Citation Nr: 21009871 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 96-22 109 DATE: February 23, 2021 ORDER Entitlement to an initial 10 percent rating, but no higher, for residuals, sprain, left knee (“left knee disability”) prior to November 9, 1982, is granted. Entitlement to an initial 10 percent rating, but no higher, for residuals, sprain, right knee (“right knee disability”) prior to November 21, 1990, is granted. Entitlement to an initial rating in excess of 10 percent for left knee disability since November 9, 1982, is denied. Entitlement to an initial rating in excess of 10 percent for right knee disability since August 30, 1991, is denied. Entitlement to a compensable rating for rhinitis prior to March 20, 2017, and in excess of 10 percent thereafter is denied. Service connection for bilateral shoulder disability is granted. Service connection for pruritus ani is granted. REMANDED Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with major depressive disorder prior to February 29, 2012, and in excess of 70 percent from February 29, 2012, to July 13, 2016, is remanded. Entitlement to service connection for diabetes mellitus, to include as due to an undiagnosed illness or chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Service connection for an eye disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Service connection for prostate disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Service connection for heart disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Service connection for hypertension, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Service connection for gastrointestinal disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Service connection for fatigue disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Service connection for rectal disability, other than pruritis ani, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Entitlement to a finding of individual unemployability (TDIU) prior to February 29, 2012, is remanded. FINDINGS OF FACT 1. The evidence reflects that the Veteran experienced painful motion of the left knee for the entire appeal period; left knee flexion is not limited to 45 degrees or less nor is extension limited to 5 degrees or greater. 2. The evidence reflects that the Veteran experienced painful motion of the right knee for the entire appeal period; right knee flexion is not limited to 45 degrees or less, nor is extension limited to 5 degrees or greater. 3. Prior to March 20, 2017, there is no evidence of atrophic rhinitis with definite atrophy of intranasal structure, 50 percent obstruction of nasal passage on both sides or complete obstruction on one side, and from March 20, 2017, there is no evidence of polyps. 4. The most probative evidence shows that the Veteran’s bilateral shoulder disability is related to service. 5. The probative evidence shows that the Veteran’s pruritis ani is related to service. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent rating, but no higher, for left knee disability prior to November 9, 1982, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 2. The criteria for an initial 10 percent rating, but no higher, for right knee disability prior to November 21, 1990, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 3. The criteria for an initial rating in excess of 10 percent for left knee disability since November 9, 1992, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 4. The criteria for an initial 10 percent rating for right knee disability since August 30, 1991, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 5. The criteria for a compensable rating for rhinitis prior to March 20, 2017, and in excess of 10 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.97, Diagnostic Code 6501 (1996); 38 C.F.R. §§ 4.7, 4.10, 4.97, Diagnostic Code 6523. 6. The criteria for service connection for bilateral shoulder disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for pruritis ani have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from November 1970 to March 1973 and from November 1990 to August 1991. The Veteran also had service with the New York Army National Guard. These matters come before the Board of Veterans’ Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). July 2016 and January 2018 Board remands recount the extensive and complicated procedural history of the appeal. Here, the Board has reframed several issues on appeal. In the prior Board remands, the issues on appeal included service connection for ulcer and service connection for colonic polyps. However, in the Board’s most recent remand, the Board requested that a VA examiner address all gastrointestinal disabilities including diverticulitis and diverticulosis. Accordingly, the Board finds that the issue is expanded and more properly characterized as service connection for a gastrointestinal disability. In addition, the Board has also expanded the Veteran’s claim for service connection for prostate cancer to service connection for prostate disability given the evidence of record and a diagnosis of benign prostatic hypertrophy. Finally, as the Board is granting service connection for pruritis ani, the Board has reframed the issue of entitlement to service connection for rectal disability as entitlement to service connection for rectal disability, other than pruritis ani. The Board notes that a March 2014 rating decision also granted TDIU effective February 29, 2012. However, as the issue of entitlement to TDIU was raised pursuant to the Veteran’s claims for increased ratings, the issue of entitlement to a TDIU prior to February 29, 2012, remains on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). The RO’s grant of TDIU for only a portion of the period on appeal does not bifurcate the issue of entitlement to TDIU from the underlying increased rating claim. Harper v. Wilkie, 30 Vet. App. 356, 360 (2018). VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided in March 2004, May 2006, January 2009, and May 2018. The RO associated the Veteran’s service and VA and private outpatient treatment records with the claims file. Walter Reed Hospital records are associated with the record. The Veteran also identified that he was seen for evaluation in April 1995 at Fort Monmouth/Patterson Army clinic for Gulf War syndrome. Fort Monmouth initially responded that there were no records pertaining to the Veteran, but the Veteran’s records now contain a March 1995 record and an April 1995 comprehensive clinician evaluation program completion form and no further development is required. Updated VA treatment records were obtained in accordance with the Board’s prior remands. Service records from the Veteran’s second period of service, New York Army National Guard, and Reserve service are unavailable. A formal finding of unavailability was issued, and the Veteran was notified. Therefore, the Board’s December 2009 remand directive was completed. The Veteran has submitted some records in his possession and there are records dated during that second period of service, but the Board cannot conclude that the records are complete. Thus, the Board has a heightened duty to assist the Veteran and to carefully consider the benefit of the doubt doctrine. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Veteran also reported on numerous occasions that he had treatment with VA facilities associated with the New York Harbor Healthcare System (HHS) since 1973. However, records prior to August 1996 were not located, the RO issued a formal finding of unavailability, and the Veteran was notified. Accordingly, the Board’s December 2009 remand directive was completed. Concerning the two boxes of medical records that the Veteran reported that he had submitted, the RO searched for any records and did not find them. The RO did note that approximately 533 documents were uploaded to the electronic file in 2012. The Veteran was notified concerning the RO’s efforts to locate boxes of records and the Board’s July 2016 remand directive has been completed. Concerning private treatment records, the Veteran was provided releases, but the Veteran stated in May 2018 that there are no further private medical records to be obtained. Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. The Board finds that the VA examinations and addendum opinions concerning the issues on appeal are adequate and comply with the Boards’ remands. As such, VA has satisfied its duty to assist. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Disability Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as “staged” ratings.” Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Left and Right Knees Under Diagnostic Code 5260, a 10 percent rating is warranted where flexion is limited to 45 degrees; a 20 percent rating is warranted where flexion is limited to 30 degrees; and a maximum 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Full knee flexion is to 140 degrees. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5261, a 10 percent rating is warranted where extension is limited to 10 degrees; a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating is warranted where extension is limited to 30 degrees; and a maximum 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Full knee extension is to 0 degrees. 38 C.F.R. § 4.71a, Plate II. A separate rating may also be assigned for instability of the knee. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a maximum 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. In evaluating any disability based on limitation of motion, VA must consider the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). While pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Additionally, flare-ups must be factored into an examiner’s assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). In Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Section 4.59 is entitled “Painful motion” and provides that “[i]t is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.” 38 C.F.R. § 4.59; see Petitti v. McDonald, 27 Vet. App. 415, 424-26 (2015) (“Under § 4.59, the trigger for a minimum disability rating is an ‘actually painful, unstable, or malaligned joint[].’” (quoting 38 C.F.R. § 4.59)). During the pendency of the appeal concerning the claims for increased initial ratings for left and right knee disabilities, the RO granted a 10 percent rating for the left knee disability based on painful motion and assigned an effective date of November 9, 1982. For the right knee, the RO assigned a 10 percent rating for painful motion and assigned an effective date of August 30, 1991. The RO indicated that the effective dates were assigned based on the dates that the Veteran’s claims were received. However, as pointed out by the prior Board remands, the Veteran’s claims for increased initial ratings for the left and right knee disabilities have been on appeal from a March 1973 claim for service connection for right and left knee disabilities. In this respect, a September 1973 rating decision granted initial noncompensable ratings for the left and right knees effective March 13, 1973. The Veteran filed a timely notice of disagreement, a Statement of the Case (SOC) was issued in November 1973, and the Veteran filed a timely substantive appeal. The matter did not come before the Board until April 2006 when the Board determined that the matters were on appeal since his March 1973 claims. Accordingly, the Board must review the entire record on appeal to determine whether a higher rating is warranted. The Veteran’s right knee and left knee disabilities were originally evaluated under Diagnostic Code 5257 for instability and the disabilities were assigned noncompensable ratings. When the Veteran was assigned compensable ratings for painful motion of the left and right knees, the ratings were assigned under Diagnostic Code 5260 for limitation of flexion. VA treatment records and service medical treatment records show that the Veteran consistently reported knee pain on running, walking, and walking up stairs. An August 1973 VA examination report shows that the Veteran reported that his knees started hurting during service. He stated that he had trouble when walking, running, or walking up stairs. There was no tenderness or swelling. A December 1984 VA examination report shows a report of knee pain when standing and walking on stairs. There was no instability. A September 1992 VA joints examination report showed that there was no subluxation or lateral instability. The examiner indicated that there were no abnormal objective physical findings. A March 1994 VA joints examination report shows that the Veteran reported pain when running or climbing stairs or any other activity with excessive stress on the knees. There was no swelling or deformity. There was no pain at rest. There were no clinical findings pertaining to the right and left knees. An August 1996 VA examination report shows reports of pain in both knees when the Veteran went on long walks and climbed stairs. There was no swelling and minimal fluid in the knees. There was no instability of either knee. A September 1996 VA radiographic report shows that the Veteran had a horizontal degenerative tear of the posterior horn of the meniscus. There was no fracture or dislocation. There was a small joint effusion and cyst. A September 1996 VA MRI study of the right knee shows that the Veteran likely had a partial distal ACL tear. A September 1996 VA MRI of the left knee showed a small joint effusion, small cyst, and no tear. In April 1996, the Veteran reported that he had severe pain whenever he climbed stairs and walked a lot. He stated that he had to curtail his actions due to the knee pain. A July 2012 VA treatment record shows chronic complaints of pain in the right and left knees. The Veteran also reported stiffness for 15 minutes in the morning. He reported that the pain did not interfere with activities. An August 2012 VA treatment record reveals that the Veteran had pain and stiffness in the knees. He stated that he had difficulty with squats, stairs, prolonged standing and ambulation, and transferring from low surfaces. It was noted that the range of motion was normal in the lower extremities. A September 2012 VA examination report shows that the Veteran had persistent chronic knee pain. He had daily pain in the knees to a degree of 6/10 with stiffness and clicking. He complained of difficulty climbing stairs. He could not run and could not walk more than two blocks at a time when a cane that he used. He never had surgery for the knees. The Veteran reported flare-ups with inclement weather and pain can go up to 8/10. The examiner indicated that the Veteran experienced less movement than normal; weakened movement; pain on movement; and disturbance of locomotion of both knees. Concerning range of motion findings, there is no indication as to passive range of motion testing or weight-bearing/non weight bearing. The examiner also did not provide an opinion as to whether the Veteran would experience additional loss of range of motion during flare-ups and/or periods of repeated use. Accordingly, the examination is inadequate concerning the range of motion findings. Muscle strength testing was 4/5 in all areas tested. Stability testing was normal. There was no history or evidence of recurrent patellar subluxation or dislocation. The Veteran did not have any other tibial or fibular involvement. He did not have any meniscal conditions. The examiner found that the Veteran’s knee disabilities impacted his ability to work. The examiner stated that the Veteran reported that he had to retire in 2011 because he had to do a lot of walking and standing at work. He was unable to do any running, frequent stair climbing, and no kneeling, no stooping, and no squatting. In March 2017, the Veteran was provided a VA examination for his knees. The examiner commented that it would be mere speculation to comment on any additional functional impairment during periods of flare-ups and repeated use. The examiner did not provide sufficient rationale and, therefore, the range of motion findings are not considered adequate. The Veteran reported intermittent pain and that he experienced pain when he walked a lot, ran, or walked up and down stairs. His pain level was 6-7/10. He reported flare-ups as pain when he walked up and down stairs. Concerning functional impairment and loss during repeated use over time, the Veteran had increased pain in the knees with excessive walking, running, or going up and down the stairs. There was objective evidence of localized tenderness or pain on palpation of the medial knees. There was normal muscle strength of all areas tested. There was no ankylosis of either knee. There was no instability and no recurrent effusion. The examiner found that the veteran’s bilateral knee disability would impact his ability to work. It was noted that he previously worked as a customs and immigration officer and that going up and down stairs, walking, and running, was painful. In March 2019, the Veteran was provided a VA examination for his knees. The Veteran stated that his pain was worse with prolonged standing, walking, and running as well as kneeling. He reported pain as sharp pressure to a degree of 6/10 along the anterior aspect of both knees. The Veteran reported flare-ups that were worse with prolonged standing, walking, and running as well as kneeling. He also reported additional functional impairment and loss during repeated use over time. He described the functional impairment as limited prolonged standing, walking, and running as well as kneeling. There was localized tenderness to the medial aspect of the knees. There was pain on weight-bearing of both knees. The left and right knees exhibited normal flexion to 140 degrees and extension to 0 degrees. Pain on flexion and extension caused functional loss. The Veteran was able to perform repetitive-use testing and there was no additional functional loss or loss of range of motion after testing. Muscle strength testing was 5/5 in all areas tested. There was no ankylosis. There was no instability of either knee on testing. The Veteran regularly used a cane. The examiner found that the Veteran’s bilateral knee disability impacted his ability to work. The Veteran’s knees limited prolonged standing, walking, running, as well as kneeling. The examiner determined that the Veteran had bilateral knee pain with passive range of motion with passive range of motion, weight-bearing, and non weight-bearing. The examiner did not provide opinions regarding additional functional impairment and loss during flare-ups and periods of repeated use. However, in June 2020, an adequate addendum opinion was provided by another suitably qualified clinician. The clinician explained that the medical evidence was reviewed and that the Veteran had normal range of motion on examination in 2019. The clinician stated that, considering the Veteran’s history, examination, and records, the Veteran’s knees would only lose a few degrees (0 to 10) of flexion during repeated use over time. The clinician noted that up to 10 degrees of loss may occur if repeated use over time led to a flare-up. No loss of extension was anticipated. Concerning flare-ups, the clinician found that the Veteran would only experience 0 to 10 degrees of loss of flexion of the knees until the flare-up subsided. The clinician determined that the Veteran could expect up to 10 degree of loss of flexion with a severe flare-up. First, the Board finds that the Veteran’s left and right knee disabilities should each be assigned an initial 10 percent rating for the entire period on appeal. Concerning the time period prior to November 9, 1982, for the left knee and the time period prior to August 30, 1991, for the right knee, the evidence reflects reports of painful motion of the right and left knees, not only made by the Veteran, but recorded in medical treatment records. While the medical evidence is sparse, the August 1973 VA examination report noted that the Veteran reported pain in both of his knees that was not constant, but manifested on running or going up stairs. The examiner noted that range of motion was full, but also concluded that the Veteran had minimal residuals of the right and symptomatic of the left despite the absence of objective findings on examination. The examiner’s finding of residuals and that the left knee was symptomatic, indicates that he considered the Veteran’s reports of pain. In addition, in December 1984, the Veteran reported painful knees when standing to a VA examiner. The Board will resolve doubt in the Veteran’s favor and finds that under 38 C.F.R. § 4.59, a 10 percent rating is warranted for the right knee disability and a 10 percent rating is warranted for the left knee disability for the entire appeal period. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Concerning disability ratings in excess of 10 percent, the Board will first address limitation of flexion and limitation of extension. The VA medical evidence of record and VA examination reports do not reflect flexion limited to 45 degrees or less or limitation of extension to 5 degrees. Accordingly, a higher rating under Diagnostic Code 5260 is not warranted for either knee. In addition, a separate rating under Diagnostic Code 5261 is not warranted for either knee. With respect to additional functional impairment and loss during periods of flare-ups and repeated use, the evidence does not show that the Veteran’s flexion of the knees would be limited to 45 degrees or extension limited to 10 degrees. Accordingly, higher ratings are not warranted for the left and right knee disabilities. Concerning instability or subluxation of the right knee, the Board finds that a compensable rating is not warranted for the right knee. The VA treatment records, and VA examination reports do not reflect any findings of instability or subluxation. Therefore, a compensable rating is not warranted under Diagnostic Code 5257. As to the left knee, a July 29, 2012, VA treatment record reflects an assessment of mild instability of the left knee after testing. However, the evidence of record does not reflect recurrent instability or subluxation to warrant a compensable rating. See Diagnostic Code 5257. The VA examinations provided both before and after the July 2012 VA treatment record show that there was no instability on testing. The September 2012 VA examination report shows that the Veteran reported pain, stiffness, and clicking with no other associated features or stiffness. He used a cane, but did not use braces. There were no findings of instability and no history of recurrent subluxation or instability. During his March 2017 VA examination, the Veteran reported pain and there was no instability on testing and no history of recurrent instability or subluxation. The Veteran reported during his March 2019 VA examination that he did not wear a knee brace and that his main complaint was pain. The March 2019 VA examiner found that the Veteran did not have a history of recurrent subluxation or instability. Accordingly, a compensable rating is not warranted under Diagnostic Code 5257. Finally, there is no evidence of ankylosis, removal or dislocated cartilage, impairment of the tibia and fibula, or genu recurvatum. Therefore, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not for application. Accordingly, a preponderance of the evidence is against the claims, aside from the assignment of a 10 percent rating for left knee instability, and the claims are denied. Rhinitis The Veteran’s rhinitis is currently rated as allergic or vasomotor rhinitis under Diagnostic Code 6523. 38 C.F.R. § 4.97. Under the criteria in effect at the time of the Veteran’s claim for an increased rating, a 10 percent rating was warranted for chronic, atrophic rhinitis with definite atrophy of intranasal structure, and moderate secretion. 38 C.F.R. § 4.97, Diagnostic Code 6501. A 30 percent rating was warranted for moderate crusting and ozena, atrophic changes. A 50 percent rating was warranted for massive crusting with marked ozena, with anosmia. Effective October 7, 1996, the criteria for evaluating allergic rhinitis were revised. 61 Fed. Reg. 46720 (Sept. 5, 1996). Under these criteria, Diagnostic Code 6522 provides for a 10 percent rating for allergic or vasomotor rhinitis without polyps with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. A 30 percent rating is warranted with polyps. The Board notes that a prior April 2006 Board remand indicated that the Veteran’s claim for a higher rating for rhinitis was on appeal since March 1973. However, as pointed out by the July 2016 Board decision, such a characterization was incorrect as a final October 1986 Board decision denied the Veteran’s claim for an initial compensable rating for vasomotor rhinitis. Thereafter, the Veteran submitted several claims concerning his rhinitis; however, a January 1993 rating decision denied the Veteran’s claim for a compensable rating for rhinitis. In March 1996, the Veteran then filed a claim for an increased rating for rhinitis. Accordingly, the Board will review the evidence dated one year prior to the Veteran’s claim and after. VA medical treatment records show nasal obstruction and nasal congestion. An August 1996 VA examination report shows complaints of intermittent nasal congestion and paroxysmal nocturnal dyspnea (PND). There was slight septal deviation and boggy turbinates. The record indicates multiple allergic attacks per week. A February 2000 VA treatment record shows that the Veteran complained of nasal congestion and that he had allergies. He had itchy and watery eyes. Examination of the nose showed clear discharge, erythematous mucosa, and boggy turbinates. A July 2000 VA treatment record shows reports of sinus congestion and mild nasal secretions. A March 2004 VA examination report shows that the Veteran reported allergies and that he experienced nasal interference. There was no purulent discharge. He reported allergy problems once a week sometimes. Currently there was no evidence of nasal swelling. A September 2004 CT scan showed mild mucosal thickening bilaterally and there was deviation of the septum. A May 2007 VA treatment record reflects that the Veteran reported a prior history of sinusitis. He complained of several months of chronic cough, throat clearing, PND, and nasal congestion. The Veteran reported chronic, right greater than left, nasal obstruction. The Veteran was started on Nasalide with improvement in nasal symptoms. On examination, there was moist mucosa and no lesions. There was mild septal deviation with spur to the left and right inferior turbinate hypertrophy. There was cobblestoning posterior pharyngeal wall, remainder of mucosa was normal with no masses or lesions. The March 2009 VA examination report shows that the Veteran had many years of bilateral nasal obstruction and occasional clear rhinorrhea. He had no discolored rhinorrhea and no facial pain. A sinus CT showed an assessment of bilateral moderate sinusitis and a small osteoma was seen in the left frontal sinus. There was no sinus tenderness. On examination, there were no polyps or pus. The examiner noted that the condition was mild. In March 2017, the Veteran was provided a VA examination for his rhinitis. The Veteran complained of nasal obstruction and rhinorrhea dating back to the early 1970s. Since that time, he had ongoing nasal complaints causing him to use medication on an ongoing basis. He had used nasal steroid sprays and antihistamines throughout the years with varying results. The Veteran did not have rhinitis or sinusitis at the present time. There was 70 percent obstruction of the nasal passage on the right and 60 percent obstruction of the nasal passage on the left. There was not complete obstruction on one side. There was permanent hypertrophy of the nasal turbinates as well as considerable mucosal inflammation. There were no nasal polyps and no granulomatous changes. The Veteran did not have a traumatic deviated septum, but his septum was somewhat deviated. The examiner stated that his disability impacted his ability to work because the Veteran had to take off up to two to three times per month when his nose became so obstructed. Here, the Veteran’s rhinitis would not warrant a compensable rating prior to March 20, 2017, under the old or revised rating criteria. There is no evidence of atrophic rhinitis with definite atrophy of intranasal structure, or ozena under the old criteria or 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. Though the Veteran has hypertrophy, there is no atrophy. Again, the Veteran has nasal obstruction but there is no evidence to show that he experienced at least 50 obstruction on both sides or complete obstruction on one side prior to March 20, 2017. From March 20, 2017, a rating in excess of 10 percent is not warranted. There is no evidence of nasal polyps for a higher rating under the new criteria and no evidence of atrophy or ozena to warrant a higher rating under the old criteria. A preponderance of the evidence is against the Veteran’s claim and the claim is denied. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Bilateral shoulder disability The Veteran’s available service treatment records do not reflect any report of a shoulder injury or pain. In September 1992, the Veteran was evaluated for bilateral shoulder pain, but the x-rays were negative. A March 2004 VA joints examination shows that the Veteran reported shoulder pain since his service in the Gulf War. The report listed a diagnosis of mild bilateral rotator cuff tendonitis. A March 2019 VA examination report shows that the Veteran reported chronic shoulder pain. The examiner reviewed the evidence and noted the assessments of chronic shoulder pain and that the Veteran performed airborne jumps in the service. The examiner provided a positive opinion relating the Veteran’s bilateral shoulder rotator cuff tendonitis to service and his parachute jumps. In an addendum opinion, a VA examiner provided a negative opinion noting that a few parachute jumps were unlikely to cause a shoulder condition. The examiner also noted that the 1992 x-rays for the shoulders were negative. In addition, the examiner noted that the Veteran never had a detailed workup and that an MRI would have been ordered had the Veteran had symptoms consistent with bilateral rotator cuff tendonitis prior to 2019. The examiner indicated that the current shoulder condition was most likely quite recent. Here, the Board notes that both VA opinions of record are flawed. The March 2019 positive nexus opinion related the Veteran’s shoulder complaints to his first period of active service and his parachute jumps without considering the absence of objective shoulder complaints until decades after that service and the Veteran’s reports that he experienced bilateral shoulder pain since his service in the Gulf War. In addition, the May 2020 negative opinion did not consider the Veteran’s chronic and consistent complaints of pain since the 1990s. In addition, the examiner indicated that the Veteran was recently diagnosed with rotator cuff tendonitis despite the presence of that diagnosis in 2004. Given the Veteran’s competent and credible reports that he had bilateral shoulder pain since his second period of service, his medical treatment for bilateral shoulder pain beginning in 1992 and reports of pain until his diagnosis of bilateral rotator cuff tendonitis of the bilateral shoulders in 2004, the Board will resolve the benefit of the doubt in the Veteran’s favor and finds that service connection for a bilateral shoulder disability is warranted. Pruritus ani The available service treatment records do not reflect any pruritis ani or itching. A February 1994 medical record shows an assessment of chronic itching and pain in the anal area. The Veteran reported that he had seen three doctors since Desert Storm. An October 1995 medical record shows an assessment of pruritis ani. A May 2000 VA treatment record shows that the Veteran had longstanding history of a small amount of bleeding with bowel movements. It was noted that the Veteran had rectal pain and itching secondary to perianal erythema and fissure. In February 2003, the Veteran was again assessed with pruritis ani. The March 2019 VA examination report shows that the Veteran was diagnosed with pruritis ani. The Board finds the Veteran’s reports of chronic symptoms of itching since his service in the Gulf War to be competent and credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Board finds it highly probative that the Veteran sought medical treatment for this condition in 1994, shortly after separation from service and related the onset of his symptoms to his Gulf War service. Accordingly, the Board will resolve doubt in the Veteran’s favor, and finds that service connection for pruritis ani is warranted. REASONS FOR REMAND Entitlement to a disability rating in excess of 30 percent for PTSD prior to February 29, 2012, and in excess of 70 percent from February 29, 2012 to July 13, 2016, is remanded. In the January 2018 remand, the Board determined that a retrospective opinion was required as to the manifestations of the Veteran’s PTSD prior to February 2012. The Board noted that the RO assigned an effective date of July 14, 2016, to the 100 percent rating for PTSD without reasons or bases. The Board noted that the October 2016 VA examiner who opined that the Veteran had total and occupational impairment referenced findings prior to the examination to support his conclusion, but did not specify any particular date or time period when the Veteran’s PTSD increased in severity. The January 2018 remand requested that the examiner determine when the Veteran’s PTSD resulted in total occupational and social impairment and how his symptoms impacted his ability to work and perform activities of daily living. In March 2019, the Veteran was provided a VA examination for his PTSD. The examiner stated that a retrospective opinion concerning the severity of PTSD could not be provided. Specifically, the examiner stated that there was limited documentation aside from a 1995 evaluation and 2005 notes. The examiner also noted that the Veteran was gainfully employed until 2011. The Board finds the March 2019 VA examiner’s opinion inadequate and it does not comply with the Board’s remand. See Stegall v. West, 11 Vet. App. 268 (1998). The Board recognizes that the January 2018 remand directive requested that the examiner provide a retrospective opinion prior to February 29, 2012. However, it appears that the Board intended to ask for a retrospective opinion prior to July 14, 2016, when the Veteran was assigned a 100 percent rating for his PTSD. Though the examiner only addressed the period prior to February 29, 2012, the examiner indicated that the record was sparse. However, the Board directs attention to the voluminous VA treatment records that document the Veteran’s PTSD symptomatology over time as well as a March 2014 VA PTSD examination report indicating total occupational and social impairment. The examiner at that time had stated that there was a marked severity of the Veteran’s symptoms since his wife’s death and his retirement in 2011. Given the evidence, the Board finds that remand is required for the examiner to provide a retrospective opinion prior to July 14, 2016, concerning the severity of the Veteran’s PTSD and when the Veteran’s total occupational and social impairment onset. Service connection for diabetes mellitus, an eye disability, a prostate disability, a heart disability, and/or hypertension, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. Here, the Board notes that the Veteran has made assertions during the period on appeal noting that his ailments are related to his exposure to environmental hazards during his service in the Persian Gulf War. These assertions have not been considered by any of the obtained VA opinions concerning the aforementioned disabilities, rendering those opinions inadequate. Moreover, the VA opinions did not adequately address whether the claimed conditions constitute a medically unexplained chronic multisymptom illness as defined by 38 C.F.R. § 3.317 (a)(2)(ii). See Stewart v. Wilkie, 30 Vet. App. 383 (2018) (holding VA relied on an inadequate examination when it determined a claimant’s asthma was not a medically unexplained chronic multisymptom illness when an examiner failed to address both the etiology and pathophysiology of the condition in the context of the claimant’s unique circumstances). In addition, as detailed below, there are further deficiencies with the March 2019 VA medical opinions. With respect to diabetes mellitus, the March 2019 VA examiner provided a negative nexus opinion, noting that there was no evidence of diabetes mellitus during service. Rationale based solely on the absence of a condition in the service treatment records renders that opinion inadequate. A new opinion is required. Concerning the Veteran’s eye disability, the March 2019 VA examiner provided a negative nexus opinion based solely on the lack of diagnosis of an eye disability during service. Moreover, the examiner did not address the other diagnoses of record, and instead relied on current examination findings. A new opinion regarding direct service connection is required. Finally, VA treatment records dated in May 2009 indicated a possible relationship between the Veteran’s allergies and his dry eye syndrome. Therefore, an opinion regarding secondary service connection must be obtained. Concerning prostate disability, the Board notes that the Veteran claimed service connection for prostate cancer. However, given the medical findings and the Veteran’s statements, the Board finds that the claim should be expanded. In this respect, the March 2019 VA examiner did not address the etiology of the Veteran’s benign prostatic hypertrophy and a new opinion is required. Finally, regarding the Veteran’s heart disability, the March 2019 VA examiner only provided a negative opinion based on the absence of a heart condition during service or the one-year periods following the periods of active service. Rationale solely based on the absence of a condition during service is not adequate. A new opinion is required. Entitlement to service connection for gastrointestinal disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards and chemicals, is remanded. The Board’s January 2018 remand requested that the Veteran be provided a VA examination for his gastrointestinal disability. The examiner was asked to address the Veteran’s complaints of ulcer, diverticulitis, and colonic polyp and whether the Veteran otherwise had a functional gastrointestinal disorder as related to his service in the Persian Gulf War. The March 2019 VA examiner opined that the Veteran did not have any intestinal condition and did not give a history of a condition. No opinion as to etiology was provided. However, the VA treatment records, as recently as 2017, show a finding of diverticulosis and removal of a polyp. Given the evidence, the VA examiner’s opinion is inadequate, and a new opinion is required. Service connection for fatigue disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War, is remanded. In March 2019, the Veteran was provided a VA examination for chronic fatigue syndrome. The examiner noted that the Veteran had only complained of fatigue for several years but that the Veteran had never been worked up for chronic fatigue syndrome. The examiner stated that an opinion was not provided because the Veteran was not diagnosed with chronic fatigue syndrome. In May 2020, a VA clinician provided an addendum opinion concerning fatigue. The clinician provided a negative opinion noting that the Veteran had not been medically worked up for chronic fatigue or for fibromyalgia. In addition, the clinician determined that the Veteran’s fatigue could be due to a collagen vascular disorder or gout. The clinician stated that there was no evidence of chronic fatigue or fibromyalgia during active service or for many years thereafter. The Board finds that the VA opinions are flawed. Though the March 2019 VA examiner determined that the Veteran did not have chronic fatigue syndrome, the examiner also noted that the Veteran had only complained of fatigue for several years. However, the medical evidence of record shows that the Veteran began to complain of fatigue in the 1990s. Further, the addendum opinion also provided a negative opinion, but only noted that the Veteran had never been worked up for chronic fatigue syndrome and failed to note the complaints of fatigue since the 1990s. Moreover, neither opinion addressed whether the Veteran’s fatigue could be considered a disability. Therefore, a new opinion is required. Finally, the December 2019 VA examiner indicated a relationship between fatigue and the Veteran’s service-connected PTSD and depressive disorder. Therefore, the Board finds that an opinion concerning secondary service connection is required. Service connection for rectal disability other than pruritis ani, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness and exposure to environmental hazards during the Gulf War In January 2018, the Board remanded the Veteran’s claim for service connection for rectal disability for additional development. Specifically, concerning hemorrhoids, the examiner was asked to provide an opinion as to whether hemorrhoids, first demonstrated in February 1990, were clearly and unmistakably not aggravated during his second period of active service. The March 2019 VA examination report noted that there was no history of hemorrhoids. The examiner then commented that the service treatment records did not reveal any evidence of treatment for the condition. There is no opinion as to whether the Veteran’s preexisting hemorrhoids were not clearly and unmistakably aggravated by service. Thus, the examiner’s opinion does not comply with the Board January 2018 remand. A new opinion is required. Entitlement to TDIU prior to February 29, 2012, is remanded. The evidence indicates that the Veteran was unable to work due to his service-connected disabilities prior to February 29, 2012. However, at the present, the Veteran does not meet the schedular criteria for TDIU on a schedular basis prior to February 29, 2012. Accordingly, the matter should be referred for extraschedular consideration. The Veteran reported that he retired in 2011 but had to use a lot of sick leave years prior to his retirement. The Veteran should be asked to provide any additional information regarding his used sick leave prior to his retirement. The matters are REMANDED for the following action: 1. Request that the Veteran provide any information concerning the sick leave used prior to his retirement in 2011. If appropriate, request that he complete and provide a release form for records from his prior employer. 2. Request an addendum mental health opinion from a suitably qualified clinician. The claims file must be made available for review. The reviewer must provide a retrospective medical opinion concerning the severity of the Veteran’s service-connected PTSD prior to July 14, 2016. The clinician must specifically address how the Veteran’s PTSD impacted his ability to work prior to February 29, 2012. A full and complete rationale must be provided for any opinion reached. The clinician is advised that the Veteran’s claim for a higher initial rating for PTSD has been pending since April 7, 1993. 3. Obtain an addendum opinion from an appropriate clinician concerning the nature and etiology of any diabetes mellitus. The claims folder must be made available for review. The clinician must address the following: (a) Specify whether the Veteran’s diabetes mellitus is an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI), including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (b) If diabetes mellitus is not an undiagnosed illness or MUCMI, opine whether it is at least as likely as not that the Veteran’s diabetes mellitus is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. The examiner must provide a full and complete rationale for any opinion reached. 4. Obtain an addendum opinion from a suitably qualified clinician regarding the etiology of the Veteran’s eye disability. The claims folder must be made available to the clinician. The clinician must address the following: (a) Specify whether any eye disability is an undiagnosed illness or MUCMI, including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (b) If any eye disability is not an undiagnosed illness or MUCMI, opine whether it is at least as likely as not that the Veteran’s eye disability is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. A full and complete rationale must be provided for any opinion reached. 5. Obtain an addendum opinion from a suitably qualified clinician regarding the etiology of the Veteran’s prostate disability. The claims folder must be made available to the clinician. The clinician must address the following: (a) Specify whether the Veteran’s prostate disability is an undiagnosed illness or MUCMI, including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (b) If the prostate disability is not an undiagnosed illness or MUCMI, opine whether it is at least as likely as not that the Veteran’s prostate disability is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. A full and complete rationale must be provided for any opinion reached. 6. Obtain an addendum opinion from a suitably qualified clinician regarding the etiology of the Veteran’s heart disability. The claims folder must be made available to the clinician. The clinician must address the following: (a) Specify whether the Veteran’s heart disability is an undiagnosed illness or MUCMI, including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (b) If the heart disability is not an undiagnosed illness or MUCMI, opine whether it is at least as likely as not that the Veteran’s heart disability is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. A full and complete rationale must be provided for any opinion reached. 7. Obtain an addendum opinion from a suitably qualified clinician regarding the etiology of the Veteran’s hypertension. The claims folder must be made available to the clinician. The clinician must address the following: (a) Specify whether the Veteran’s hypertension is an undiagnosed illness or MUCMI, including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (b) If hypertension is not an undiagnosed illness or MUCMI, opine whether it is at least as likely as not that the Veteran’s hypertension is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. A full and complete rationale must be provided for any opinion reached. 8. Obtain an addendum opinion from a suitably qualified clinician regarding the etiology of the Veteran’s gastrointestinal disability. The claims folder must be made available to the clinician. The clinician must address the following: (a) Specify whether the Veteran’s gastrointestinal disability, including reported ulcer, diverticulitis, diverticulosis, colonic polyps, and any other symptoms is an undiagnosed illness, functional gastrointestinal disorder, or MUCMI, including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (b) If the gastrointestinal disability is not an undiagnosed illness, functional gastrointestinal disorder or MUCMI, opine whether it is at least as likely as not that the Veteran’s gastrointestinal disability is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. A full and complete rationale must be provided for any opinion reached. 9. Obtain an addendum opinion from a suitably qualified clinician regarding the etiology of the Veteran’s fatigue. The claims folder must be made available to the clinician. The clinician must address the following: (a) Specify whether the Veteran’s fatigue is an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI), including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (b) If the Veteran’s fatigue is not an undiagnosed illness or MUCMI, address whether the Veteran’s fatigue may nonetheless be considered a disability. If so, opine whether it is at least as likely as not that the Veteran’s fatigue disorder is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. (c) If the Veteran’s fatigue is considered a disability, opine whether it was caused or aggravated by any service-connected disability. The Veteran is service-connected for PTSD with major depressive disorder; headaches; TMJ; left knee; right knee; tinnitus; dermatitis and nevi; degenerative disc disease of the cervical spine; degenerative disc and joint disease of the lumbosacral spine; varicose veins, left leg; bilateral hearing loss; rhinitis; and condyloma acuminata. A full and complete rationale must be provided for any opinion reached. 10. Obtain an addendum opinion from a suitably qualified clinician regarding the etiology of the Veteran’s rectal disability. The claims folder must be made available to the clinician. The clinician must address the following: (a) Provide an opinion as to whether the Veteran’s hemorrhoids were at least as likely as not related to his first period of active service. (b) Provide an opinion as to whether the Veteran’s hemorrhoids were clearly and unmistakably not aggravated by his second period of active service from November 1990 to August 1991. (c) For any other rectal symptoms, other than pruritis ani and hemorrhoids, specify whether those symptoms may be considered an undiagnosed illness or MUCMI, including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran’s unique circumstances. (d) If a rectal disability is identified and it is not an undiagnosed illness or MUCMI, opine whether it is at least as likely as not that the rectal disability, other than hemorrhoids and pruritis ani, is related to his active service, to include exposure to environmental hazards while serving in the Gulf War. A full and complete rationale must be provided for any opinion reached. 11. Refer the Veteran’s claim for TDIU on an extraschedular basis prior to February 29, 2012, to the Director of Compensation Service, for an opinion. 12. Then, readjudicate the remanded issues, and if still denied, return the matters to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Seay, 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.