afforded a VA Gulf War examination in July 2013. The Veteran reported that he had fibromyalgia due to his Gulf War service. After an in-person examination and a review of the Veteran's claims file, the examiner found that the Veteran did not have a current diagnosis, or was ever diagnosed with fibromyalgia. The examiner reported that the Veteran did not currently have any findings, signs, or symptoms attributable to fibromyalgia. The Veteran provided testimony at a December 2017 Board hearing. The Veteran testified that re received treatment for fibromyalgia at a VA medical center. He reported that his arms and legs would get numb. He also indicated that he was being treated for and had been diagnosed with fibromyalgia. The November 2018 Board decision remanded this issue to obtain the Veteran's post-service treatment records. Based on the Veteran's 2017 testimony, the Board sought to obtain his medical records to confirm that he had been diagnosed with fibromyalgia. As previously discussed, the Veteran's outstanding treatment records were associated with his claims file. A review of the private treatment records did not reveal any diagnosis for fibromyalgia. His VA treatment records similarly did not contain any diagnosis for fibromyalgia. For example, his treating medical professionals suspected that his upper extremity symptoms were carpal tunnel syndrome, but diagnostic testing did not reveal any abnormalities. The Veteran was afforded a VA examination in August 2019. The Veteran reported that the onset of his symptoms was in the 1990s and that he experiences widespread joint pain, all of the time. He reported that his condition has worsened over time. After an in-person examination and a review of the Veteran's claims file, the examiner found that the Veteran did not have a current diagnosis, or was ever diagnosed with fibromyalgia. The examiner explained that there was no clear diagnosis for fibromyalgia in the medical records and not enough documentation in the records to come to the conclusion that the Veteran has been diagnosed with fibromyalgia during the period on appeal. The examiner reported that the Veteran did not currently have any findings, signs, or symptoms attributable to fibromyalgia. The examiner reported that the Veteran did not have any tender points for pain, or any other pertinent physical signs. Here, given that the Veteran testified that he had been diagnosed with fibromyalgia, his outstanding treatment records were sought, and a VA examination was ordered. However, his post-service private and VA treatment records did not reveal any diagnosis for fibromyalgia. Further, an in-person VA examination was provided, and the examiner found that there was no diagnosis for fibromyalgia, at any time. To the extent that the Veteran believes that he is diagnosed with fibromyalgia, or that his chronic generalized pain and numbness are the result of his deployment in the Gulf War, such medical opinions require medical expertise, and those determinations cannot simply be made by lay observation alone; and the Veteran is not considered competent (meaning medically qualified by training or experience) to provide such a diagnosis or a medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given the Veteran's assertions, his outstanding treatment records were sought, and a VA examination was ordered, which took into account the evidence of record. Fortunately, the October 2019 VA examiner did not find a diagnosis for fibromyalgia, or any other conditions. The Board notes that the Veteran has not offered any medical opinion that would undermine the October 2019 VA examiner's findings. The Board acknowledges the Veteran's assertion that he is diagnosed with fibromyalgia. However, the contemporaneous evidence of record does not support his assertion. His private and VA treatment records have been carefully reviewed, which shows no diagnosis for fibromyalgia, at any time. Further, a 2019 in-person examination did not reveal a fibromyalgia diagnosis. Here, there are two competent medical findings of record, provided by the 2013 and 2019 VA examiners. The examiners were both able to examine the Veteran in-person, yet found no diagnosis for fibromyalgia, now, or at any other time. The Board also emphasizes that the Veteran had a nerve conduction test performed and showed normal results. See VA Treatment Record dated September 21, 2011. In the absence of proof of a current chronic disability of hypertension, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. Here, although the Veteran has reported symptoms of numbness and pain in his upper and lower extremities, there has been no diagnosis that explains those symptoms. The Board also notes that the Veteran is not service-connected for any spinal disability. The Veteran has not submitted any medical evidence reflecting treatment for or a diagnosis of fibromyalgia. As such, the Board cannot conclude that the Veteran currently suffers from fibromyalgia. Until the Veteran can show a diagnosis for fibromyalgia, or another neurologic condition, and/or provides a competent medical opinion that attributes such a diagnosis or his complaints of chronic numbness and pain to his active-duty service, service connection cannot be granted. Accordingly, service connection for fibromyalgia is denied. Should the Veteran obtain a medical opinion regarding the Veteran's claim for fibromyalgia, or even a diagnosis of the condition, those medical records should be associated with the Veteran's claims file and a supplemental claim should be filed. 2. Service connection for costochondritis is denied. The Veteran asserts that his costochondritis is due to his active-duty service. Specifically, he testified that during his service, he was working in oil fields, which exposed him to smoke and caused him to cough. The Veteran's STRs show that he reported occasional shortness of breath at the separation examination. He also reported that he did not have a chronic cough. The Board notes that the clinical evaluation at the separation examination showed normal results for all body systems, including the lungs and chest. The Veteran testified at the 2017 Board hearing that he worked in the oil fields and that he inhaled too much smoke. As a result of inhaling too much smoke, he reported that he started to experience chest pains. He testified that when he was having chest pains, he believed it was a heart attack, but when he sought medical treatment, he was told it was pain in the muscles of the chest, not the heart itself. He reported that from 1996, till the time he was diagnosed with costochondritis, he had constant chest pain. The Board acknowledges the Veteran's VA Form 21-4138. See Statement in Support of Claim received January 18, 2018. The Veteran stated that he was not given a VA examination and provided his STRs, which showed complaints for shortness of breath, VA progress notes, and private treatment records from Palmetto Richland hospital. A review of the Veteran's post-service treatment records shows that he did report non-specific chest pain in 1996. See VA Treatment Record dated December 11, 1996. However, at subsequent routine office visits, he consistently denied chest pain. See VA Treatment Records dated February 4, 1997, June 23, 1999, and December 14, 1999. The next complaint for chest pain was in January 2006, when he complained of sinus congestion, dry cough, and chest wall pain. He reported that he worked on a psych unit where patients were sick, with similar symptoms. He appears to have been diagnosed with costochondritis in November 2014, by a private physician. The November 2014 discharge summary included a description and explanation of costochondritis. The summary reported that costochondritis was due to an inflammation of the cartilage joining the ribs and the breastbone, and was not caused by heart or lung problems. Although the exact cause for costochondritis is not known, it often occurs during times of emotional distress. The Veteran was afforded a VA examination in August 2019. The examiner noted that the Veteran was diagnosed with chronic costochondritis. The Veteran reported that he experienced chest pain about twice a month, with varying levels of duration. After the in-person examination and a review of the claims file, the examiner provided a negative nexus opinion. The examiner explained that there was no evidence-based material that supported costochondritis comes from smoke inhalation or any other environmental exposures. The examiner indicated that costochondritis could be secondary to a respiratory condition that caused persistent coughing, over an extended period of time. However, there was no corresponding respiratory condition caused by smoke inhalation that would suggest costochondritis. Simple coughing on isolated instances does not cause chronic costochondritis and there has to be an associated respiratory condition that would cause persistent coughing over time, which does not exist in this case. The Veteran testified at the 2021 Board hearing that his chest pain is due to working in the oil fields because he would cough so much. He reported that he was first diagnosed with costochondritis in 1990, when he thought he was having a heart attack. He testified that he went to the hospital because he thought he was having a heart attack, but turned out to be costochondritis. Here, the Board finds that the weight of the evidence is against finding that service connection for costochondritis is warranted. The Board recognizes the positive evidence provided by the Veteran, namely his lay statements and testimony, the STRs which show in-service complaints of shortness of breath, and the post-service treatment records which show complaints of chest pain. However, the competent medical evidence of record indicates that the onset of his costochondritis was not during his active-duty service, or is otherwise related to his active-duty service. First, the Board will address the Veteran's testimony at the 2017 and 2021 Board hearings. At the 2021 Board hearing, he reported that he was diagnosed with costochondritis in 1990, but at the 2017 hearing, he reported that from 1996, till the time he was diagnosed with costochondritis, he had constant chest pain. Here, the Board notes that the Veteran has provided inconsistent statements regarding when he was diagnosed with costochondritis. The Veteran's representative indicated that he was diagnosed at the Palmetto Richmond Hospital in South Carolina. The private treatment records, submitted by the Veteran, show that he was diagnosed with costochondritis in April 2015, at Palmetto Health in South Carolina. Regarding his testimony that he experienced constant chest pain, the contemporaneous evidence of record does not support his assertion. For example, at his routine annual check-ups at VA, he reported chest pain in 1996, but denied chest pain in February 1997 and in June and December 1999. The next complaint of chest pain was in 2006. The Board notes that only the Veteran's assertions have suggested the possibility of any relationship between his in-service exposure to environmental hazards and his costochondritis, whereas none of the treating physicians of record have provided any suggestion that there even might be a medical connection between his active-duty service and the claimed condition. To the extent that the Veteran believes that his costochondritis is the result of his in-service exposure to environmental hazards, such a medical opinion requires medical expertise, and that determination cannot simply be made by lay observation alone; and the Veteran is not considered competent (meaning medically qualified by training or experience) to provide a medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, given the Veteran's testimony and assertions, a VA examination was ordered. Unfortunately, the August 2019 VA examiner provided a negative nexus opinion. Further, the Veteran's private treatment records shows that a November 2014 discharge summary for the treatment of costochondritis, appears to agree with the opinion of the August 2019 VA examiner. The summary reported that costochondritis is not caused by lung problems. Here, the Board is sympathetic to the Veteran's assertions and belief that service connection is warranted based on his in-service exposure to environmental hazards. The Board has reviewed the Veteran's STRs and it does show that he was reported shortness of breath at the separation examination. However, the August 2019 VA examiner explained that periods of isolated coughing would not cause chronic costochondritis; instead, costochondritis could be secondary to a respiratory condition that caused persistent coughing, over an extended period of time. However, there was no corresponding respiratory condition caused by smoke inhalation that would suggest a mechanism for causing costochondritis. A careful review of the Veteran's STRs does not reveal any complaints of respiratory conditions, or diagnosis for any respiratory conditions. At the separation examination, his clinical evaluation showed a normal examination of the lungs and chest. Based on the foregoing, the Board affords the August 2019 VA examiner's opinion great probative weight because the contemporaneous evidence of record, to include the STRs, and the post-service treatment records appears to bolster the examiner's rationale. Whereas the Veteran's lay statements and assertions are afforded little probative weight because he is not competent to provide medical opinions. Id. The Board has also considered whether service connection is warranted by way of continuity of symptomatology. However, as previously discussed, the Veteran's assertion that he has experienced constant chest pain, since his active-duty service is not corroborated by the contemporaneous evidence of record. He did report shortness of breath at the May 1996 separation examination and chest pain in December 1996. However, in the next few years following the December 1996 check-up, he consistently denied the presence of chest pain. As such, the Board finds that any continuity has been severed, based on the Veteran's objective medical records and the weight of the evidence is against his claim. Accordingly, service connection for costochondritis is denied. 3. Service connection for a prostate condition is denied. The Veteran asserts that his chronic prostatitis is due chemical exposure, while deployed in Southwest Asia. The Veteran's STRs show that he complained of frequent, urgent, and burning urination. See STR dated May 7, 1991. His separation examination showed a normal clinical evaluation of the prostate and in the report of medical history, he denied frequent or painful urination. The Veteran testified at the 2017 Board hearing that his prostate problems began in the Persian Gulf, when medics tried to treat him and other service members. He reported having urinary problems and was told that something got in the water because so many people were having problems. He asserted that the symptoms he experiences today are the same symptoms that he was treated for during his active-duty service. The Board acknowledges the statements provided by the Veteran and his wife. See Correspondences received April 24, 2017 and January 18, 2018. The Veteran reported that he had in-service symptoms of urinary problems, and sought treatment from Dorn VA within a year of his separation from the military. He reported that he had to miss many days of work due to this problem and was currently being treated for the prostate condition. His wife reported that she noticed serious urinary problems, that were causing him to go to the bathroom constantly. She also noted that he had painful urination. The Veteran testified at the 2021 Board hearing that he was of the belief that his exposure to the oil fields caused his urinary problems. He also testified that he was exposed to chemicals during his active-duty service. He explained that one day, alarms went off, indicating that chemicals were in the air. He reported that F14s tried to sweep the air to remove the chemicals, but nobody could determine what type of chemical it was. He described that due to this exposure, many service members mouths became filled with a deep and bitter lemon taste. The Veteran was afforded a VA examination in August 2019. After an in-person examination and a review of the Veteran's claims file, the examiner provided a negative nexus opinion. The examiner acknowledged that the Veteran was diagnosed with chronic prostatitis, but explained that there was no evidence of prostatitis during his active-duty service. The examiner noted that the Veteran separated from service in 1996, and that the STRs only reported on isolated incident of frequent urination in 1991. The examiner concluded by stating that there was no evidence of chronic prostatitis with an in-service onset, or was otherwise related to his active-duty service, to include environmental exposures. To the extent that the Veteran believes that his chronic prostatitis is the result of his active-duty service, to include environmental and/or chemical exposures, such a medical opinion requires medical expertise, and that determination cannot simply be made by lay observation alone; and the Veteran is not considered competent (meaning medically qualified by training or experience) to provide a medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given that the Veteran's STRs showed in-service complaints and treatment of urinary problems, a VA examination was ordered to address the medical and lay evidence of record and to provide an etiology opinion. Unfortunately, after an in-person examination and a review of the claims file, the August 2019 VA examiner provided a negative nexus opinion regarding an in-service onset and direct service connection. The Board notes that the Veteran has not offered any medical opinions that would undermine the August 2019 VA examiner's medical opinion. Here, there is only one competent medical opinion of record, the August 2019 VA examiner's opinion that the Veteran's prostate condition did not have its onset during his active-duty service, or was otherwise related to his active-duty service to include environmental and chemical exposures. The examiner explained that there was no medical documentation of prostate condition in-service because there was only one isolated incident of frequent urination in 1991. Further, the Board notes that the Veteran's May 1996 separation examination showed a denial of frequent urination and the clinical evaluation of the Veteran's prostate was shown to be normal; and the medical evidence of record indicates that the Veteran was diagnosed with a prostate condition many years after service. The Board acknowledges his statement that he was treated for frequent urination at Dorn VA, within a year of his separation from the military. However, a careful review of his Dorn VA treatment records from the years immediately after his separation does not reveal any complaints or treatment for urinary problems. The Board affords the August 2019 VA examiner's opinion great probative weight because the examiner had a chance to examine the Veteran in-person and reviewed his claims file. To rebut the November 2019 VA examiner, the Veteran must provide a medical opinion from a competent medical professional, with a sufficient rationale that supports their opinion. The Board acknowledges the Veteran's belief that the onset of his prostate condition was during his active-duty service. The Board also recognizes the medical evidence of record, as well as his lay statements. However, the August 2019 VA examiner explained that the Veteran only had one isolated incident of urinary problems. The first instance in the Veteran's post-service treatment records that he had frequent urination was in August 2006, about 10 years after his separation from the military. Given the lack of objective evidence pointing to a continuity of symptomatology, the Board find that presumptive service connection is not warranted. Further, his wife did report that the Veteran had urinary problems, but she did not state when she started to see such problems, or how long they have persisted. The Board is sympathetic to the Veteran's belief that his prostate condition is related to service and does not wish to minimize such assertions or beliefs. However, no matter how sincere the Veteran's belief in their claim is, his lay assertions cannot be considered competent medical evidence and he cannot provide an etiology opinion for a condition such as costochondritis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, service connection for a prostate condition is denied. Increased Rating A rating in excess of 30 percent for a left knee disability is denied. The Veteran asserts that he is entitled to a higher rating for the service-connected left knee disability. The Veteran's 30 percent rating for his left knee disability is rated under Diagnostic Code 5262 for malunion of the tibia and fibula, with marked knee or ankle disability. See Rating decision dated May 10, 2005. VA received the Veteran's increased rating claim for his left knee disability in June 2012. An October 2013 rating decision denied his claim, which the Veteran disagreed with. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Diagnostic Code 5256 evaluates ankylosis of the knee. The record contains no evidence of right knee ankylosis. As such, this Diagnostic Code is not applicable. Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of a knee. The record contains no evidence of recurrent subluxation or lateral instability of the right knee. As such, this Diagnostic Code is not applicable. Diagnostic Codes 5258 and 5259 evaluate the semilunar cartilage, which is synonymous with the meniscus. Under Diagnostic Code 5258, when the meniscus is dislocated with frequent episodes of locking, pain and effusion into the joint a 20 percent rating is assigned. Under Diagnostic Code 5259, when the meniscus has been removed, but remains symptomatic, a 10 percent rating is assigned. Diagnostic Code 5262 evaluates impairment of the tibia and fibula. The record contains no evidence of an impairment of the tibia and fibula. Diagnostic Code 5263 evaluates genu recurvatum. The record contains no evidence of genu recurvatum. As such, this Diagnostic Code is not applicable. Under Diagnostic Codes 5260 and 5261 (limitation of knee flexion and knee extension respectively), a noncompensable rating may be assigned where either knee flexion is limited to 60 degrees or knee extension is limited to 5 degrees. A compensable (i.e. at least 10 percent) rating is assigned for either flexion limited to 45 degrees or extension limited to 10 degrees. A 20 percent rating is assigned for either flexion limited to 30 degrees or extension limited to 15 degrees. Of note, separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. It is noted that the VA regulations governing the rating of knee disabilities was revised as of February 7, 2021. However, because the period on appeal in this case is limited to the time prior to the issuance of the supplemental statement of the case (SSOC) in October 2019, the revised regulations do not apply and will not be addressed further. The Veteran was afforded a VA examination in July 2013 at which he reported experiencing constant left knee pain, with increased stiffness. He also reported experiencing flare-ups. On examination, he demonstrated flexion to 140 degrees and extension to 0 degrees in the left knee. There was no evidence of painful motion. The Veteran was able to perform repetitive use testing and did not result in the loss of range of motion, or weakness, fatigability, discoordination, or loss of function. Muscle strength testing showed full strength in all areas. Joint stability testing was performed, which did not show any joint instability in either knee. There was no evidence of tibial or fibular impairment or ankylosis. There was no evidence of meniscal surgery or any other surgical procedures. The Veteran was noted to use a knee brace. The Veteran provided a Disability Benefits Questionnaire (DBQ) conducted by a private medical professional, dated June 20, 2014. The Veteran reported having flare-ups and described increased pain and swelling, with activity. He reported his functional loss was being unable to run, squat, kneel, or crawl. On examination, he showed flexion to 120 degrees and extension to 0 degrees. Pain was noted on examination and with weight-bearing and non-weight-bearing, which resulted in weakened movement, pain, atrophy of disuse, and disturbance of locomotion. The examiner opined that the Veteran's flexion would be limited to 90 degrees during a flare-up, but did not provide an indication for extension. Muscle strength testing showed 4/5 strength in all planes of motion. The examiner noted that the Veteran had muscle atrophy, but reported that they did not measure to confirm. There was no evidence of ankylosis. There was no history of recurrent subluxation or lateral instability. There was a history of recurrent effusion, with activity. The examiner indicated that there was no joint instability in the left knee. There was no indication of any tibial or fibular impairment. The examiner indicated that the Veteran had a left meniscal tear and had undergone arthroscopic surgery 20 years earlier. The examiner reported that the Veteran had pain and swelling due to the meniscectomy. The examiner noted that the Veteran did not use any assistive devices. The Veteran was scheduled for a VA examination in July 2014, but he failed to report. The Veteran was afforded a VA examination in June 2017. The Veteran reported experiencing flare-ups and described a sharp, stabbing pain and being unable to stand on a leg. He reported that his functional loss was being unable to stand, walk, or squat for long periods of time. On examination, he showed flexion to 90 degrees and extension to 0 degrees. Pain was noted on examination, but did not result in functional loss. There was evidence of pain on both weight-bearing and non-weight-bearing. The Veteran was able to perform repetitive use testing, with no additional loss in terms of range of motion. The examiner indicated that the examination was not done during a flare-up, but reported that pain, weakness, fatigability, or incoordination would not significantly limit functional ability during flare-ups. Muscle strength testing showed normal strength in all planes of motion and there was no muscle atrophy. There was no evidence of ankylosis or tibial and/or fibular impairment. Joint stability testing showed no joint instability. The examiner noted a 1994 arthroscopic debridement of the left knee, but reported that there was no evidence or history of a meniscus condition. The examiner indicated that the Veteran regularly used a knee brace. Corriea testing showed objective evidence of pain on passive motion, pain on non-weight-bearing, and the opposing joint did not have evidence of damage. The Veteran testified at the 2017 Board hearing that the 2015 and 2017 VA examinations for the knee were inadequate because both examiners did not even look up from their computers during the examinations. He reported that neither examiner provided any range of motion testing, or any other type of physical testing. He reported that he wanted a new VA examination for the left knee. The Veteran declined to provide any testimony regarding his left knee at the 2021 Board hearing. The November 2018 Board decision found that remand was necessary to afford the Veteran a new VA examination to determine the current nature and severity of the service-connected left knee disability. The examiner was asked to perform Corriea testing and to elicit information regarding the Veteran's flare-ups. The Veteran was afforded a VA examination in August 2019. The Veteran reported that his left knee disability had worsened since its onset. He reported that he did not have flare-ups in his knees. He reported that he had functional loss and described that his knees hurt all the time. On examination, he showed flexion to 90 degrees and extension to 0 degrees. Pain was noted on examination and caused functional loss (limited range of motion for both flexion and extension). However, the Veteran was able to perform repetitive use testing, with no additional loss in terms of range of motion. The examiner noted that pain would significantly limit functional ability with repeated use over period of time. Muscle strength testing showed 4/5 strength in all planes of motion. There was no evidence of muscle atrophy. There was no evidence of ankylosis or tibial and/or fibular impairment. Joint stability testing showed no joint instability. The examiner noted a 1994 arthroscopic surgery of the left knee, but reported that there was no evidence or history of a meniscus condition. The examiner indicated that the Veteran constantly used a cane and occasionally used a knee brace. Corriea testing showed objective evidence of pain on passive motion in both knees and pain on non-weight-bearing in both knees. Here, the Veteran was afforded a VA examination, which helped to determine the current nature and severity of the left knee disability. The examiner also conducted and provided the results for Corriea testing. The examiner also attempted to elicit information about the Veteran's flare-ups, but the Veteran denied having them. As such, the Board finds that there has been substantial compliance with the November 2018 Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A review of the Veteran's post-service treatment records does not reveal any findings that would warrant a higher rating for the left knee disability. Regarding a limitation of flexion, the Veteran consistently showed flexion in his left knee to well over 60 degrees, the threshold for even a noncompensable rating to be assigned. For example, at worst, he showed flexion to 90 degrees at the last VA examination; and the private 2014 examiner opined that during a flare-up, his flexion would be limited to 90 degrees. Although the Veteran was reported to have increased pain, on examination, there was no evidence to show any additional loss in terms of range of motion. The Board acknowledges the Veteran's previous reports of flare-ups at prior VA examinations. However, there has been no indication by the medical professionals of record, that his flexion would be limited to 60 degrees or worse, or reports from the Veteran that his range of motion is significantly affected during flares. The Board acknowledges the Veteran's testimony that the 2015 and 2017 VA examinations were inadequate because he was not given a physical examination. The Board also notes that the Veteran was not provided a VA examination in 2015, but speculates that he meant the 2013 examination. To the extent that he is correct, he was afforded a VA examination in 2019, which did not show compensable results regarding a limitation of flexion. Here, there is simply no objective positive evidence that the Veteran has met the criteria for a separate rating for limitation of flexion. It is also worth noting that the Veteran was capable of performing repetitive motion testing without seeing additional limitation of motion, suggesting that while flare-ups might have caused an increase in symptoms, they did not lead to significant additional functional limitation. Turning to limitation of extension, the Veteran consistently showed full extension (0 degrees) in the left knee at all of the VA examinations and the private examination, during this period on appeal. Here, there has been no suggestion that either flare-ups or repetitive use would lead to limitation of extension to 10 degrees, the minimum limitation required for a separate compensable rating. As such, the Veteran is not found to meet the criteria for a separate rating for limitation of extension. Turning to knee instability, the Veteran has not reported instability in his knees. Further, there does not appear to be any complaints of left knee instability in the post-service treatment records. Clinical examinations of the Veteran's joint stability have shown normal results and the Veteran did not report symptoms of instability at any of the VA examinations. Additionally, the VA examiners of record have indicated that the Veteran did not have a history of episodes of dislocation or recurrent subluxation. As such, the Veteran has not met the criteria for a separate rating under Diagnostic Code 5257. While the Veteran does wear a knee brace on occasion, it is not noted that such a brace was prescribed to alleviate or protect against instability. Regarding meniscus problems, the Board acknowledges the private 2014 examiner's indication that the Veteran had a left meniscal tear and had arthroscopic surgery 20 years earlier. The examiner reported that the Veteran had pain and swelling due to the meniscectomy. However, a review of the Veteran's STRs shows that the 1994 arthroscopic knee surgery report indicated that the Veteran had an intact, stable, and pristine medial meniscus. The report indicated that his knee underwent an arthroscopic shave, in the anteromedial portal and the medial portion of the medial patellar facet. After the arthroscopic shaving, the knee was inspected again, with no additional pathology. Here, the Board finds that the weight of the evidence is against finding that the Veteran has had a left meniscus tear. For example, each of the VA examinations of record has indicated that there was no history of meniscal conditions. As such, the Veteran has not met the criteria for a separate rating under Diagnostic Codes 5258 and 5259. Regarding Diagnostic Code 5262, during the period on appeal, there has been no showing of impairment of the tibia and fibula. Given such, the Board finds that a 40 percent rating is not warranted under this Diagnostic Code and the Board will not disturb the previous favorable findings in regard to impairment of the tibia and fibula. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, the VA examinations of record have shown 4/5 strength in the Veteran's left knee. Despite his complaints of pain and decreased range of motion, the Veteran retained flexion and extension well in excess of compensable ratings. Thus, while the Veteran's flare-ups may have caused some additional loss in terms of range of motion, the limitation was not so extensive as to merit greater ratings for limitations of flexion and extension and are also not warranted under DeLuca. The Board once again acknowledges the Veteran's assertion that the 2013 and 2017 VA examinations were inadequate because both examiners did not get off of their computers during the entirety of the examination and did not provide physical testing. Given his assertions, this Board decision has placed slightly less probative weight to the findings of those examinations. However, the Board notes that a presumption of regularity is applied to all manner of VA processes and procedures. Miley v. Principi, 366 F.3d 1343, 134647 (Fed. Cir. 2004) ("The presumption of regularity provides that, in the absence of clear evidence to the contrary, the court will presume that public officers have properly discharged their official duties."); see also Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2008) (applying the presumption of regularity to VA examination). However, there was no indication from the Veteran or his representative that the 2019 VA examination suffered from the same inadequacies of the 2013 and 2017 VA examinations. As such, the Board finds that the 2019 VA examination was fully adequate. Of note, the findings at the 2019 examination were quite similar to findings in the earlier examination reports. The Board would like to express that it is sympathetic towards the Veteran's claim and acknowledges that his knee causes him impairment. However, the clinical evidence of record does not warrant a higher rating for the service-connected left knee disability. Accordingly, a rating in excess of 30 percent for a left knee disability is denied. REASONS FOR REMAND 1. Service connection for a low back condition is remanded. The Veteran asserts that his current lumbar spine condition is related to back pain and spasms he experienced during active-duty service. This issue was remanded by the November 2018 Board decision. The Board found that remand was required for an adequate VA examination. The Board acknowledged the Veteran's STRs which indicated the Veteran experienced low back pain, due to left knee mechanical alteration, during his service. See STR dated May 21, 1996. The treatment records also indicated that he has consistently reported low back pain since service. The Veteran was afforded a VA examination in July 2013, where a VA examiner provided a negative nexus opinion, explaining that degenerative disc disease (DDD) had an etiology due to trauma/age and was independent of any Gulf War service. The Veteran was also provided an April 2017 VA opinion that found that the Veteran had transitional lumbosacral vertebra, which is a congenital condition that was prone to degeneration over time. However, the Board decision found that the July 2013 opinion did not address whether secondary service connection was warranted, based on the low back pain being attributed to the now service-connected left knee disability. The Board decision also found that the April 2017 VA examiner did not provided an adequate rationale as to whether the development of DDD represented a superimposed disease that was caused or aggravated by either the Veteran's active service, or his service-connected left knee disability. The Veteran was afforded a VA examination in August 2019. After an in-person examination and a review of the Veteran's claims file, the examiner provided negative nexus opinions. The examiner found that the claimed condition clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner acknowledged that the Veteran had arthritis in the lumbar spine and transitional lumbosacral vertebra, which is congenital condition. The examiner explained that the congenital condition can lead to degenerative arthritis in adults. Regarding secondary service connection, the examiner explained that arthritis in one joint does not cause arthritis in another joint. The Board acknowledges that the Veteran was afforded a VA examination for his low back and was provided nexus opinions, as requested by the November 2018 Board remand directives. However, the Board finds that the August 2019 VA examiner's medical opinions are inadequate. The examiner did not explain why the Veteran's pre-existing low back condition was not aggravated during service. The examiner simply stated that transitional lumbosacral vertebra can lead to arthritis in adults. The examiner also did not provide an opinion regarding whether the Veteran's DDD of the lumbar spine had its onset during, or was otherwise related to his active duty service. Lastly, the examiner provided a secondary service connection opinion, that arthritis in one joint does not cause arthritis in another. However, the examiner did not acknowledge the STR that indicated the Veteran experienced low back pain, due to left knee mechanical alteration, during his service. As such, the Board finds these errors to be pre-decisional duty to assist errors and an addendum opinion should be obtained on remand. Accordingly, service connection for a low back condition is remanded. 2. Service connection for OSA is remanded. The Veteran asserts that de developed OSA due to his service in the Gulf War. Specifically, he testified that service members were simply not able to get a lot of sleep due to the conditions of their deployment. The Veteran's May 1996 separation examination showed that he complained of frequent trouble sleeping. The Veteran testified at the December 2017 Board hearing that he had sleep problems during his deployment. He reported that his roommates used to wake him up in the morning because they thought he was dead. He reported that although he felt he had a full night's sleep, he still had no energy during the day, in the military. The November 2018 Board decision noted that the Veteran had not been afforded a VA examination for OSA and remanded this issue to provide the Veteran a VA examination and medical opinion regarding his OSA. The examiner was asked to provide a medical opinion regarding direct service connection, and that they must consider and address the environmental exposures during service in Southwest Asia and the Veteran's testimony regarding in-service sleep problems and documented complaints of insomnia since his separation from the military. The Veteran was afforded a VA examination in August 2019. After an in-person examination and a review of the Veteran's claims file, the examiner provided a negative nexus opinion. The examiner acknowledged the Veteran's diagnosis for OSA, but explained that there was no evidence based literature that supported sleep apnea being related to environmental exposures. The Veteran testified at the May 2021 Board hearing that he developed sleep problems due to the Gulf War. He reported that it was hard for anyone to get sleep because of constant movement and getting shot at. He testified that after he got back from deployment, he still experienced sleep problems. Although the Veteran was afforded a VA examination and was provided a medical opinion, the Board finds that the August 2019 VA examiner did not address the Veteran's 2017 testimony that he experienced in-service sleep problems, nor complaints of insomnia since his separation from the military. As such, the Board finds that the August 2019 VA examination report is not in compliance with the November 2018 remand by the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Further, the Board also finds the August 2019 VA examiner's medical opinion to be inadequate because it does not address the Veteran's STRs, which show an in-service complaint of sleep trouble. As such, the Board finds these errors to be pre-decisional duty to assist errors and an addendum opinion should be obtained on remand. Given the foregoing, the Board regrets that another remand will further delay a decision in this case, but nonetheless finds that a remand is necessary. Under, Stegall, a remand by the Board confers on the veteran the right to compliance with its remand orders. Id. Accordingly, service connection for OSA is remanded. 3. Service connection for a skin condition is remanded. The Veteran asserts that de developed a skin condition due to his service in the Gulf War. Specifically, he testified that he and fellow service members developed a skin problem, where their skin would turn white, ashy looking, and flaky. The Veteran's May 1996 separation examination showed that he complained of a skin rash. See STR dated May 15, 1996. The Veteran testified at the December 2017 Board hearing that he had skin problems during his deployment. He reported that he was seen by medics, but they could not determine whether something in the sand or something in the air was causing the skin problems. He reported that him and 14 other service members developed rashes, that became flaky, and then would become sores. He reported that he continued to experience skin problems and has actually gotten worse over time. The November 2018 Board decision noted that the Veteran was afforded a VA examination in July 2013. The examiner found that he was diagnosed with seborrheic dermatitis and tinea corporis. However, the examiner provided a negative nexus opinion, explaining that his skin conditions have a specific etiology, independent of any Gulf War service. However, the etiology the examiner referred to was not discussed, nor were any other possible etiological links to the Veteran's service. The Board remanded for a new VA examination and medical opinion. In providing their medical opinion, the examiner was asked to address the Veteran's statements regarding a rash during service, the in-service symptoms, and the periodic outbreaks after his separation from the military. The Veteran was afforded a VA examination in August 2019. After an in-person examination and a review of the Veteran's claims file, the examiner provided a negative nexus opinion. The examiner acknowledged that the Veteran was diagnosed with a skin disorder, but noted that there was none seen on examination. The examiner explained that seborrheic dermatitis affected the scalp, and other oily areas of the body, but that there was no documentation or evidence of seborrheic dermatitis during service, with the only documentation of the condition after service. The Veteran testified at the May 2021 Board hearing that he developed skin problems due to his deployment. He testified that he developed white ashy and flaky looking skin. He reported that he and his wife had to sleep in separate beds because so much of his skin would shed off. Although the Veteran was afforded a VA examination and was provided a medical opinion, the Board finds that the August 2019 VA examiner did not address the Veteran's 2017 testimony that he experienced in-service skin problems, nor complaints of skin problems since his separation from the military. As such, the Board finds that the August 2019 VA examination report is not in compliance with the November 2018 remand by the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Further, the Board also finds the August 2019 VA examiner's medical opinion to be inadequate because it does not address the Veteran's STRs, which show an in-service complaint of a skin rash. Here, the Board finds these errors to be pre-decisional duty to assist errors and an addendum opinion should be obtained on remand. Given the foregoing, the Board regrets that another remand will further delay a decision in this case, but nonetheless finds that a remand is necessary. Under, Stegall, a remand by the Board confers on the veteran the right to compliance with its remand orders. Id. Accordingly, service connection for a skin condition is remanded. 4. Undiagnosed illness or medically unexplained chronic multi-symptom illness In August 2019, the Veteran underwent a VA Gulf War examination. It was noted that the Veteran had complaints of joint pains. The Veteran has also testified to the Board that he began experiencing joint pain in service. However, the examination report contains no indication as to whether the Veteran is considered to have either a medically unexplained chronic multi-symptom illness or an undiagnosed illness manifested by joint pain. As such, this is a pre-decisional duty to assist error and a remand is necessary to correct it. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the transitional lumbosacral vertebra and/or DDD of the lumbar spine. The examiner should provide the following opinions: a) Was the pre-existing congenital condition, transitional lumbosacral vertebra, subject to a superimposed disease or injury during the Veteran's active-duty service? b) Was the pre-existing congenital condition, transitional lumbosacral vertebra, clearly and unmistakably not aggravated during service? The examiner's attention is directed towards the August 2019 VA examination report for the lumbar spine. This Board decision found that the prior August 2019 VA examiner's medical opinion was inadequate because the VA examiner did not provide any rationale to support their negative nexus opinion. c) Is it at least as likely as not (50 percent or greater) that the DDD of the lumbar spine had its onset in, or is otherwise related to, active-duty service. In addressing direct service connection, the examiner should address the May 1991 showing a 2-month history of back pain and the May 1996 separation examination which showed he complained of back spasms due to putting excessive weight on his right leg. d) Is it at least as likely as not (50 percent or greater) that the DDD of the lumbar spine was caused or aggravated by the service-connected left knee disability. In addressing secondary service connection, the examiner should address the service treatment record which indicated the Veteran experienced low back pain, due to left knee mechanical alteration, during his service. See STR dated May 21, 1996. The Veteran's assertion that he was a high level three sport athlete in high school without back problems prior to service. 2. Obtain an addendum VA medical opinion to address the etiology of the Veteran's obstructive sleep apnea (OSA). If an opinion cannot be provided without a physical examination, one should be scheduled. The examiner should answer the following question: a) Is it at least as likely as not (50 percent or greater) that the Veteran's OSA either began during or was otherwise caused by his military service? Why or why not? The examiner should address the Veteran's testimony in 2017 and in 2021 that he experienced sleep problems during his active-duty service, to include having trouble waking up, and feeling tired even though he felt he had a full night's rest; the Veteran's wife's statement that she noticed sleep trouble when he returned from the Gulf War; and the May 1996 separation examination, where he complained of trouble sleeping. See Hearing Transcript dated December 12, 2017 and May 24, 2021; Buddy/Lay Statement received January 18, 2018; and STR dated May 15, 1996. b) Is it at least as likely as not (50 percent or greater) that the Veteran's OSA is etiologically related to his service, to include exposure to the environmental hazards of Southwest Asia. Why or why not? 3. Obtain an addendum VA medical opinion to address the etiology of the Veteran's skin conditions. If an opinion cannot be provided without a physical examination, one should be scheduled. The examiner should answer the following question: a) Is it at least as likely as not (50 percent or greater) that the Veteran's skin condition either began during or was otherwise caused by his military service? Why or why not? b) Is it at least as likely as not (50 percent or greater) that the Veteran's skin conditions are etiologically related to his service, to include exposure to the environmental hazards of Southwest Asia. Why or why not? The examiner should address the Veteran's testimony in 2017 and in 2021 that he experienced skin rashes, to include flaky skin during his active-duty service; the Veteran's wife's statement that she noticed deep flakey patches of dry skin on his head, neck, chest, back, and areas of the groin, buttocks, and thighs when he returned from the Gulf War; and the May 1996 separation examination, where he complained of a skin rash. See Hearing Transcript dated December 12, 2017 and May 24, 2021; Buddy/Lay Statement received July 22, 2021; and STR dated May 15, 1996. 4. Schedule the Veteran for a Gulf War examination. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has either an undiagnosed illness or a medically unexplained chronic multi-symptom illness based on his reports of intermittent joint pains since service. Why or why not? MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Fu, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.