Citation Nr: 21012088 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 15-07 120 DATE: March 3, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for patellofemoral pain syndrome of the right knee is granted. Entitlement to service connection for patellofemoral pain syndrome of the left knee is granted. Entitlement to service connection for cardiovascular condition is denied. Entitlement to service connection for a neurological condition other than memory loss and headaches is denied. Entitlement to service connection for memory loss is denied. Entitlement to service connection for fatigue (claimed as chronic fatigue syndrome), to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness, is granted. Entitlement to service connection for unspecified joint pain, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness, is granted. Entitlement to service connection for headaches, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness, is granted. Entitlement to service connection for disability manifested by muscle pain and gastrointestinal disturbances (claimed as fibromyalgia), to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness, is granted. REMANDED Entitlement to service connection for disability manifested by difficulty walking and abnormal gait is remanded. FINDINGS OF FACT 1. The Veteran’s bilateral hearing loss was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease, to include in-service noise exposure. 2. The Veteran’s patellofemoral pain syndrome of the right knee is related to service. 3. The Veteran’s patellofemoral pain syndrome of the left knee is related to service. 4. The preponderance of the evidence of record is against finding that the Veteran has had a cardiovascular condition at any time during or approximate to the pendency of the claim. 5. The preponderance of the evidence of record is against finding that the Veteran has had any neurological symptoms other than memory loss and headaches at any time during or approximate to the pendency of the claim. 6. The preponderance of the evidence shows that the claimed memory is a symptom of the Veteran’s service-connected PTSD, and not a separately ratable disability. 7. Resolving the benefit of the doubt in favor of the Veteran, the Veteran’s fatigue is due to an undiagnosed illness. 8. Resolving the benefit of the doubt in favor of the Veteran, the Veteran’s unspecified joint pain is due to an undiagnosed illness. 9. Resolving the benefit of the doubt in favor of the Veteran, the Veteran’s headaches are due to an undiagnosed illness. 10. Resolving the benefit of the doubt in favor of the Veteran, the Veteran’s disability manifested by muscle pain and gastrointestinal disturbances is due to an undiagnosed illness. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for patellofemoral pain syndrome of the right knee are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for patellofemoral pain syndrome of the left knee are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a cardiovascular condition are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a neurological condition other than memory loss and headaches are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for memory loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.14, 4.130, Diagnostic Code 9411. 7. The criteria for entitlement to service connection for fatigue (claimed as chronic fatigue syndrome) due to an undiagnosed illness are met. 38 U.S.C. §§ 1110, 1117, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. 8. The criteria for entitlement to service connection for unspecified joint pain due to an undiagnosed illness are met. 38 U.S.C. §§ 1110, 1117, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. 9. The criteria for entitlement to service connection for headaches due to an undiagnosed illness are met. 38 U.S.C. §§ 1110, 1117, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. 10. The criteria for entitlement to service connection for disability manifested by muscle pain and gastrointestinal disturbances (claimed as fibromyalgia) due to an undiagnosed illness are met. 38 U.S.C. §§ 1110, 1117, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from May 1997 to May 2001. In August 2018 and February 2020, the Board remanded this case for additional development. With respect to the issues decided herein, the Board finds that there has been substantial compliance with the prior Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to service connection for tinnitus was also on appeal and remanded by the Board. However, service connection was awarded in the November 2020 rating decision; representing a full grant of the benefit sought on appeal. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C. §§ 1137; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. The Veteran has asserted that his disabilities are due to an undiagnosed illness or other qualifying, chronic disability, pursuant to 38 U.S.C. § 1117. The Board previously found that the Veteran’s military personnel records show that he served in the Southwest Asia Theatre of Operations and, in turn, is considered a Persian Gulf War veteran pursuant to 38 C.F.R. § 3.317. Service connection may be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome (IBS)) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B). Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317 (a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain;(6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317. Entitlement to service connection for bilateral hearing loss The Veteran contends that his bilateral hearing loss is due to in-service noise exposure. He has also reported that he has experienced hearing loss since service. Certain chronic diseases will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. Specific to claims for service connection, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The September 2020 VA examination shows that the Veteran meets the VA requirements for impaired hearing. The question for the Board is whether the Veteran has a chronic disease that was noted as chronic in service or that manifested to a compensable degree in service or within the applicable presumptive period, or whether continuity of symptomatology has existed since service. The Board concludes that, while the Veteran has bilateral hearing loss, which is a chronic disease under 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a), it not shown as chronic in service or within a presumptive period, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Service treatment records are silent with respect to any complaints, findings or diagnosis of hearing loss. Importantly, a June 2019 VA examination, 18 years after his discharge from service, showed that the Veteran had normal hearing for VA purposes. Importantly, the first medical evidence that the Veteran met the criteria for hearing loss for VA purposes was the September 2020 VA examination. In sum, there is no medical evidence showing hearing loss within one year of service or pertinent symptomatology. While the Veteran is competent to report experiencing symptoms of hearing loss since service, the Board finds the reports of continuity of symptomatology not credible. The Veteran’s reports are internally inconsistent to his reports in contemporaneous treatment records, which show no reports of hearing loss for many years. Significantly, VA treatment records dated in March 2007, six years after his discharge from service, show that the Veteran expressly denied hearing loss. Again, the Veteran did not have hearing loss for VA purposes as recent as the June 2019 VA examination. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Board gives more probative weight to competent medical evidence, including the September 2020 VA examination, which determined that the Veteran’s hearing loss was not due to in-service noise exposure. The examiner offered a detailed rationale for this finding, which is discussed further below. Service connection for bilateral hearing loss may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s hearing loss and an in-service injury, event or disease. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. Again, the September 2020 VA examiner opined that the Veteran’s bilateral hearing loss was not at least as likely as not caused by or a result of an event in military service. The examiner rationalized that the Veteran’s military occupational specialty was health services management journeyman. The Veteran received air force training ribbon and an armed forces expeditionary medal. Enlistment examination was normal, but no separation examination could be located. Testing in the claims file from June 2019, 18 years after end of service dates, shows normal hearing. While hearing loss is noted on today's examination, it was not present 18 years after service, and is therefore less likely than not related to military noise exposure as loss will not occur as a result of noise, after removed from the noise, and the Veteran did not have loss when tested 18 years after military service. The Board finds that the VA examination is adequate because it was based upon consideration of the Veteran’s pertinent medical history, review of the claims file, his lay assertions and current complaints. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Moreover, as discussed further above, the remaining lay and medical evidence reflects that the Veteran’s hearing loss did not manifest until many years after service. In sum, when taking the VA examination in conjunction with the other evidence of record, the preponderance of the evidence is against finding that hearing loss is related to service. While the Veteran believes his bilateral hearing loss is related to an in-service injury, event, or disease, including reported inservice noise exposure, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical knowledge and the ability to interpret audiogram findings. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the remaining evidence of record. For all the foregoing reasons, the Board finds that the claim for service connection for bilateral hearing loss must be denied. In reaching the conclusion to deny each claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Entitlement to service connection for patellofemoral pain syndrome of the right knee and left knee The Veteran asserts that his right and left knee disabilities are due to in-service injuries. The Veteran has reported chronic knee pain since active service. The Board concludes that the Veteran has a current disability that began during active service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service treatment records document reports of knee pain following a soccer game in 1999. The impression was likely patellofemoral syndrome. Likewise, trauma to the knees was again observed following a soccer game in 2001. Importantly, a March 2001 VA examination, conducted prior to discharge, showed a diagnosis of episodes of musculoligamentous strain in both knees. Significantly, the September 2020 VA examination diagnosed patellofemoral syndrome of both knees. The examiner opined that it is as likely as not that the Veteran’s current bilateral knee patellofemoral syndrome is due to his time while on active duty. The examiner rationalized that the Veteran suffers from bilateral patellofemoral syndrome. The onset of this knee pain was while on active duty. Service treatment records identified and reviewed which support onset of these symptoms while on active duty. The nature of the knee pain has persisted and has not changed in nature other than worsening. In sum, after considering the totality of the evidence, the Board finds that, when resolving the benefit of the doubt in favor of the Veteran, service connection for patellofemoral pain syndrome of the right knee and left knee is warranted. In reaching this conclusion, the Board finds that the evidence is in at least a state of equipoise. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for cardiovascular condition The Veteran contends that he has a cardiovascular condition due to an undiagnosed illness or exposure to environmental hazards while stationed in the Southwest Asia Theatre of Operations. The Board concludes that the Veteran does not have a current diagnosis of cardiovascular condition, or objective indications of a chronic disability; and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Importantly, the September 2020 VA examiner reviewed the claims file, evaluated the Veteran and determined that he did not have a diagnosis of a heart condition. The examiner explicitly found that the Veteran did not have a significant cardiac condition. The examiner also found that there was no functional impact from any cardiovascular condition. See Saunders v. Wilkie, 886 F.3d 1356 (2018). In sum, the medical evidence does not contain any specific objective findings of any diagnoses or illnesses pertaining to a cardiovascular condition. While the Veteran believes he has a current diagnosis of a cardiovascular condition, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examination. In conclusion, based on the analysis above, a preponderance of the evidence is against the Veteran’s claim for service connection for cardiovascular condition, to include as due to under undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b).   Entitlement to service connection for a neurological condition other than memory loss and headaches The Veteran contends that he has a neurological condition due to an undiagnosed illness exposure to environmental hazards while stationed in the Southwest Asia Theatre of Operations. The Board concludes that the Veteran does not have a current diagnosis of neurological condition other than memory loss and headaches, or any objective indications of chronic disability; and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Importantly, the September 2020 VA examiner reviewed the claims file, evaluated the Veteran and determined that he did not have a central nervous system condition or Parkinson ’s disease. The examiner explicitly found that the only neurological diagnoses for the Veteran were memory loss and headaches. In sum, there is no competent medical evidence of any symptoms of a neurological disorder other than memory loss and headaches, which are addressed separately in this decision. While the Veteran believes he has a current diagnosis of a neurological condition, he is not competent to provide a diagnosis in this case. Moreover, his described symptoms are primarily memory loss and headaches, which are addressed separately in this decision. The issue is medically complex, as it requires specialized medical knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examination. In conclusion, based on the analysis above, a preponderance of the evidence is against the Veteran’s claim for service connection for a neurological condition other than memory loss and headaches, to include as due to under undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b).   Entitlement to service connection for memory loss The Veteran also contends that he has memory loss due to an undiagnosed illness exposure to environmental hazards while stationed in the Southwest Asia Theatre of Operations After reviewing all of the lay and medical evidence, the Board finds that the weight of the evidence is against finding the Veteran has or has had a current separate memory loss disability. Here, the Veteran’s memory loss symptoms have been attributed to his service-connected PTSD. In this regard, the September 2020 VA psychiatric examiner concluded that the Veteran did not show signs of clinically relevant memory loss and, therefore no diagnoses of memory loss were assigned. The examiner found that the Veteran is less likely than not to meet the criteria for a diagnosis of memory loss secondary to any psychiatric disorder, including the current service connected PTSD and Alcohol Use Disorder in Sustained Remission. The examiner rationalized that the Veteran does not endorse significant symptoms of memory loss, cognitive issues, or functional impairments related to such. Any mild disruption in attention and memory is likely due to PTSD and his history of heavy alcohol use, which have been shown to have begun during service. He has been successful at his current position with the VA and was able to achieve a master's degree with honors in 2017. Therefore, he has not been diagnosed with a separate diagnosis of memory loss. The Board recognizes that another September 2020 VA examiner indicated that the Veteran’s memory loss was an undiagnosed illness and therein nature and etiology are unknown. However, the Board finds that this opinion is less probative than the VA psychiatric opinion as this examiner offered no rationale for this finding; whereas the VA psychiatric examiner expressly tested the Veteran’s memory and attributed any mild memory loss found to the Veteran’s PTSD. Moreover, this examiner also noted that the Veteran’s memory loss was subjective with no objective findings. Importantly, he did not discuss whether it was a symptom of PTSD. The Board finds that the VA psychiatric opinion, which found a clear etiology of any mild memory loss, to have more probative weight. In sum, the VA psychiatric examiner's opinion is more probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, in light of the more probative VA psychiatric opinion, memory loss is contemplated in the rating assigned for the Veteran’s service-connected PTSD. 38 C.F.R. § 4.130, Diagnostic Code 9411; see 38 C.F.R. § 4.25 (stating that the evaluation of the same manifestation under different diagnoses is to be avoided). The Board acknowledges the Veteran’s assertions that he has memory loss. Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Veteran is competent to report his memory loss symptoms; notably, however, his own descriptions have associated his memory loss with his PTSD. Moreover, the question of whether the Veteran has a memory loss disorder separate from symptoms of PTSD is a question too complex to be addressed by other than expert evidence. Hence, any assertion made by the Veteran on that matter is not competent evidence. Although the lay contentions have been carefully considered, these contentions are outweighed by the other evidence of record. In conclusion, the weight of the evidence shows no current separate disability of memory loss at any time proximate to or during the pendency of this claim. Instead, the most probative evidence of record demonstrates the Veteran’s current memory loss is already contemplated in the already service-connected PTSD. In view of the foregoing, the Board concludes that the preponderance of the evidence is against a current memory loss disability, and the claim for service connection must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).   Entitlement to service connection for fatigue (claimed as chronic fatigue syndrome, unspecified joint pain, headaches, and disability manifested by symptoms of muscle pain and gastrointestinal disturbances (claimed as fibromyalgia) The Veterans seeks service connection for chronic fatigue syndrome, unspecified joint pain, headaches and fibromyalgia, which he claims is related to his service in the Southwest Asia Theatre of Operations. The Board notes that chronic fatigue syndrome and fibromyalgia are examples of medically unexplained chronic multisymptom illnesses, while fatigue, headaches, joint pain, muscle pain, and gastrointestinal symptoms are examples of signs or symptoms of such or an undiagnosed illness. Entitlement to service connection may therefore be warranted for symptoms, such as fatigue and muscle pain even where a diagnosis of chronic fatigue syndrome or fibromyalgia has not been supported. After reviewing all of the lay and medical evidence, when resolving the benefit of the doubt in favor of the Veteran, the Board finds that he suffers from various signs and symptoms due to an undiagnosed illness from his service in the Southwest Asia Theatre of Operations. The Board notes that the September 2020 VA examiner found that the Veteran did not meet the criteria for a diagnosis of chronic fatigue syndrome or fibromyalgia. However, the examiner attributed the Veteran’s fatigue, joint pain, headaches, muscle pain and gastrointestinal disturbances to an undiagnosed illness due to his service in the Gulf War. Moreover, the Veteran is competent to report continuous symptoms since service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In this case, the Board finds that the Veteran’s reports of continuous symptoms credible as there is nothing in the record to explicitly contradict his reports and they are consistent with the VA treatment notes of record. As such, the Board finds that the evidence is, at the very least, in relative equipoise as to whether the Veteran’s current fatigue, unspecified joint pain, headaches, muscle pain and gastrointestinal disturbances are due to an undiagnosed illness and/or medical unexplained chronic illness due to his service in the Gulf War. Therefore, when resolving the benefit of the doubt in favor of the Veteran, the Board finds that service connection for fatigue (claimed as chronic fatigue syndrome, unspecified joint pain, headaches, and disability manifested by symptoms of muscle pain and gastrointestinal disturbances (claimed as fibromyalgia) is warranted. REASONS FOR REMAND Entitlement to service connection for disability manifested by difficulty walking and abnormal gait is remanded. The Board previously remanded this issue for further development, to include a VA examination. Unfortunately, it does not appear that the September 2020 VA examiner addressed whether the Veteran had a disability manifested by difficulty walking and abnormal gait. Moreover, this matter was not readjudicated in the most recent November 2020 supplemental statement of the case (SSOC) as required under 38 C.F.R. § 19.31 (b)(1). Thus, this issue must be returned in order to comply with the Board’s prior remands. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of disability manifested by difficulty walking and abnormal gait. The examiner should identify any objective evidence of the Veteran’s claimed disability manifested by difficulty walking and abnormal gait; render a diagnosis with respect to each claimed symptom which is due to a known clinical diagnosis; and, provide an opinion with respect to each currently diagnosed disorder as to whether it is at least as likely as not that the disorder is etiologically related to the Veteran’s military service, to include service in the Southwest Asia theatre of operations. The examiner should also specifically identify any objectively demonstrated symptoms that are not attributable to a known clinical diagnosis and whether such constitute a medically unexplained chronic multisymptom illness. The examiner should further indicate whether such disabilities existed for 6 months or more or whether they exhibit intermittent worsening over a 6-month period. A detailed rationale for any opinion proffered should be provided. 2. Readjudicate the remaining issue on appeal. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.N. Moats 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.