Citation Nr: 21027784 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-39 880 DATE: May 6, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for residuals of melanocarcinoma with scars is denied. REMANDED The claim of entitlement to service connection for a psychiatric disability other than PTSD is remanded. The claim of entitlement to service connection for insomnia (claimed as a sleeping disorder), including as secondary to an undiagnosed or medically unexplained chronic multi-symptom illness, is remanded. The claim of entitlement to service connection for skin rashes affecting the right leg, including as secondary to an undiagnosed or medically unexplained chronic multi-symptom illness, is remanded. The claim of entitlement to service connection for a left foot disability, including skin rashes affecting the left foot secondary to an undiagnosed or medically unexplained chronic multi-symptom illness, is remanded. The claim of entitlement to service connection for a right foot disability, including residuals of right hallux valgus with bunionectomy, and skin rashes secondary to an undiagnosed or medically unexplained chronic multi-symptom illness, is remanded. The claim of entitlement to service connection for right arm pain is remanded. FINDINGS OF FACT 1. Bilateral hearing loss did not initially manifest during or within a year of active service and is not otherwise related to active service, including in-service noise exposure and/or acoustic trauma. 2. There is no medical evidence of record diagnosing PTSD. 3. The in-service melanocarcinoma on the Veteran's right thigh has not recurred or metastasized, and the Veteran does not have any non-scar residuals of that condition or his right thigh surgery. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 2. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for residuals of melanocarcinoma with scars have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the National Guard, with periods of active duty (AD) from May 1973 to October 1973, and from December 1990 to November 1991, including in the Southwest Asia theater of operations from December 1990 to February 1991. His claims come before the Board of Veterans' Appeals (Board) on appeal of a May 2015 Department of Veterans Affairs (VA) rating decision. The Veteran and his spouse testified in support of these claims in April 2019, before a Decision Review Officer at the Agency of Original Jurisdiction (AOJ), and in January 2021, virtually, before the undersigned Veterans Law Judge. Based on the Veteran's clarifying hearing testimony, the Board has recharacterized a few of the claims on appeal to reflect more accurately the disabilities for which the Veteran is seeking service connection. Service Connection The Veteran claims entitlement to service connection for hearing loss, PTSD and melanocarcinoma. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. "Active military, naval or air service" includes: (1) AD; (2) any period of active duty for training (ACDUTRA) during which an individual became disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of inactive duty training (INACDUTRA) during which an individual became disabled or died from an injury incurred or aggravated in the line of duty, or from an acute myocardial infarction, cardiac arrest, or cerebrovascular accident occurring during such training. 38 U.S.C. § 101(24). The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases, including organic diseases of the nervous system, will be presumed related to service if they were noted as chronic in service, manifested to a compensable degree within a year of separation from service, or if continuity of the same symptomatology of those diseases existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). The questions for the Board are thus: (1) whether the Veteran currently has these claimed disabilities; and, if so, (2) whether they began during service, or are at least as likely as not related to an in-service injury, event, or disease, or, (3) in the case of the hearing loss, whether it initially manifested to a compensable degree within a year of separation from service. Entitlement to service connection for bilateral hearing loss The Veteran seeks service connection for hearing loss on a direct basis as related to in-service noise exposure. He testified that he had no hearing problems prior to enlisting, but after deployment, where he reportedly worked in ammunition and storage a hundred or a few hundred feet from the flight line (prepared ammunition, bombs and missiles during 12-hour duty shifts), he developed such problems; at the time, he used ear inserts, not the muffs that go over the inserts. His tent was set up beside the flight line, and during Desert Storm, the aircraft lifted off (took three hours) and returned, wave after wave. Until all aircraft got to the ground, there was no quiet. His hearing wasn't tested when he returned from deployment because he had to go right to work seven days a week. The Veteran further testified that, after discharge, he was not exposed to anything as loud as the aircraft. Upon returning, he worked in a plant for 21 years as a switchboard technician, drawing up or drafting switchboards and panels, wire connects and flat steel parts. When he first got hired, he reportedly worked in the shop for six to eight months. It was noisy there, but he wore hearing protection, which the company required. After that period, he began working in the office, but whenever he had to go in the shop, he wore hearing protection. He denied recreational noise exposure. He testified that he first noticed that he had an issue with his hearing six months to a year after returning from service. He couldn't hear what his spouse was saying and had to ask her to repeat herself. He also testified that he does not wear hearing aids and has not recently sought treatment for his hearing loss, but it might have played a role in him not being able to maintain his job. His boss told him that he lost his job because he became easily distracted and couldn't remain focused, but he couldn't hear others when they were relaying messages to him. The Veteran's spouse testified that, within six months to a year after the Veteran returned from his deployment, she noticed that he had difficulty hearing. If the television was on, he couldn't hear her speaking from the kitchen, which was nearby. He would put the television up and talk really loudly on the phone. Since then, his hearing has reportedly worsened, but when VA evaluated him, they told him it was normal. The spouse further testified that the Veteran never participated in any recreational activities that would have hurt his hearing. The preponderance of the evidence is against this claim. There are indeed no post-service treatment records addressing the Veteran's hearing difficulties, but based on the report of the VA examination to which the Veteran's spouse referred during the most recent hearing, the Board finds that, although the Veteran has hearing loss bilaterally, it did not manifest during or within a year of his discharge from active service and is not otherwise related to active service, including any in-service noise exposure and/or acoustic trauma. To meet VA's definition of hearing loss, or hearing loss sufficiently severe to constitute a disability, the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz must be 40 decibels or greater, or the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz must be 26 decibels or greater, or the speech recognition scores using the Maryland CNC Test must be less than 94 percent. 38 C.F.R. § 3.385. When the Veteran underwent a VA hearing loss and tinnitus examination in February 2015, the findings satisfied this definition bilaterally. The auditory thresholds at the 3000 and 4000 Hertz frequencies were 40 decibels bilaterally, resulting in a diagnosis of sensorineural hearing loss, right and left ears. The question is therefore whether this hearing loss initially manifested during active service or is otherwise related to such service. The Veteran had active service from May 1973 to October 1973 and from December 1990 to November 1991. He had normal hearing (auditory thresholds ranging from 0 to 10 at 1000 through 4000 Hertz frequencies bilaterally) on audiogram in February 1973. A technician first diagnosed hearing loss in August 1989, during an audiogram conducted for the purpose of the Veteran's enlistment in the National Guard, but based on the auditory thresholds ranging from 0 to 25 at 1000 through 4000 Hertz frequencies bilaterally (a worsening since February 1973 but normal hearing by VA standards), the examiner did not note hearing loss in the examination report and found the Veteran qualified for National Guard enlistment. The Veteran deployed to Saudi Arabia in late December 1990 and stayed until late February 1991, and during the two months there, he did not report hearing difficulties. Similarly, during an April 1991 demobilization examination, the Veteran did not report, and the examiner did not note, hearing difficulties or loss. In December 1991, just prior to returning to National Guard status and presumably based on the August 1989 audiogram, the Veteran was profiled for high frequency hearing loss with a requirement to wear hearing protection while in hazardous noise areas. The Veteran first mentioned his hearing during a May 2014 Persian Gulf examination. He reported that his hearing had diminished the last several years, and he was exposed to loud noises but did not work with explosives or guns. A whisper test corroborated a decrease in hearing. In its May 2015 rating decision, the AOJ conceded that the Veteran experienced acoustic trauma in service. The VA examiner is the only medical professional who has addressed whether the Veteran's hearing loss is related to such trauma and/or the noise exposure the Veteran has described, and his opinion is unfavorable. In his report, he found that the Veteran's hearing loss is not at least as likely as not caused by or the result of an active service event. He based this finding on the Veteran's description of his in-service and post-service noise exposure (in-school cabinet making and mill work prior to active service, munitions, fork lifts, other tools, and sirens (loudest exposure) during active service, and manufacturing work (metal fabrication), punches and presses after active service), concluding that the Veteran described more quiet settings during military service than before and after service. The Veteran has not since submitted a medical opinion refuting that of the VA examiner and relating the hearing loss to one of his periods of active duty, including the two months in the Persian Gulf. Therefore, his and his spouse's assertions represent the only nexus evidence of record, and these assertions may not be considered competent evidence of a nexus. While the Veteran and his spouse are competent to report when they first noticed lay-observable hearing difficulties, neither may diagnose hearing loss, including by VA standards or otherwise. There is no indication of record that they are trained in medicine or audiology, and such a diagnosis requires specialized knowledge of audiograms and an ability to interpret all pertinent responses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). For the sake of further discussion, even were the Board to consider such assertions competent, this claim would still fail. The pre-service, service and post-service noise exposure the Veteran described initially, during his February 2015 VA examination, conflicts with his descriptions of the exposure provided during his April 2019 and January 2021 hearings, calling into question his credibility. In February 2015, the Veteran reported that the noise from sirens represented the loudest to which he was exposed in service. During his hearings, he did not mention sirens, instead focusing on noise from the flight line, to which his tent was reportedly in close proximity, in particular, aircraft taking off and landing. In addition, in February 2015, he reported post-service noise exposure from manufacturing equipment, but during his hearings, he indicated that he protected himself from such exposure and primarily worked in an office away from such noise. As the hearing testimony is favorable to him, the Board wonders why the Veteran did not share it with the examiner initially, in February 2015. Rather, after the examiner provided an unfavorable opinion based solely on the Veteran's February 2015 description of his noise exposure, the Veteran began testifying about flight line noise to which he was exposed during service. It's possible these conflicting reports result from a misunderstanding of the law rather than any lack of credibility. To prove entitlement to this benefit, the evidence must show that hearing loss is related to noise exposure that occurred during a period of AD or a specific ear injury (acoustic trauma) that occurred during a period of ACDUTRA or INACDUTRA. In some cases, it appears that the Veteran and his spouse might be describing noise exposure that occurred during the Veteran's service in general, including in the National Guard, rather than a period of AD, which would account for the different types of noise exposure described. Regardless, the Veteran's and his spouse's assertions may not be considered competent evidence of a nexus in this case. In the absence of competent and credible evidence relating the Veteran's bilateral hearing loss to active service, the criteria for entitlement to service connection for bilateral hearing loss are not met. Entitlement to service connection for PTSD The Veteran seeks service connection for PTSD due to encounters during the Gulf War. The preponderance of the evidence is against this claim. During his hearings, the Veteran testified that he has not been diagnosed with PTSD but had stress during service and, due to a racing mind, has had sleeping difficulties since returning. He explained that, the night before the war started, they were driving past the gate to get on base, when they learned that someone had already fired on the gate; consequently, they weren't able to get on base until the next morning. While deployed, he experienced scud attacks, during which he found shelter, and some guys got injured (broken limbs) and caught in the Constantine bar. Once, he was assigned to pull a guy with a chemical suit out of the wire. Also, when his spouse's surgery was planned, her doctor informed him of its seriousness, but the military guys in charge were telling him it was routine surgery. This upset him to the point that he began to shake, tremble and get upset and resentful; he had young kids, but because he couldn't speak to his spouse, he was unable to determine whether there was someone available to care for them. He was led to believe his spouse was going to be okay, but lo and behold, he ended up going home after the problem turned out to be more severe than they described. This changed his ability to believe in people. According to a January 2015 written statement from the Veteran's spouse and her hearing testimony, the Veteran is experiencing PTSD. When the Veteran returned home from Operation Desert Storm in January 1991, he became withdrawn from her and the children, easily frustrated and agitated, had difficulty focusing on the task at hand (affected employment evaluations, promotions and status), and, when not at work, spent countless hours in his garage. He now appears depressed, demonstrates sporadic outbursts of frustration and anger, changes his behavior when he hears planes doing practice runs next to his house (as of April 2019, was living next to Air Force base), and has abnormal sleep patterns. He is also resentful of the fact that, because he got ill, he was not able to complete his last month with his unit. The spouse reportedly witnessed the emotional stress the Veteran was experiencing upon return from deployment due to encounters during the Gulf War. While deployed, he was diagnosed with skin cancer. A biopsy was performed, and the skin abnormality appeared to be benign, but he was told he would need further testing and possible surgery once he returned to the United States. Meanwhile, his spouse was struggling with a life-threatening gastrointestinal disease requiring immediate hospitalization and extreme pre-surgery detoxification, and uncertainty regarding her chance of survival resulted in the surgeon attempting to reach the Veteran's commanding officer on numerous occasions so that the Veteran could be sent home. Following his spouse's surgery, the Veteran underwent the removal of the skin cancer from his inner thigh. Prior to surgery, he struggled through long periods of sleeplessness, agitation, skin rashes and stomach ailments. Service personnel records substantiate the timeline the Veteran and his spouse describe. The Veteran was initially ordered to active duty from December 1990 to December 1991. However, within months of deploying to Saudi Arabia on December 25, 1990, his spouse was scheduled for surgery that necessitated his return home. Meanwhile, he discovered a skin lesion on his right thigh (February 1991 pathology report showed suspected early melanocarcinoma) and was in the midst of being treated for it and right foot complaints when his spouse's surgery was scheduled. He therefore returned home on February 25, 1991, after which he underwent two separate surgeries on his right thigh and right foot and was placed on medical hold to convalesce. He was released from active duty in November 1991, earlier than planned due to his medical issues, and found fit to return to National Guard status in December 1991. A July 2019 written statement from JW, the Veteran's former co-worker and manager and fellow soldier who served with the Veteran stateside and in Saudi Arabia, substantiates that, over the years, the Veteran became unable to stay focused on a single task through completion. There is no evidence, however, substantiating the Veteran's spouse's assertion that the Veteran has PTSD. The Veteran has admitted that he has not been diagnosed with PTSD, and, despite undergoing VA general medical, Persian Gulf and PTSD examinations in August 2011, May 2014 and March 2015, there are no records in the file that include a PTSD diagnosis. During the March 2015 PTSD examination, the examiner indicated that the Veteran met criterion A for PTSD, but he concluded that the Veteran's symptoms were insufficient to support a PTSD diagnosis. His conclusion is based on a thorough examination, a review of the pertinent evidence of record, an interview of the Veteran and his spouse, and rationale. Prejean v. West, 13 Vet. App. 444 (2000); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The spouse's assertion that the vet is experiencing PTSD therefore represents the only evidence of record diagnosing PTSD, and these assertions may not be considered competent evidence of a diagnosis. While the Veteran and his spouse are competent to report when they first noticed lay-observable mental health difficulties, neither may diagnose PTSD. There is no indication of record that they are trained in medicine or psychology, and such a diagnosis requires specialized testing and interpretation of test results. Jandreau v. Nicholson, 492 F.3d at 1377. In the absence of medical evidence of record diagnosing PTSD, the criteria for entitlement to service connection for PTSD are not met. Entitlement to service connection for residuals of melanocarcinoma with scars When the Veteran filed his claim for this benefit in January 2015, he indicated that he was seeking service connection for "melanocarcinoma while on AD scars from surgery." During AD, a pathology report indeed showed a suspicion of this condition on the Veteran's right thigh, necessitating wide-excision surgery for its removal. The AOJ has since service connected the Veteran for post-surgical scarring. The question that remains is whether the melanocarcinoma has recurred or the Veteran currently has non-scar residuals of the surgery. In written statements and during his hearing, the Veteran and his spouse reported no such residuals and referred generally to skin rashes affecting his lower extremities, including his feet. These rashes are addressed separately below, in the Remand section of the decision, as part of the Veteran's claims for service connection right leg and right and left foot disabilities. The preponderance of the evidence is against this claim for service connection for melanocarcinoma or residuals thereof. The Veteran has not claimed that he has skin cancer, including on his right thigh. He has sought treatment for multiple conditions since he underwent the initial surgery in 1991, including skin rashes, and, according to treatment records in the file, no medical professional has noted a recurrence or metastasis of the melanocarcinoma or diagnosed melanoma or any other type of skin cancer on any other part of the Veteran's body. During August 2011 and February 2015 VA skin examinations, examiners acknowledged the in-service history, including the surgery, specifically noted that the Veteran did not have residuals or complications of the in-service neoplasm, including metastasis, and indicated that the Veteran was in watchful, waiting status. In the absence of evidence of melanocarcinoma or non-scar residuals thereof, the criteria for entitlement to service connection for this condition are not met. REASONS FOR REMAND Entitlement to service connection for a psychiatric disability other than PTSD Entitlement to service connection for insomnia (claimed as a sleeping disorder), including as secondary to an undiagnosed or medically unexplained chronic multi-symptom illness The Veteran initially claimed service connection for "PTSD conditions", which the AOJ interpreted as a claim for PTSD only. Although the Veteran has not been diagnosed with PTSD, resulting in the above denial, treatment records suggest that he might have another mental health disability that manifests partially as sleep disturbances, which too should be considered part of the Veteran's initial mental health claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). During an August 2011 VA examination, an examiner found that the Veteran had an unclaimed stress disorder manifesting as recurrent thoughts and fatigue, which most likely explained his claim for service connection for chronic fatigue syndrome. In addition, during a May 2014 VA Persian Gulf examination, a VA examiner diagnosed sleep disorder/insomnia (no sleep study done) and difficulty with concentration and focus from a mental standpoint. The examiner noted that, although the Veteran was alert and oriented, his speech was rapid and associated with random thoughts. During a March 2015 PTSD examination, an examiner recorded multiple mental health symptoms and noted that the Veteran met criterion A for a PTSD diagnosis but found that there was insufficient evidence to diagnose PTSD. That examiner did not indicate whether the Veteran had any other mental health disability. To date, no medical professional has addressed whether a mental health disorder other than PTSD, manifesting partially as insomnia, initially began during active service or is otherwise related to active service, including any undiagnosed or medically unexplained chronic multi-symptom illness that developed secondary to the Veteran's service in the Persian Gulf. Entitlement to service connection for skin rashes affecting the right leg, including as secondary to an undiagnosed or medically unexplained chronic multi-symptom illness Entitlement to service connection for a left foot disability, including skin rashes secondary to an undiagnosed or medically unexplained chronic multi-symptom illness Entitlement to service connection for a right foot disability, including residuals of right hallux valgus with bunionectomy and skin rashes secondary to an undiagnosed or medically unexplained chronic multi-symptom illness The Veteran seeks service connection for right leg and left and right foot disabilities, including skin rashes, on either a direct basis, as related to documented in-service right foot abnormalities and surgery and boots he wore during service, or presumptive basis, as skin symptoms of an undiagnosed or medically unexplained chronic multi-symptom illness that developed secondary to his service in the Persian Gulf. According to the Veteran's and his spouse's August 2010 and August 2011 written statements and April 2019 and January 2021 hearing testimony, the skin rashes developed secondary to exposure to environmental hazards, including depleted uranium, while serving in the Southwest Asia theater of operations from December 25, 1990 to February 25, 1991, and have continued to manifest since returning home. The foot pain reportedly developed from wearing military boots, and the growth reportedly developed after the in-service foot surgery. Service treatment records show post-operative changes of the Veteran's right foot. Treatment records and a May 2014 report of a VA Persian Gulf examination objectively confirm that the Veteran has skin rashes of his extremities of unknown etiology and has been seen for a growth (callus) on his right great toe. Although he underwent VA foot and skin examinations during this appeal, the reports of these examinations are inadequate to decide these claims. Neither addresses whether the growth is related to the Veteran's in-service right foot problems and/or surgery, and whether the skin rashes represent a sign or symptom of an undiagnosed or medically unexplained chronic multi-symptom illness that developed secondary to the Veteran's service in the Persian Gulf. Entitlement to service connection for right arm pain The Veteran claims entitlement to service connection for right arm pain on a direct basis as related to an in-service right arm injury. In his January 2015 claim, he asserted that he had had this pain since active duty. In January 2021. he testified that he recalls lifting something, when he heard a "crack or whatever", and then it became difficult and uncomfortable to rotate that arm, and he had to be careful lifting it. He did not seek treatment or get medication for the injury in service because the war was going on, and they would have treated him in the field and sent him right back to work (nowhere to go). He further testified that, from 1991 to 2018, he self-medicated to manage the pain. In 2018, he sought treatment for his arm, and although x-rays showed no abnormalities, VA gave him medication for pain and inflammation. His spouse testified that the Veteran told her what happened during service and has been complaining about his right arm for years; she has witnessed him having to adjust his position when he's lifting, and she knows the arm pain sometimes interferes with sleep. "[P]ain is an impairment because it diminishes the body's ability to function, and that pain need not be diagnosed as connected to a current underlying condition to function as an impairment." Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018). A veteran may not demonstrate service connection simply by asserting subjective pain. Rather the pain must be functionally impairing of earning capacity. Id. at 1367-68. Here, not only is the Veteran claiming that he currently has lay-observable right arm pain that has been continuously manifesting since service, when he injured that arm, but the record includes lay testimony suggesting functional impairment secondary to the pain. It also includes evidence that the Veteran has right shoulder degenerative joint disease and tendinosis of the right shoulder, which might account for the pain. To date, VA has not obtained an opinion objectively confirming the functional impairment or addressing whether the pain is attributable to the right shoulder disability and related to the in-service incident. These matters are REMANDED for the following action: 1. After obtaining any necessary authorization, secure and associate with the file records of the Veteran's initial evaluation by the psychiatrist to whom he referred during his January 2021 hearing. 2. Afford the Veteran a VA mental health examination. The examiner should review the Veteran's file, including: (a) the Veteran's hearing testimony; (b) his spouse's January 2015 written statement; (c) the August 2011 VA examination report noting insomnia and a stress disorder condition manifesting as recurrent thoughts and fatigue; (d) the March 2015 VA PTSD examination report noting multiple mental health symptoms; (e) post-service treatment records dated since 2011, which refer to insomnia and symptoms often attributed to mental health conditions; and (f) the May 2014 VA Persian Gulf examination. The examiner should record in detail the Veteran's history of insomnia, stress and other mental health symptoms. After conducting all necessary testing, the examiner should diagnose each psychiatric disability other than PTSD shown to exist. The examiner should indicate whether the Veteran's insomnia is attributable to a known diagnosed disability, including affecting the Veteran's mental health. If the insomnia is not attributable to a known diagnosed disability, the examiner should opine whether it represents a sign or symptom of an undiagnosed or medically unexplained chronic multi-symptom illness that developed secondary to the Veteran's service in the Persian Gulf. If it does, the examiner should describe the severity of such illness. Accepting as competent all reports of pertinent lay-observable symptoms, the examiner should opine whether any psychiatric disability other than PTSD initially manifested during active service or is at least as likely as not otherwise related to active service. The examiner should provide clear rationale for each opinion. 3. Afford the Veteran a VA examination of his lower legs and feet, including the skin. The examiner should review the Veteran's file, including: (a) the Veteran's and his spouse's August 2010 and August 2011 written statements and April 2019 and January 2021 hearing testimony; (b) service treatment records showing post-operative changes in the Veteran's right foot; (c) post-service treatment records dated since 2011, which mention skin rashes and a right foot growth; (d) an August 2011 VA skin examination report, which includes the Veteran's descriptions of his skin rashes and diagnoses for the rashes affecting his feet; (e) a May 2014 VA Persian Gulf examination report, which mentions skin rashes of unknown etiology; and (f) a February 2015 VA examination report noting rashes on other parts of the Veteran's body. The examiner should record in detail the Veteran's history of skin rashes, including on the feet, ankles and lower legs, right foot growths, and right and left foot pain, cramping and swelling. The examiner should indicate whether the skin rashes affecting the Veteran's lower legs, ankles and/or feet are attributable to a known diagnosed disability (evidence conflicts), and if so, diagnose the disability and opine whether it is at least as likely as not related to a period of active service, including any environmental toxins such as depleted uranium. If the skin rashes are not attributable to a known diagnosed disability, the examiner should opine whether they represent a sign or symptom of an undiagnosed or medically unexplained chronic multi-symptom illness that developed secondary to the Veteran's service in the Southwest Asia theater of operations from December 25, 1990 to February 25, 1991. If it does, the examiner should describe the severity of the rashes. The examiner should also diagnose all right and left foot disabilities shown on examination, to include any growth on the right foot. The examiner should opine whether each such disability initially manifested in service or is at least as likely as not otherwise related to such service, including the right foot surgery. If pain is the sole diagnosis on the left, the VA examiner should indicate whether that pain is causing functional loss. The examiner should provide clear rationale for each opinion. 4. Afford the Veteran a VA examination of his right arm, including his shoulder. The examiner should review the Veteran's file, including: (a) the Veteran's and his spouse's April 2019 and January 2021 hearing testimony describing the in-service right arm incident, the symptoms the Veteran has experienced since that incident, and the functional impairment caused by his current right arm pain; (b) an August 2011 VA general medical examination report referring to x-rays showing right shoulder degenerative joint disease; and (c) treatment records confirming the right shoulder arthritis and pain. The examiner should record in detail the Veteran's history of right arm pain, including where it is located, and the nature of the in-service right arm injury. The examiner should diagnose any right arm disability shown to exist, including, if applicable, affecting the shoulder. If right arm pain is the sole disability, the examiner should indicate whether that pain amounts to a functional impairment. For any other disability, the examiner should opine whether it is at least as likely as not related to a period of active service, including the reported in-service right arm injury. The examiner should provide clear rationale for each opinion. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. N. 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.