Citation Nr: 21027381 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 16-43 188 DATE: May 5, 2021 REMANDED Entitlement to service connection for chronic joint pain of the fingers and toes to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness under 38 C.F.R. § 3.317 and/or due to herbicide exposure is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1970 to December 1971, and from January 1991 to July 1991. The Veteran served in the Republic of Vietnam in the early 1970s and in Saudi Arabia during the Gulf War in the early 1990s. In January 2019, the Veteran testified at a Board hearing. The transcript is of record. In June 2019, the Board remanded the case for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for chronic joint pain of the fingers and toes secondary to herbicide exposure and/or Gulf War environmental exposures Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). At the Gulf War examination in October 2013 the examiner concluded that the Veteran's claimed chronic joint pain does not represent a multi-symptom illness or disability pattern related to military service to include a specific exposure event in Southwest Asia. The examiner concluded that there is no objective evidence of a chronic joint pain condition during or within two years of active duty and that joint pain is not a Gulf War presumptive condition. In September 2016 the Veteran attended a VA examination for peripheral nerves. The examiner found no diagnosis of a peripheral nerve condition explaining that despite self-reported numbness and tingling of the fingers and toes bilaterally the examination did not reveal any objective sensory, motor, or deep tendon reflex loss. However, the examiner did note symptoms of mild intermittent pain, paresthesias and/or dysesthesias and numbness and functional limitation of needing to sit during muscle cramping. The Board finds that further development is required for adjudication. As the Veteran consistently alleges joint pain and medical imaging reveals degenerative changes in the feet, the Board finds that a musculoskeletal examination is warranted. 38 C.F.R. § 3.159(c)(4)(i). Additionally, the Veteran has also alleged entitlement to service connection for joint pain due to herbicide exposure. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Id. at 1367-69. As such, a remand is necessary for a VA examination to determine if the Veteran has a qualifying disability pursuant to Saunders and if so, a medical opinion addressing service connection on a direct service connection basis due to in-service exposure to agent orange. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Obtain updated VA and/or private treatment records. If such records are unavailable, the Veteran's claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Schedule the Veteran for a musculoskeletal VA examination and obtain a medical opinion from a medical professional with appropriate expertise to determine the nature and etiology of his chronic joint pain. The examiner should review the Veteran's claims file. Based on a review of the record, the examiner must address the following: (a.) Opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's claimed symptoms manifested by pain, tingling and numbness in the bilateral hands and feet is due to a (1) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (2) a disease with a clear and specific diagnosis. If it is the latter, the examiner must provide the diagnosis of the disability(ies). (b.) If the Veteran's disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, opine as to whether it is at least as likely as not that the Veteran's current disability was incurred during a period of active service, to include as a result of his exposure to environmental hazards while serving in Southwest Asia during the Persian Gulf War. (c.) If the examiner determines that the Veteran's disability pattern is neither a diagnosable chronic multi-symptom illness with a partially explained etiology nor a disease with a clear and specific etiology and diagnosis, then the examiner should opine whether the Veteran's claimed disability is due to objective indications of a qualifying chronic disability to include (1) an undiagnosed illness, or (2) medically unexplained chronic multisystem illness. If no disability, undiagnosed illness, or medically unexplained chronic multi-symptom is identified, an explanation should be provided. (d.) If a diagnosis is not established, describe any functional impairments related to the Veteran's upper and lower extremity symptoms, to include pain, numbness, and tingling. The examiner is advised that the Veteran's pain may qualify as a disability if it reaches the level of a functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). (e.) For all diagnoses, to include pursuant to Saunders, opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's disability is related to the Veteran's military service, to include due to exposure to herbicide agents. The examiner should consider and address the Veteran's testimony regarding onset of pain and numbness of his fingers and toes. The fact that a particular diagnosis is not a disability presumed to be related to herbicide agent exposure is not sufficient to serve as a rationale in this case. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). (Continued on the next page) If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Upon completion of the above directives, complete any other necessary development after review of any additionally received records, to include additional VA examinations if warranted. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.