Citation Nr: 21030491 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-29 740 DATE: May 19, 2021 ORDER Entitlement to service connection for a left hip disability to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War is denied. Entitlement to service connection for a respiratory disability to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War, is denied. Entitlement to service connection for gastrointestinal disability to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War is denied. Entitlement to service connection for sinusitis to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War, is granted. Entitlement to service connection for left hand tingling to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War, is denied. Entitlement to service connection for right foot tingling to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War, is denied. Entitlement to service connection for left foot tingling to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War is denied. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and insomnia as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War, is granted. Entitlement to service connection for headaches, to include migraines and as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War, is granted. Entitlement to service connection for chronic fatigue syndrome (CFS) to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War, is denied. REMANDED Entitlement to an evaluation in excess of 10 percent for right hip femoral acetabular impingement syndrome (claimed as pain) is remanded. Entitlement to service connection for right hand tingling to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War is remanded. FINDINGS OF FACT 1. The Veteran does not have a diagnosed left hip disability or disability due to an undiagnosed or medically unexplained chronic multi-symptom illness. 2. The Veteran does not have a respiratory disability or disability due to an undiagnosed or medically unexplained chronic multi-symptom illness. 3. The Veteran does not have a gastrointestinal disability or disability due to an undiagnosed or medically unexplained chronic multi-symptom illness. 4. The Veteran's sinusitis is related to service. 5. The Veteran does not have a left-hand disability or disability due to an undiagnosed or medically unexplained chronic multi-symptom illness. 6. The Veteran does not have a right-foot disability or disability due to an undiagnosed or medically unexplained chronic multi-symptom illness. 7. The Veteran does not have a left-foot disability or disability due to an undiagnosed or medically unexplained chronic multi-symptom illness. 8. The Veteran's insomnia and anxiety is related to service. 9. The Veteran's headaches are related to service. 10. The Veteran does not have a diagnosed CFS disability or disability due to an undiagnosed or medically unexplained chronic multi-symptom illness. CONCLUSIONS OF LAW 1. The criteria for service connection for a left hip disability are not met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for service connection for a respiratory disability are not met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for service connection for a gastrointestinal disability are not met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for service connection for a sinusitis disability are met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 5. The criteria for service connection for a left-hand disability are not met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 6. The criteria for service connection for a right-foot disability are not met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 7. The criteria for service connection for a left-foot disability are not met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 8. The criteria for service connection for a psychiatric disability are met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 9. The criteria for service connection for a headaches are met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 10. The criteria for service connection for CFS are not met. 38 U.S.C. §§ 1101, 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1992 to April 1995, April 1996, to November 1996, November 1999 to March 2000, February 2003 to April 2004, June 2007 to August 2007, September 2010 to November 2010, and from July 2011 to July 2013. Active duty includes Southwest Asia Theater service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at a July 2020 videoconference hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is associated with the claims folder. 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, 1131; 38 C.F.R. § 3.303 (a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). When determining service connection, a presumption of soundness ordinarily applies. 38 U.S.C. §§ 1111, 1132; 38 C.F.R. § 3.304 (b). Pursuant to such presumption, a Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). Only such conditions as are recorded in examination reports are to be considered as noted. The burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. 38 U.S.C. § 1153; Wagner, 370 F.3d at 1096. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. See 38 U.S.C. § 1153; 38 C.F.R. §§ 3.304, 3.306(b). A preexisting disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306 (a). Furthermore, temporary or intermittent flare-ups of a preexisting condition during service are not sufficient to be considered aggravation of the condition, unless the underlying condition, as contrasted to symptoms, worsens. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991). A Persian Gulf veteran is defined as a veteran who served on active duty in the Armed Forces in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(d)(2). Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. To constitute a "qualifying" chronic disability, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term "objective indications of chronic disability" includes both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(3). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: Fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, menstrual disorders. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(b). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): An undiagnosed illness; the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: Chronic fatigue syndrome; Fibromyalgia; Irritable bowel syndrome; Any diagnosed illness that the Secretary determines warrants a presumption of service-connection; or Any other illness that the Secretary determines meets the following criteria for a medically unexplained chronic multi-symptom illness. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(2). The term medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(2). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability shall be considered service connected for purposes of all laws of the United States. 38 U.S.C. § 1117 38 C.F.R. § 3.317(a)(4). The applicable presumptive period specified in 38 C.F.R. § 3.317(a)(1)(i) has been extended several times and it currently ends December 31, 2021. Compensation shall not be paid if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(c). 1. Entitlement to service connection for a left hip disability 2. Entitlement to service connection for a respiratory disability 3. Entitlement to service connection for gastrointestinal disability The Veteran claims a left hip disability, a respiratory disability, and a gastrointestinal (GI) disability are related to service. For the reasons discussed below, the Board finds the evidence weighs against a finding that the Veteran has a current disability related to the left hip, respiratory, and GI. Therefore, service connection is not warranted. Service treatment records (STRs) do not reflect any symptoms, diagnosis, or treatment for a GI disability. In a February 1995 medical examination, normal clinical findings were noted for the lower extremities, lungs, and chest. During a period of inactive service, a January 2002 medical examination reflected normal clinical findings for the lungs, chest, and abdomen. During service, in an August 2003 pre- deployment assessment, the Veteran reported she was in excellent health. In a December 2003 post deployment health assessment (PDHA) she denied chronic cough, swollen, stiff, or painful joints, muscle aches, difficulty breathing, diarrhea, frequent indigestion, or vomiting. In a March 2007 pre- deployment assessment, the Veteran reported she was in excellent health. In an August 2007 PDHA the Veteran reported her health has remained the same since the last examination. She denied chronic cough, swollen, stiff, or painful joints, muscle aches, difficulty breathing, diarrhea, frequent indigestion, or vomiting. In August 2011 the Veteran complained of difficulty breathing. She was given medication for dyspnea. In November 2011 STRs the Veteran complained of bilateral hip pain. An examination revealed calcification adjacent lateral acetabulum with some flattening of the head neck junction- suspicious for possible acetabular impingement morphology for the right hip. Post service, in August 2014 the Veteran complained of abdominal pain. The only symptom present was oily diarrhea. A physical examination for the abdomen was normal. It was assessed as gastroenteritis. A June 2016 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited her complaints. The examination revealed a normal left hip. The Veteran complained of right hip pain with exercise and weighted movement. There were no left hip pain complaints. The examiner determined there was no functional impact. Upon completion of a respiratory examination, the June 2016 VA examiner determined there is insufficient medical evidence of a respiratory condition as the chest x-ray, pulmonary function testing, and Pre-bronchodilator testing were all normal. The Veteran reported occasional difficulty breathing when exercising. The examiner determined there was no functional impact. Upon completion of an intestinal examination, the June 2016 VA examiner determined there is no diagnosed GI condition. At the examination the Veteran had no complaints and was found to be asymptomatic. The examiner determined there was no functional impact. In a June 2017 statement the Veteran reported he is seeing a chiropractor mainly, in pertinent part, for his right hip pain. The June 2017 private treatment records reflected a hip examination noting right hip pain only. The left hip flexion was normal. During the July 2020 Board hearing the Veteran's testimony indicated she develops a raspy type of breathing when exercising. As it relates to the digestive claim, testimony indicated she has not had a ton of issues with that lately. She does have "oily bile type of smelling stuff" that develops with certain foods, but the digestive issues are not as bad as it was in the past. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the Veteran does not have a current disability related to the left hip, respiratory, and GI. The threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement in a claim of service connection of current disability "is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim." See McClain v. Nicholson, 21 Vet. App. 319 (2007). Additionally, for the purposes of service connection, pain alone, without any underlying pathology or disease process, can constitute a current disability if there is objective evidence that the pain causes functional impairment resulting in a decrease of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018). Here, the totality of the competent evidence does not reflect that the Veteran has or has had a disability related to the left hip, respiratory, or gastrointestinal system. The June 2016 VA examination revealed a normal left hip. There were no post service treatment records identifying a left hip condition. Furthermore, the June 2016 VA examiner found there was no functional impact for either hip, and the Veteran does not allege that her left hip impairs her from working. Notably, she only complained of right hip pain associated with exercise and weighted movement. Thus, there is no objective evidence that the Veteran's left hip causes functional impairment, which results in a decrease of earning capacity. See Saunders, 886 F.3d at 1363. For the alleged respiratory condition, the June 2016 VA examination revealed a normal chest x-ray, pulmonary function testing, and Pre-bronchodilator testing. As such, the examiner found there was insufficient medical evidence of a respiratory condition. The Veteran specifically reported the breathing is an issue when exercising. It's plausible that the average person may have difficulty breathing when exercising just as the Veteran does. Furthermore, the June 2016 VA examiner found there was no functional impact as a result of the breathing complaints and the Veteran does not allege that her breathing issues impairs her from working. Notably the Veteran reported the breathing issue occurs with exercise. Thus, there is no objective evidence that the Veteran's breathing cause functional impairment, which results in a decrease of earning capacity. See Saunders, 886 F.3d at 1363. For the alleged gastrointestinal condition, during the June 2016 VA examination the Veteran had no complaints and was found to be asymptomatic. Thus, the VA examiner determined there is no diagnosed gastrointestinal condition. Furthermore, during the July 2020 Board hearing the Veteran testified that she has not had a ton of issues with gastrointestinal symptoms lately. She reported an "oily bile type of smelling stuff" that develops with certain foods only. The June 2016 VA examiner found there was no functional impact as a result of the gastrointestinal complaints and the Veteran does not allege that her gastrointestinal issues impairs her from working. Thus, there is no objective evidence that the Veteran's alleged gastrointestinal issues cause functional impairment, which results in a decrease of earning capacity. See Saunders, 886 F.3d at 1363. In cases involving Persian Gulf veterans, when the medical evidence of record (e.g., VA examination reports) does not provide a diagnosis or medical explanation for symptoms, VA is required to address whether such signs or symptoms allow for presumptive service connection under 38 C.F.R. § 3.317, to include as a medically unexplained chronic multi-symptom illness (MUCMI). See Lucas v. Wilkie, 2020 U.S. App. Vet. 548 (Vet. App. Mar. 31, 2020). In Lucas, the Court found the VA examiner's failure to explain the etiology of [Veteran's] unspecified joint pain renders the examination inadequate as to whether the veteran suffers from a MUCMI, citing to Stewart v. Wilkie, 30 Vet. App. 383, 389 (2020) (holding that under 38 C.F.R. § 3.317, "an illness is a MUCMI where either etiology or pathophysiology of the illness is inconclusive"). Lucas, 2020 U.S. App. Vet. at 548. The Board finds the holding in Lucas is inapplicable to the left hip, respiratory, and gastrointestinal disability claims. The Veteran has not provided any symptoms of a left hip condition and the evidence of record has revealed a normal left hip examination. During the June 2016 VA examination she reported right hip pain only. Although, she reported difficulty breathing, she reported that in the context of exercising and as noted above chest x-ray, pulmonary function testing, and Pre-bronchodilator testing were all normal. For the gastrointestinal claim the Veteran did not report any symptoms during the June 2016 VA examination and she testified to one specific symptom that develops with certain foods. In sum, the Board finds the Veteran is not suffering from symptoms related to the alleged claims, thus the Veteran does not have a qualifying chronic disability under 38 C.F.R. § 3.317. Furthermore, the Veteran's alleged left hip disability, respiratory disability, and a gastrointestinal condition are not otherwise related to service as there is insufficient medical evidence to support a diagnosis related to the alleged disabilities. Also, the evidence has not demonstrated any symptoms associated with the alleged disabilities results in functional impact as explained above. See Saunders, 886 F.3d at 1363. As such, the first element of service connection has not been established and the Board need go no further with its analysis. See Brammer, 3 Vet. App. at 225. Accordingly, service connection for a left hip disability, a respiratory disability, and a gastrointestinal condition is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C.§5107(b); 38 C.F.R.§ 3.102; see also Gilbert, 1 Vet. App.at 53-56. 4. Entitlement to service connection for sinusitis The Veteran claims she has sinusitis due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War. STR's reflect a May 1992 enlistment examination noting normal clinical findings for the sinuses. In a February 1995 separation medical examination normal clinical findings for the sinuses were noted. In January 2002, during a period of inactive service, a medical examination reflected normal clinical findings for the sinuses. Acute sinusitis was noted. In August 2011 she was diagnosed with sinusitis. In October 2011 treatment records noted sinusitis as a chronic problem. In June 2012 the Veteran complained of ongoing sinus for two to three days. A December 2015 report of medical history, the Veteran reported sinusitis. A December 2016 medical examination the Veteran reported two to three sinus infections a year. A June 2016 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited her complaints. She reported an onset of 2007 to 2008 which she attributed to traveling and flying to the east coast. She has 1 to 2 episodes a year which require antibiotics. The examiner found there is insufficient evidence of sinusitis of a chronic nature, as the Veteran had multiple episodes of acute sinusitis. It was noted, one to two episodes a year of sinusitis does not constitute chronic sinusitis. During the July 2020 Board hearing the Veteran's testimony indicated she has chronic or multiple sinus infections as she has infections often. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current disability is related to service. Upon review of the evidence in conjunction with applicable laws and regulations, and for the reasons explained below, the evidence is relative equipoise as to whether the Veteran's current sinusitis was incurred in or is a result of active duty service. The Board finds it is at least as likely as not that the Veteran's current sinusitis disability developed during her period of active duty service. The STRs note sinus complaints beginning in August 2011 while in service. The Veteran was subsequently diagnosed with sinusitis. The October 2011 STRs described the sinusitis as chronic. In June 2012 she complained of ongoing sinus for two to three days, and post service, she reported two to three sinus infections a year. Although the June 2016 VA examiner provided a negative opinion the rationale is internally inconsistent. The Veteran competently reported she has one to two episodes a year which require antibiotics. The examiner found there is insufficient evidence of sinusitis of a chronic nature, as the Veteran had multiple episodes of acute sinusitis. Multiple episodes of sinusitis yearly does reflect a chronic disability. The Board finds the in-service sinusitis diagnosis, coupled with the current sinusitis diagnosis, and the Veteran's competent and credible lay statements, support a grant. Accordingly, reasonable doubt is resolved in favor of the Veteran and service connection for a sinusitis disability is warranted. 5. Entitlement to service connection for left hand tingling 6. Entitlement to service connection for right foot tingling 7. Entitlement to service connection for left foot tingling The Veteran claims she suffers from left hand, right foot, and left foot numbness and tingling related to service. For the reasons discussed below the Board finds the Veteran does not have a left hand, right foot, or left foot disability. STRs do not reflect any symptoms, diagnosis, or treatment for a left hand, right foot, or left foot disability. In an August 2007 PDHA the Veteran denied numbness or tingling in both hands and feet. Post service, a June 2016 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited her complaints. The examiner indicated the Veteran only provided complaints for the right hand and left foot. No peripheral neuropathy diagnosis was found. The Veteran reported right hand numbness and tingling when driving and upon waking up. She has left plantar numbness when walking long distances or during exercise. The examiner noted medical records indicated the Veteran had a right-hand EMG where she was borderline for carpal tunnel. Physical examination for all nerves were normal. However, mild numbness for the left lower extremity was noted. Subsequently, the examiner found there is insufficient medical evidence of a right upper and left lower extremity peripheral neuropathy as all testing was normal. The physical examination to include, visualization, strength testing, reflex testing, monofilament testing and vibratory sensation, were all normal. As such the examiner determined there was no functional impact. During the July 2020 Board hearing the Veteran's testimony indicated the tingling occurs when she is walking or exercising. She indicated two months prior to the Board hearing, she had surgery for a diagnosed carpal tunnel for the right hand and now she has a trigger finger in the right hand. She indicated the right hand is worse than the left hand. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the Veteran does not have a current disability related to the left hand, right foot, and left foot. The threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. 319. Additionally, for the purposes of service connection, pain alone, without any underlying pathology or disease process, can constitute a current disability if there is objective evidence that the pain cause functional impairment resulting in a decrease of earning capacity. Saunders, 886 F.3d at 1363. Here, the totality of the competent evidence does not reflect that the Veteran has or has had a disability related to the to the left hand or either foot. The June 2016 VA examination revealed a normal physical examination to include, visualization, strength testing, reflex testing, monofilament testing and vibratory sensation. Furthermore, the June 2016 VA examiner found there was no functional impact and the Veteran does not allege that the alleged numbness and tingling in the right and left hands or feet impairs her ability to working. Notably, during the July 2020 Board hearing she testified to a tingling that occurs, mostly in the right foot, whenever she gets on the treadmill and exercise. Thus, there is no objective evidence that the Veteran's alleged numbness and tingling for the left hand, left foot, and right foot cause functional impairment, which results in a decrease of earning capacity. See Saunders, 886 F.3d at 1363. The Board the Representative's July 2020 Board hearing argument indicating appropriate consideration wasn't given under the multi-symptom illnesses as it relates to the tingling of the hands and feet claims. The Board finds the holding in Lucas is inapplicable to the left hand, left foot, and right foot. Although the Veteran has alleged numbness and tingling for each claim, the neurological testing was normal. The Board notes the June 2016 VA examination noted mild numbness for the left lower extremity but that is insufficient evidence of a multi-symptom illness. Numbness is just one symptom. Furthermore, the Veteran testified to tingling only while walking or exercising. In sum, the Board finds the Veteran is not suffering from multiple symptoms related to the alleged claims, thus the Veteran does not have a qualifying chronic disability under 38 C.F.R. § 3.317. Furthermore, the Veteran's alleged left hand, left foot, and right foot disability are not otherwise related to service as there is insufficient medical evidence to support a diagnosis related to the alleged disabilities. Also, the evidence has not demonstrated any symptoms associated with the alleged disabilities results in functional impact as explained above. See Saunders, 886 F.3d at 1363. As such, the first element of service connection has not been established and the Board need go no further with its analysis. See Brammer, 3 Vet. App. at 225. Accordingly, service connection for a left hand, left foot, and right foot disability is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C.§5107(b); 38 C.F.R.§ 3.102; see also Gilbert, 1 Vet. App.at 53-56. 8. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and insomnia The Veteran claims she has an acquired psychiatric disorder, to include anxiety and insomnia as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War. STR's for September 2012 indicated the Veteran suffered from sleep disturbances. It was noted, the Veteran is capable of falling asleep but wakes frequently, likely from anxiety stimulation of her brain. She was prescribed klonopin with a plan to consider trazodone if the klonopin was not successful. An October 2012 medical note reflected sleeping complaints. She was diagnosed with insomnia and prescribed Lunesta. It was noted she had no initial insomnia. In March 2016 VA treatment records indicated the Veteran was prescribed zolpidem and the active problems included fatigue and anxiety. A June 2016 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited her complaints. She was diagnosed with other specified anxiety disorder. She reported that she is currently prescribed zolpidem by her primary care physician. The examiner opined "based upon this evaluation, it appears that the Veteran's symptoms of Other Specified Anxiety Disorder [are] less likely than not caused by or a result of the Veteran's military service. It was reasoned, During today's evaluation, [the Veteran] endorsed the following symptoms: Veteran reported that she takes zolpidem one to two nights per week. She reported that when she takes the medication, she has no sleep difficulties. She indicated that when she does not take the medication, she typically accrues five and a half hours of sleep and experience difficulties maintaining sleep... The examiner noted, [The Veteran] was occasionally prescribed zolpidem, as well as Lunesta for brief periods of time during her military service to facilitate sleep. She denied being consistently prescribed psychotropic medication during her service. She denied psychiatric hospitalizations. Veteran denied receiving any psychotherapy or counseling. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current psychiatric disability is related to service. Upon review of the evidence in conjunction with applicable laws and regulations, and for the reasons explained below, the evidence is relative equipoise as to whether the Veteran's current psychiatric disability was incurred in or is a result of active duty service. The Board finds it is at least as likely as not that the Veteran's current psychiatric disability developed during her period of active duty service. The STRs note an October 2012 in-service insomnia diagnosis and STRs suggested the anxiety is related to the insomnia. The Board notes the Veteran is prescribed similar medication for the insomnia and anxiety. Although the June 2016 VA examiner provided a negative opinion the examiner failed to offer an opinion as to whether the Veteran's Insomnia is related to service, rendering the examination inadequate. The examiner noted the Veteran was prescribed sleep-aid medication in-service, the report failed to address how the in-service insomnia could be related to the current insomnia. Furthermore, STR's indicated the anxiety and insomnia were related and the examiner failed to reconcile those records as well. Accordingly, reasonable doubt is resolved in favor of the Veteran and service connection for a psychiatric disability, to include anxiety and insomnia is warranted. 9. Entitlement to service connection for headaches, to include migraines The Veteran claims her migraines/headaches are related to service. For the reasons discussed below, the Board finds the evidence is relative equipoise and service connection is warranted. STRs reflect a 1994 complaint of slight headaches when reading for long periods of time. In a February 1995 medical examination normal clinical findings were noted for the head and neurological system. In the concurrent report of medical history, the Veteran denied frequent or severe headaches. In a February 2000 report of medical history, the Veteran reported frequent or severe headaches. A January 2002 enlistment medical examination reflected normal clinical findings for the neurological system. In the concurrent report of medical history, the Veteran noted she has suffered from or does suffer from frequent or severe headaches. In an August 2003 pre-deployment assessment, the Veteran reported she was in excellent health. In a December 2003 post deployment health assessment (PDHA) she denied headaches. In an August 2007 PDHA the Veteran reported her health has remained the same since the last examination. She denied headaches. In August 2011 the Veteran complained of a migraine headache. She reported the headaches began 2 to 3 days prior. Migraine headaches were listed as a chronic problem. Post service, in a December 2015 report of medical history, the Veteran reported frequent or severe headaches. In a June 2017 statement the Veteran reported she is seeing a chiropractor mainly for his right hip pain, headaches, and neck pain. A June 2016 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited her complaints. She was diagnosed with migraines. The reported onset was in 2011. She reported the stabbing pain starts right behind her right eye and results in symptoms such as nausea, sensitivity to light, sensitivity to sound, and changes in vision. In July 2016 the VA examiner opined the claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. It was reasoned, the earliest report of a headache in the record appears to occur about January 1998 and the clinical description of headache between 1998 and the present appears similar. The examiner noted, "while frequent or severe headache is noted on a Report of Medical History dated 2/26/2000, during a period of active service, there is still no clinically significant change apparent between 1998 and the present." In a June 2017 statement the Veteran reported he is seeing a chiropractor mainly for his right hip pain, headaches, and neck pain. In a January 2019 private migraine follow up appointment, the Veteran reported the headaches began while she was in the middle east and she thinks its related to her military or tarry combat. During the July 2020 Board hearing the Veteran's testimony indicated the migraines began in-service while she was in the desert. Currently, she has the migraines approximately 9 times every 4 to 6 weeks. She takes medication and has to go to a dark room and lay down when she has a migraine. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current headache condition is related to service. Upon review of the evidence in conjunction with applicable laws and regulations, and for the reasons explained below, the evidence is relative equipoise as to whether the Veteran's current headache disability was incurred in or is a result of active duty service. The Board finds it is at least as likely as not that the Veteran's current headache disability developed during her period of active duty service. Specifically, the record documents reports as early as 1994. More importantly, the August 2011 STRs reflected migraine headaches as a chronic problem. The Board finds the June 2016 VA examination is inadequate. The examiner noted the earliest report of a headache is in 1998, however, that's inaccurate as the Veteran complained of a headache in service in 1994. Also, the examiner did not address all periods of service, as only the February 2000 in-service headache complaint was addressed. As noted above, the Veteran had a 1994 and August 2011 headache complaint. Notably, the August 2011 STRs had migraine headaches listed as a chronic problem and the examiner failed to address this record. Accordingly, reasonable doubt is resolved in favor of the Veteran and service connection for a headache disability is warranted. 10. Entitlement to service connection for CFS The Veteran claims she has fatigue due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War. For the reasons discussed below the Board finds the Veteran does not have a CFS disability. STRs do not reflect any symptoms, diagnosis, or treatment for a CFS disability. In February 2016 VA treatment records, a nurse noted the psychiatric history included insomnia and anxiety. Insomnia was also noted as a chronic disease. A June 2016 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited her complaints. She reported difficulty sleeping which results in fatigue. She indicated the lack of sleep causes fatigue which impacts her productivity at work. The examiner found the Veteran does not meet diagnostic criteria for CFS. It was noted the Veteran has insomnia and does not get adequate hours of sleep which causes her to be fatigued. The examiner found CFS does not result in a functional impact. During the July 2020 Board hearing the Veteran's testimony indicated "I can't stay asleep sometimes, and then, I'm just --I don't know if that's part of the issue with being fatigued." Further, she stated "I am just absolutely exhausted at work. Really hard for me to, just to try to stay awake and keep moving, and stay functioning, and focusing on what I need to at work." The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the Veteran does not have a current CFS disability. The threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. 319. Additionally, for the purposes of service connection, pain alone, without any underlying pathology or disease process, can constitute a current disability if there is objective evidence that the pain cause functional impairment resulting in a decrease of earning capacity. Saunders, 886 F.3d at 1363. Here, the totality of the competent evidence does not reflect that the Veteran has or has had a CFS disability. The June 2016 VA examiner found the Veteran does not meet diagnostic criteria for CFS. It was noted the Veteran has insomnia and does not get adequate hours of sleep which causes her to be fatigued. The Board notes as a result of this decision service connection for a psychiatric disability to include insomnia has been granted. The Board acknowledges the Veteran's testimony indicating the fatigue makes it difficult to stay awake, however, that testimony supports the notion that the Veteran's issue is not CFS, but instead is insomnia which leaves her sleepy and fatigued. The Veteran has consistently complained the difficulty to stay asleep results in fatigue. The examiner found she did not meet the criteria for CFS. To the extent that she argues the fatigue results in functional impairment, the Board finds this argument is misplaced. It's the lack of sleep that affects her employment. Notably, the VA examiner found CFS does not result in a functional impact. As the Veteran does not have a current CFS diagnosis, the Board finds the evidence supports the VA examiner finding there is no functional impact. Thus, there is no objective evidence that the Veteran's fatigue as related to CFS causes functional impairment, which results in a decrease of earning capacity. See Saunders, 886 F.3d at 1363. Furthermore, the Veteran's alleged CFS is not otherwise related to service as there is insufficient medical evidence to support a diagnosis related to the alleged disability. Also, the evidence has not demonstrated any symptoms associated with CFS results in functional impact as explained above. See Saunders, 886 F.3d at 1363. As such, the first element of service connection has not been established and the Board need go no further with its analysis. See Brammer, 3 Vet. App. at 225. The Board finds the holding in Lucas is inapplicable. Although the Veteran has alleged she suffers from fatigue, she has indicated lack of sleep results in fatigue. She has an insomnia diagnosis which the Board has found is related to service. The June 2016 examiner found the Veteran did not meet the criteria for CFS and it appears the only symptom she has is sleep related fatigue. As such, the Board finds the Veteran is not suffering from multiple symptoms related to the alleged CFS, thus the Veteran does not have a qualifying chronic disability under 38 C.F.R. § 3.317. Accordingly, service connection for CFS is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C.§5107(b); 38 C.F.R.§ 3.102; see also Gilbert, 1 Vet. App.at 53-56. REASONS FOR REMAND 1. Entitlement to an evaluation in excess of 10 percent for right hip The Veteran contends that her right hip disability warrants an increased rating. For the reasons discussed below, the Board finds a remand is warranted. A June 2016 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited her complaints. She was diagnosed with femoral acetabular impingement syndrome of the right hip. She reported dull pain with exercise and a popping sensation. The initial range of motion for flexion, extension, abduction, and adduction were 125, 30, 45, and 25, or all normal, respectively. There was no pain with weightbearing, evidence of localized tenderness, or objective evidence of crepitus. Upon completion of repetitive use testing there was no additional loss of function or range of motion. Muscle strength was normal and there was no evidence of ankylosis. There was no evidence of malunion or nonunion of femur, flail hip joint, or leg length discrepancy. Images of the right hip revealed alignment of the femoral acetabular joints within normal limits, finding suggestive of hydroxyapatite deposition adjacent to the right superior lateral acetabulum, and herniation pits noted within the proximal femurs. In a June 2017 statement the Veteran reported she is seeing a chiropractor mainly for her right hip pain, headaches, and neck pain. In June 2017 private treatment records, the Veteran was diagnosed with calcium deposits in right hip. She reported going to the gym regularly to exercise, however, the hip pain symptoms are now interfering with her ability to exercise. The evaluation indicated the Veteran's right hip condition has progressively worsened. During the July 2020 Board hearing the Veteran testified to the constant pain she experiences with her back, especially if she sits, travel in a vehicle, or walk for too long. Also, she has noticed frequent popping or clicking of the hip as it feels unstable sometimes. Specifically, she indicated, with weight, "it feels like it's going to give out." As such, due to June 2017 private treatment records reflecting evidence of a progression in the pain for the right hip and the Veteran's July 2020 testimony, the Board finds a new VA examination addressing the current right hip severity is warranted. 2. Entitlement to service connection for right hand tingling The Veteran claims she suffers from a right-hand tingling disability related to service. The Board finds a remand is warranted. In November 2011 STRs the Veteran reported a one-week history of intermittent tingling and numb sensation in the right index and long finger. In May 2012, the Veteran reported intermittent right-hand numbness. In June 2012 medical records, a period during service, a right-hand carpal tunnel assessment was noted. The Veteran was afforded a June 2016 VA examination; however, a physical examination of the right-hand was normal and no diagnosis was found. During the July 2020 Board hearing the Veteran's testimony reflects that two months prior to the Board hearing, she had surgery for diagnosed right-hand carpal tunnel syndrome and now she has a trigger finger in the right hand. However, those records are not included in the record. On remand the Veteran should be asked to identify all treatment providers that she has seen and provide authorization for VA to obtain those records. Once results are received, if there is carpal tunnel syndrome or any diagnosed disability related to the right hand, a VA etiology opinion should be rendered. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination in order to determine the current severity of her right hip condition. The examiner should interview and examine the Veteran, conduct all indicated evaluations, studies, and tests deemed necessary, and offer a rationale for any opinion expressed. The claims file should be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. Ask the Veteran to identify all treatment providers concerning right-hand symptoms, to include carpal tunnel syndrome; attempt to obtain any such records. 2. Upon receipt of the treatment records confirming the right-hand carpal tunnel surgery, schedule the Veteran for a VA examination to ascertain the current nature and etiology of a current carpal tunnel syndrome or other right-hand disability. The examiner must review the in-service treatment records related to the right hand, to include the June 2012 a right-hand carpal tunnel assessment. The examiner shall provide an opinion as to the following question: Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's right hand disability, to include carpal tunnel syndrome, is the result of an injury incurred in or as a result of her period of active duty service, to include as due to an undiagnosed Gulf War illness or exposures to environmental hazards during the Gulf War? A detailed rationale supporting the examiner's opinions should be provided. The rationale for any opinion expressed must be provided. Note that the lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. Note: The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 3. Conduct any other development deemed necessary and then readjudicate the Veteran's claim. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded for additional development or other appropriate action by the Board or United States Court of Appeals for Veterans Claims must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jackman, Associate 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.