Citation Nr: 21028411 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-22 266A DATE: May 11, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome, including as due to an undiagnosed illness and service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for headaches, including as due to undiagnosed illness and service-connected PTSD is remanded. Entitlement to service connection for intestinal problems, including as due to an undiagnosed illness is remanded. Entitlement to service connection for joint pain, including as due to an undiagnosed illness is remanded. Entitlement to service connection for a right shoulder condition is remanded. Entitlement to service connection for a left shoulder condition is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for a lower back condition is remanded. Entitlement to service connection for residuals of a rib injury on the left side is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1987 to April 1991. The Veteran testified before the undersigned Veterans Law Judge during a February 2021 hearing, and a transcript has been associated with the record. At the outset, the record reflects that there appear to be outstanding relevant treatment records. More specifically, during his February 2021 hearing, the Veteran testified that he had recent treatment, bloodwork, and x-rays at Adventist Health in Clear Lake, a VA-contracted facility. Additionally, a February 2016 treatment record from Northern California Medical Associates noted that the Veteran had been treated by VA for his PTSD and irritable bowel syndrome. As such records may have some bearing on the Veteran's claim, attempts must be made to have the records obtained and associated with the Veteran's electronic claims file. 1. Entitlement to service connection for chronic fatigue syndrome, including as due to an undiagnosed illness and service-connected PTSD is remanded. 2. Entitlement to service connection for headaches, including as due to undiagnosed illness and service-connected PTSD is remanded. 3. Entitlement to service connection for intestinal problems, including as due to an undiagnosed illness is remanded. During his February 2021 hearing, the Veteran contended that his fatigue syndrome, irritable bowel symptoms, and headaches, were associated with Gulf War syndrome and that he had the symptoms since his service during the Gulf War. See hearing transcript, Pgs. 16-17. In an August 2015 opinion, an examiner found, since there was no evidence that the Veteran actually has an intestinal condition, it was less than likely such disability was due to toxin or exposure events or environmental hazards incurred while serving in the Southwest Asia. No opinion was provided regarding the Veteran's fatigue. However, private treatment records from Dr. G.M. dated in September 2009 noted that the Veteran had fatigue. The record also reflected that the Veteran had irritable bowel syndrome with frequent loose stools that apparently started after his service during the Gulf War. Dr. G.M. reported that there was some concern about possible exposure to chemicals at that time. Dr. G.M. stated that he gave the Veteran a note to take to the VA to let them know that he was treating the Veteran for this condition. May 2016 records documented complaints of symptoms of multiple loose stools, diarrhea, and rectal urgency. Sometimes he had constipation. Irritable bowel syndrome was suspected. A June 2016 private record from Dr. H.M. noted the Veteran's history of having food poisoning around 1990 and having bowel issues ever since that time. The assessment was diarrhea with a bout of enteritis in 1990 while serving in Iraq with a picture now suggestive of post enteritis syndrome. Dr. H.M. added that it was felt that the acute enteritis may have resulted in some dysmotility of the gastrointestinal tract, which pit the patient at a higher risk of small bowel bacterial growth. As the Veteran's treatment records suggest the presence of current intestinal or fatigue disability, a remand is necessary to clarify the nature and etiology of such conditions at a new examination. Additionally, in an August 2015 VA opinion, the examiner stated, without any supporting explanation, that the Veteran's claimed disability patterns for headaches showed diagnosable illnesses with known etiologies. Thus, the headaches were deemed less than likely as not due to toxin or exposure events or environmental hazards incurred while serving in the Southwest Asia. The examiner did not provide any additional explanation or rationale. Signs and symptoms of an undiagnosed illness and medically unexplained chronic multisymptom illnesses (MUCMI) include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, upper or lower respiratory signs or symptoms, sleep disturbances, gastrointestinal signs or symptoms, abnormal weight loss, menstrual disorder, cardiovascular signs or symptoms, and presumptive service connection for infectious diseases. Id. § 3.317(b)(1)-(11). Meanwhile, a MUCMI in particular is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs that has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Id. § 3.317(a)(2)(ii). The regulation makes clear that an illness can be a MUCMI where either the etiology or the pathophysiology of the illness is inconclusive. Id.; Stewart v. Wilkie, 30 Vet. App. 383, 388 (2018) (noting that pathophysiology and etiology are decisive factors in determining whether an illness is medically unexplained). Conversely, a multisymptom illness is not a MUCMI where both the etiology and pathophysiology are partially understood, such as diabetes and multiple sclerosis, because it is not considered medically unexplained. Stewart, 30 Vet. App. at 389-90. Thus, to have sufficient information upon which to decide these claims, the Board finds a remand is necessary to obtain a Gulf War VA examination and opinion in which the examiner identifies (1) the diagnosis and (2) whether the diagnosis has a conclusive etiology or pathophysiology, and provides a rationale to support each conclusion. In addition to direct service connection, the Veteran has also indicated that his headaches and fatigue may be related to his service-connected PTSD. In a September 2019 written brief presentation, the Veteran's representative indicated that the Veteran's chronic fatigue syndrome and headaches were secondary to his service-connected PTSD. The representative referenced several articles suggesting a relationship between chronic fatigue syndrome and headaches and the Veteran's service-connected PTSD. Therefore, a VA opinion is necessary regarding his chronic fatigue syndrome and headaches on a direct and secondary basis. 4. Entitlement to service connection for joint pain, including as due to an undiagnosed illness, is remanded. 5. Entitlement to service connection for a right shoulder condition is remanded. 6. Entitlement to service connection for a left shoulder condition is remanded. 7. Entitlement to service connection for a right knee condition is remanded. 8. Entitlement to service connection for a left knee condition is remanded. 9. Entitlement to service connection for a lower back condition is remanded. 10. Entitlement to service connection for residuals of a rib injury on the left side is remanded. The Veteran contends that his bilateral shoulder, bilateral knee, lower back, and left rib conditions are related to his multiple parachute jumps in service for which he earned an Airborne Badge. See July and August 2015 VA examination reports. His DD-214 reveals that he earned the Parachute Badge. During his February 2021 hearing, the Veteran also reported that his joint pain symptoms were associated with Gulf War syndrome and that he had the symptoms since his service during the Gulf War. See hearing transcript, Pgs. 16-17. He clarified that his shoulder, knees, and low back disabilities were also included in his claim for joint pain. Service treatment records show that the Veteran was seen in March 1987 for complaints of right knee pain for three weeks as a result of a bike accident. He was diagnosed with mild overuse syndrome. In November 1988, he had complaints of pain in his right upper quadrant. He was diagnosed with a muscle strain. In February 1990, he had complaints of right and left shoulder pains for one week. At a July 2015 VA Gulf War general medical examination, regarding the Veteran's back conditions, knee and lower leg, as well as shoulder and arm conditions, the examiner checked "No", when asked if there were any diagnosed illnesses for which no etiology was established. At a July 2015 VA back conditions examination, the Veteran was diagnosed with lumbar spine degenerative joint disease. During his August 2015 VA shoulder and arm conditions examination, the examiner noted that the Veteran was diagnosed with right shoulder partial thickness rotator cuff tear status post repair with residual degenerative joint disease. He underwent right surgery in February 2003. No diagnosis was provided for the Veteran's left shoulder. During an August 2015 VA knee and lower leg conditions examination, the examiner diagnosed with Veteran with left knee degenerative joint disease and right knee meniscus tear, status post repair. In an August 2015 VA opinion, the examiner found that the Veteran's claimed right knee condition, left knee condition, lower back condition, right shoulder condition, and joint pain conditions were diagnosable illnesses with known etiologies. The examiner reported that the Veteran did not have any undiagnosed joint pains, as all of the Veteran's joint complaints had diagnoses associated with them. Therefore, the examiner opined that they were less than likely as not due to toxin or exposure events or environmental hazards incurred while serving in the Southwest Asia. At a January 2016 VA examination, regarding the Veteran's rib injury on the left side, the examiner found that the Veteran did not now have, or ever a muscle injury diagnosis. However, during the Veteran's February 2021 hearing, he reported that the left side of his rib popped in and out and he provided a demonstration of his rib popping in and out during the hearing. The Veteran's joint pain, bilateral shoulder, bilateral knee, lower back, and left rib conditions must be remanded to obtain a VA examination that addresses whether the Veteran's conditions are qualifying chronic disabilities under the provisions of 38 U.S.C. § 1117. More specifically, an opinion must be obtained that addresses whether both the etiology and pathophysiology of the Veteran's joint pain, bilateral shoulder, bilateral knee, lower back, and left rib conditions are known or unknown such that they qualify as a MUCMI. See Stewart v. Wilkie, 30 Vet. App. 383, 392 (2018). The current medical opinions do not provide adequate explanation or rationale. Indeed, although the August 2015 VA examiner provided opinions indicating that the Veteran's right knee and bilateral shoulders were neither incurred in nor related to service, the examiner did not appear to consider that the documented in-service treatment for right knee pain was of a three week duration. The examiner also did not address the Veteran's left knee and residuals of left rib injury claims. The examiner also did not consider the Veteran's assertion that his current bilateral knee, bilateral shoulder, joint pain, and residuals of left rib injury may be related to the impact from numerous jumps in service. The Veteran also has claimed that his bilateral knee disabilities are related to his back condition and his low back was related to his bilateral knee conditions. In the September 2019 written brief presentation, the Veteran's representative noted that the Veteran's award of the Parachute Badge and the Ranger Tab showed a high operational tempo and likely microtrauma. The representative referenced several articles indicating that chronic exposure to microtrauma caused cumulative trauma disorders. Other articles discussed osteoarthritis in the knees and that general back pain was present in 55% of patients with knee osteoarthritis. Also, patients with severe low-back pain had significantly more complaints in the lower limbs (such as the knees). Finally, during his hearing the Veteran claimed that his bilateral knee, bilateral shoulder, low back, left rib, and joint pain disabilities began in service and have continued since that time. New opinions are necessary which consider the Veteran's contentions, the service treatment records, and the articles referenced by the Veteran's representative. 11. Entitlement to service connection for hypertension is remanded. The Veteran contends that his hypertension is related to elevated blood pressure readings in service. The Veteran has not previously been afforded an examination addressing hypertension; however, service treatment records appear to show elevated blood pressure readings of 122/74 in October 1988 and 120/88 in January 1989. On the April 1991 separation examination, his blood pressure reading was 144/82. A remand is warranted, so that an examination and medical nexus opinion can be obtained. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 12. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran seeks entitlement to service connection for bilateral hearing loss. The Veteran has been awarded service-connection for tinnitus as a result of his military noise exposure. During his February 20201 hearing, the Veteran reported noise exposure from airplanes, small arms fire, explosions, and demolitions. He also claimed that his hearing loss was worse than when he was last examined by VA. See hearing transcript, pgs. 30-31. On remand, an examination should be scheduled to determine if the Veteran now has a hearing loss disability for VA purposes, and if so, whether such is related to his in-service noise exposure. 13. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. At his February 2021 Board hearing, the Veteran reported that at times he had to sit in church with his back against the wall, his kids have to wake him up at the foot of the bed, and his wife could not put her arms around him above his chest if he was sleeping due to his PTSD. Similar symptoms were not reported on the Veteran's last examination in May 2015 and are suggestive that his symptoms have become worse since that time. Therefore, the Board finds that the Veteran should be afforded a new VA examination to determine the current nature and severity of his service-connected PTSD. See, Weggenmann v. Brown, 5 Vet. App. 281 (1993); see also, Snuffer v. Gober, 10 Vet. App. 400 (1997) (a Veteran is entitled to a new examination where there is evidence that the condition may have worsened since the last examination). The matters are REMANDED for the following action: 1. Obtain any outstanding records of pertinent medical treatment from VA or private health care providers, including Adventist Health in Clear Lake and VA treatment records for PTSD and irritable bowel syndrome identified in a February 2016 record from Northern California Medical associates. With the Veteran's assistance, obtain copies of any pertinent records and add them to the claims file. 2. Schedule the Veteran for a VA Gulf War General Medical Examination to assess the Veteran's claimed conditions of: (i) intestinal problems, (ii) headaches, (iii) chronic fatigue, (iv) joint pain, (v) bilateral shoulder condition, (vi) bilateral knee condition, (vii) low back condition, and (viii) a left rib condition. All appropriate medical testing should be conducted to rule out a diagnosis. The examiner must consider the evidence of record. a) The examiner should characterize each of the Veteran's claimed disabilities as belonging to one of the four disability patterns: i. an undiagnosed illness, ii. a diagnosable but medically unexplained chronic multisymptom illness (MUCMI) of unknown etiology, iii. a diagnosable chronic multisymptom illness with a partially understood etiology and pathophysiology, or iv. a disease with a clear and specific etiology. b) For each claimed disability for which there is a diagnosis, the examiner must identify: i. the diagnosis (please be sure to include or exclude Chronic Fatigue Syndrome). ii. whether the diagnosis has a conclusive, partially understood, or unknown etiology. iii. whether the disease has a conclusive, partially understood, or unknown pathophysiology. c) If the examiner determines that the claimed disability has a conclusive etiology, please state what the etiology is and provide the reasoning for the conclusion. d) If the examiner determines that the Veteran's disability pattern is either a diagnosable chronic multisymptom illness with a partially explained etiology OR a disease with a clear and specific etiology and diagnosis, then the examiner should also opine as to whether it is at least as likely as not (50 percent or greater probability) that the condition began in or is caused by service, to include as a result of his exposure to environmental hazards while serving in Southwest Asia. e) If the examiner determines that the Veteran's disability pattern for headaches and chronic fatigue is either a diagnosable chronic multisymptom illness with a partially explained etiology OR a disease with a clear and specific etiology and diagnosis and did not begin in or is caused by service, then the examiner should also opine as to whether it is at least as likely as not (50 percent or greater probability) that the condition is either i) caused or ii) aggravated by the Veteran's service-connected PTSD. See September 2019 written brief presentation and referenced articles therein. f) The examiner must consider the Veteran's lay reports of onset and continuity since service as well as the following evidence with each claimed condition: Regarding the chronic fatigue: Consider treatment records from Dr. G.M. noting the Veteran's fatigue as well as the articles referenced by the Veteran's representative in September 2019 suggesting a relationship between chronic fatigue syndrome and PTSD. Also, consider the Veteran's contention that his fatigue began in service and has continued since that time. Regarding intestinal problems: Consider treatment records from Dr. G.M. and Dr. H.M. indicating that the Veteran has had bowel issues ever since 1990. Also, consider the Veteran's contention that his intestinal problems began in service and have continued since that time. Regarding headaches: Consider the articles referenced by the Veteran's representative in September 2019 suggesting a relationship between headaches and PTSD. Also, consider the Veteran's contention that his headaches began in service and have continued since that time. Regarding joint pain, bilateral shoulder, bilateral knee, low back, and left rib conditions: Consider the Veteran's contentions that such conditions were related to his multiple jumps in service and that these conditions began in service and have continued since that time. Consider treatment records from Dr. G.M., which reflect that the Veteran had a work-related accident with his right knee around 1997 and his right shoulder around 2002. Also, consider that in September 2019, the Veteran's representative indicated that the Veteran's award of a Parachute Badge and Ranger Tab showed a high operational tempo and likely microtrauma. The representative referenced articles regarding microtrauma, cumulative trauma disorders, osteoarthritis in the knees and the relation to the back. 3. Schedule the Veteran for an additional examination conducted by appropriate health care provider to determine the nature and etiology of his claimed bilateral hearing loss disability. The claims file should be sent to, and reviewed by the VA examiner. The examiner must opine as to the following: a) Identify whether clinical findings show the Veteran has a hearing loss disability in the right and/or left ear for VA purposes. b) If so, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current hearing loss disability (i) began during active service, (ii) is related to the conceded in-service acoustic trauma, or (iii) began within one year after discharge from active service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed hypertension. The claims file should be sent to, and reviewed by the VA examiner, and the examiner should take a history from the Veteran as to the progression of his symptoms. After review of the Veteran's claims file, interview and examination of the Veteran, the examiner must opine whether it is at least as likely as not (50 percent probability or greater) that the condition is related to an in-service injury, event, or disease. In answering this question, the examiner should address the in-service blood pressure readings of 122/74 in October 1988 and 120/88 in January 1989. On the April 1991 separation examination, his blood pressure reading was 144/82. A clear rationale must be provided for all opinions expressed. 5. Schedule the Veteran for a VA psychiatric examination to determine the current severity of his PTSD. The claims file should be made available to the examiner in conjunction with the examination, and the examiner should indicate that the claims file was reviewed. All tests deemed necessary by the examiner should be performed, and all findings set forth in detail. The examiner should review the record, identify, and comment on the nature, frequency and/or severity (as appropriate), of all psychiatric symptoms found to be present, to include comment on the impact of such on the Veteran's occupational and social functioning. 6. Then, readjudicate the issues on appeal. If the benefits sought are denied, in whole or in part, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Crohe, 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.