Citation Nr: 21030610 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 18-14 227A DATE: May 19, 2021 ORDER New and material evidence having been received, entitlement to service connection for a back disability is reopened. New and material evidence having been received, entitlement to service connection for fingernail and toenail fungal condition, including as due to a qualifying chronic disability as a result of service in Southwest Asia, is reopened. New and material evidence having been received, entitlement to service connection for constant fatigue, including as due to a qualifying chronic disability as a result of service in Southwest Asia, is reopened. New and material evidence having been received, entitlement to service connection for constant bone and joint pain, including as due to a qualifying chronic disability as a result of service in Southwest Asia, is reopened. New and material evidence having been received, entitlement to service connection for a sleep disorder, including as due to a qualifying chronic disability as a result of service in Southwest Asia, is reopened. Entitlement to service connection for fibromyalgia, claimed as entitlement to service connection for constant bone and joint pain, widespread muscle pain, constant fatigue, and a sleep disorder, is granted. Entitlement to service connection for a headache disability is granted. REMANDED Entitlement to a compensable rating for bilateral heating loss is remanded. Entitlement to a compensable rating for a left heel spur is remanded. Entitlement to service connection for a back disability, including lumbar spine degenerative joint disease is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right heel spur disability is remanded. Entitlement to service connection for an acquired psychiatric disorder, however diagnosed, is remanded. Entitlement to service connection for fingernail and toenail disorder, including as due to a qualifying chronic disability, is remanded. Entitlement to service connection for a rash on the neck, including as due to a qualifying chronic disability, is remanded. Entitlement to service connection for a digestive disorder, including as due to a qualifying chronic disability, is remanded. Entitlement to service connection for teeth degeneration, including as due a qualifying chronic disability, is remanded. Entitlement to service connection for memory loss, including as due to a qualifying chronic disability, is remanded. Entitlement to service connection for lack of concentration, including as due to a qualifying chronic disability, is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded FINDINGS OF FACT 1. VA has received new evidence since a final January 2004 rating decision denied the Veteran's claims for service connection for a back disability, a fingernail and toenail fungal disability, a constant fatigue disability, a bone and joint pain disability, and a sleep disorder disability which relates to the bases for the prior denials and raises a reasonable possibility of substantiating the claims. 2. It is at least as likely as not that the Veteran's current tension headache disability was onset during his active service. 3. It is at least as likely as not that the Veteran is diagnosed with fibromyalgia which has existed for period longer than six months and has manifested to a degree of 10 percent or higher following his service in Southwest Asia. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen a previously and finally denied service connection claims for a back disability, a fingernail and toenail fungal disability, a constant fatigue disability, a bone and joint pain disability, and a sleep disorder disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for service connection for tension headaches have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 3. The criteria for service connection for fibromyalgia have been met. 38 U.S.C. §§ 1110, 1117, 1118, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1968 to August 1971 and from September 1987 to January 1995. This matter is before the Board of Veterans' Appeals (Board) on appeal of a February 2013 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). In June 2020, the Veteran testified at a hearing before the undersigned. Reopening VA may review a previously denied claim if new and material evidence is submitted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence is defined as existing evidence not previously submitted to the VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The Court of Appeals for Veterans Claims (Court) held the phrase "raises a reasonable possibility of establishing the claim" must be viewed as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The Court emphasized that 38 C.F.R. § 3.156 "does not require new and material evidence as to each previously unproven element of a claim." Id. at 120. The Court further explained the provisions of 38 C.F.R. § 3.156(a) creates a "low threshold" for finding new and material evidence that is favorable to the claimant. Id. New evidence is sufficient to reopen a claim when it would trigger VA's duty to provide an examination. See Shade, 24 Vet. App. at 118-19 (indicating new evidence raises a reasonable possibility of substantiating the claim if when considered with the old evidence it would at least trigger VA's duty to assist by providing a medical opinion). A determination of whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider an underlying claim. Jackson v. Principi, 265 F.3d1366, 1369 (Fed. Cir. 2001). Therefore, regardless of the RO's action, the Board must address the question of whether new and material evidence has been presented to reopen a claim of service connection. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). For the purposes of determining whether evidence is new and material, the Board presumes it is credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. Whether new and material evidence has been received to warrant reopening of a claim of entitlement to service connection for a back disability 2. Whether new and material evidence has been received to warrant reopening of a claim of entitlement to service connection for a fingernail and toenail fungal condition, including as due to a qualifying chronic disability as a result of service in Southwest Asia 3. Whether new and material evidence has been received to warrant reopening of a claim of entitlement to service connection for constant bone and joint pain, including as due to a qualifying chronic disability as a result of service in Southwest Asia 4. Whether new and material evidence has been received to warrant reopening of a claim of entitlement to service connection for constant fatigue, including as due to a qualifying chronic disability as a result of service in Southwest Asia 5. Whether new and material evidence has been received to warrant reopening of a claim of entitlement to service connection for a sleep disorder, including as due to a qualifying chronic disability as a result of service in Southwest Asia A January 2004 rating decision continued the denial of service connection for a back disability. This rating decision also denied service connection for a fingernail and toenail fungal disability, a constant fatigue disability, a constant bone and joint pain disability, and a sleep disorder disability. The Veteran did not file a notice of disagreement, and VA did not receive additional evidence regarding the claims within one year of notice of the decision. Thus, the January 2004 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 19.20. The January 2004 rating decision continued the denial of service connection for a back disability because there was no evidence that the Veteran's current back disability was related to his military service. In February 2009, the Veteran submitted a statement that he injured his back during his service in Vietnam and his back had never been the same since. The Veteran's report of continuing back problems since his active service is new evidence as it was not previously considered. It is material because it related to an unestablished fact necessary to substantiate the claim. Reopening of the claim of entitlement to service connection for a back disability is warranted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. The January 2004 rating decision denied service connection for a fingernail and toenail disability, a constant fatigue disability, a constant bone and joint pain disability, and a sleep disorder disability because there was no evidence the Veteran was treated for the conditions during his active service and there was no evidence the conditions were related to the Veteran's service in Southwest Asia during the Gulf War. Since the January 2004 rating decision, a July 2017 VA Gulf War general medical examination, a July 2017 VA skin conditions examination, a July 2017 VA chronic fatigue syndrome examinations, and a July 2017 VA fibromyalgia examination were provided. These examination reports are new as they were not included in the record at the time of the January 2004 rating decision. They are material as they evaluate whether finger and toenail conditions, fatigue, bone and joint pain, or sleep disorders indicate any qualifying chronic disability subject to service connection under presumptions afforded to Persian Gulf Veterans under 38 C.F.R. § 3.317. Reopening of the claims is warranted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. The evidence must show (1) the existence of a current disability, (2) an 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). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. Wood v. Derwinski, 1 Vet. App. 190 (1991); Washington v. Nicholson, 19 Vet. App. 362 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert V. Derwinski, 1 Vet. App. 49 (1991). 6. Entitlement to service connection for fibromyalgia, claimed as entitlement to service connection for constant bone and joint pain, widespread muscle pain, constant fatigue, and a sleep disorder The Veteran seeks service connection for disabilities identified as constant bone and joint pain, widespread muscle pain, constant fatigue, and a sleep disorder as due to his service in Southwest Asia. The Board has recharacterized the claims as a single claim seeking service connection for fibromyalgia to better comport with the evidence of record. Service connection may be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A "qualifying chronic disability" for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness (MUCMI), such as chronic fatigue syndrome (CFS), fibromyalgia, or IBS, that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity is measured from the earliest date on which the pertinent evidence establishes the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Signs or symptoms that may be a manifestation of an undiagnosed illness or a MUCMI include, but are not limited to the following: fatigue; signs or symptoms involving the skin; headache; muscle pain; joint pain; neurologic signs or 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; and menstrual disorders. 38 C.F.R. § 3.317(b). In the case of claims based on an undiagnosed illness or a MUCMI under 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs and/or symptoms of the claimed disability. Id. The Veteran's DD 214 form confirms his service in Southwest Asia from December 1990 to May 1991. He is a Persian Gulf Veteran. VA treatment records show, over the appeal period, the Veteran reported pain. In April 2014 and June 2016, he reported "pain all over." He was treated in a VA pain management clinic. In April 2016 a VA rheumatologist evaluated his symptoms of knee effusion and pain. The rheumatologist noted the Veteran had been diagnosed with bilateral knee osteoarthritis, bilateral carpal tunnel, idiopathic peripheral neuropathy of the lower extremities, chronic right shoulder pain, tear of the supraspinatus tendon, tendinosis with rupture of the long head of biceps, tendinosis of the subscapularis, impingement syndrome, labral cysts/tears, generalized osteoarthritis, lumbar spondylosis and lumbar radiculopathy, and a history of hepatitis C. The rheumatologist recorded the Veteran's contention that his achy joints and muscles began after Desert Storm, but he opined the Veteran's condition was not consistent with a diagnosis of fibromyalgia. The VA rheumatologist is a medical professional and he is competent to diagnose medical conditions. In July 2017, a VA Gulf War general medical examination and a VA fibromyalgia examination were provided. The examiner diagnosed fibromyalgia with symptoms of widespread musculoskeletal pain, stiffness, fatigue, sleep disturbances, paresthesias, headache, depression, anxiety, and irritable bowel symptoms. This examiner provided an addendum opinion which further identified the irritable bowel symptoms associated with fibromyalgia as "one loose [bowel movement] daily." She noted the Veteran's additional diagnoses of hepatitis C, osteoarthritis, shoulder tendonitis, carpal tunnel, ulnar neuropathy, and lumbar radiculopathy would contribute to his symptom of pain. However, she explained that the Veteran's symptoms of musculoskeletal pain, stiffness, fatigue, sleep disturbances, paresthesias, depression were "multifactorial in nature." Fibromyalgia was at least a significant contributor to these symptoms. She discussed the VA rheumatologist's comments and confirmed her diagnosis of fibromyalgia. The July 2017 VA examiner is a medical professional and she is competent to provide a diagnosis of fibromyalgia. Her diagnosis is based on a review of the Veteran's reported symptoms. Here, the evidence of a diagnosis of fibromyalgia is in relative equipoise and the benefit of the doubt principle is applicable. Thus, resolving reasonable doubt in favor of the Veteran, it is at least as likely as not that fibromyalgia is diagnosed. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert, supra. The July 2017 VA examiner confirmed the Veteran used continuous medication to control his fibromyalgia symptoms, had multiple tender points, and exhibited signs and symptoms including widespread musculoskeletal pain, stiffness, fatigue, sleep disturbances, paresthesias, depression, anxiety, and a daily loose bowel movement. These symptoms were present more than one third of the time. Accordingly, fibromyalgia has manifested to a degree of 10 percent or higher. See 38 C.F.R. § 4.71a, DC 5025. Moreover, the Veteran's condition has persisted longer than six months as indicated by his September 2009 and June 2010 statements. Fibromyalgia is a qualifying chronic disability which has manifested to a degree of 10 percent or more prior to December 31, 2021. Service connection for fibromyalgia is warranted. 38 C.F.R. § 3.317. 7. Entitlement to service connection for headaches In February 2009 and June 2010, the Veteran submitted statements claiming he experienced headaches due to a Gulf War illness. In June 2020, he testified that he experienced stress and tension related to his deployments to the Gulf War and to Somalia and, during his active service, he began to have headaches. Service treatment records associated with the claims file include an October 1994 separation examination documenting the Veteran's report of two to four headaches each week. In July 2017, a VA headache examination was provided. The examiner diagnosed a tension headache disability. She opined the current headache condition was at least as likely as not a continuation of the headaches noted in service. In support of her conclusion, she observed the description of the in-service headaches and the current headaches were similar. As the July 2017 examiner is a medical professional, she is competent to diagnose and provide an etiology opinion for the headache disability. Her opinion is supported by a sound explanation and it is entitled to great weight. See Wood, supra. The Board notes, the July 2017 VA fibromyalgia examination (discussed above) identified headaches as a fibromyalgia symptom. However, the examiner also completed a separated headache examination and diagnosed a separate headache disability. The examiner's addendum fibromyalgia opinion did not identify headaches as a symptom of fibromyalgia. Resolving reasonable doubt in favor of the Veteran, the Board finds it is at least as likely as not that a tension headache disability, separate from a fibromyalgia disability, was onset during the Veteran's active service and continued thereafter. Service connection for a headache disability is warranted. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303; see also Gilbert, supra. REASONS FOR REMAND Under the duty to assist, VA must associate all available VA treatment records with the claims file and provide reasonable efforts to ensure relevant private treatment records are obtained and associated with the claims file. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). VA's duty to assist requires VA to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with military service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.§ 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). In Stewart v. Wilkie, the Court of Appeals for Veterans Claims (Court) addressed the definition of a MUCMI under 38 C.F.R. § 3.317 (a)(2)(ii) and held a diagnosed condition does not constitute a MUCMI, as defined under 38 C.F.R. § 3.317 (a)(2)(ii), when both the etiology and the pathophysiology of the illness are at least partially understood in the context of the claimant's unique circumstances. 30 Vet. App. 383 (2018) (holding VA relied on an inadequate examination when it determined a claimant's asthma was not a MUCMI when an examiner failed to address both the etiology and pathophysiology of the condition in the context of the claimant's unique circumstances). In other words, if either the etiology or the pathophysiology of a diagnosed condition is not at least partially understood, the condition may constitute a MUCMI. 1. Entitlement to a compensable rating for bilateral hearing loss is remanded. 2. Entitlement to a rating in excess of 10 percent for a left heel spur disability is remanded. The Veteran seeks increased ratings for his service-connected hearing loss and left heel spur disabilities. He testified that he receives all medical care through the VA. The most recent VA treatment records associated with the file are from August 2017. The Veteran also testified that he sees a podiatrist every week. It is not clear whether he sees a private podiatrist. Under VA's duty to assist, the outstanding VA treatment records must be associated with the claims file and reasonable efforts must be made to assist the Veteran in obtaining any outstanding private treatment records. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). 3. Entitlement to service connection for a back disability, including lumbar spine degenerative joint disease A Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by active service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The term "noted" refers to "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304(b). A [h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). When no preexisting condition is noted upon examination for entry into service, a veteran is presumed to have been sound upon entry, and the burden then shifts to VA to rebut the presumption of soundness. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.304. To rebut the presumption of soundness under 38 U.S.C. § 1111 , there must be clear and unmistakable evidence that (1) a Veteran's disability existed prior to service, and (2) that the preexisting disability was not aggravated during service. Id. When the presumption of soundness is not rebutted, the claim must be treated as a direct service connection claim. The Veteran served on active duty during two separate time periods. Prior to the Veteran's entry into active service in December 1968 and in September 1987, entrance examinations were provided. During the December 1968 examination, no back conditions were noted. In September 1987, the Veteran marked a box indicating recurrent back pain on the entrance examination form. The examiner noted back pain on one occasion and a 1983 hospitalization for a back infection with "no trouble since." Thus, the Veteran was accepted for active service without notation of a back condition. He is presumed sound as to both periods of service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Once the presumption of soundness attaches, the burden shifts to VA to rebut the presumption by showing clear and unmistakable evidence that a back condition existed prior to service and by showing clear and unmistakable evidence that the back condition was not aggravated by service. The Veteran seeks service connection for a back disability. In February 2009 he submitted a statement describing a back injury which occurred in Vietnam in 1969. He recalled a steel plate fell onto his back while he was working to tear down bunkers. He sought treatment at the company aid station and was prescribed a week of bedrest. Service treatment records document January 1970 treatment for a pulled back incurred while the Veteran was changing a tire. In the June 2010 statement, the Veteran described receiving treatment for a back condition from Dr. R. B. from 1984 to 1987. He also reported being hospitalized at the Akron General Medical Center in 1984 due to an infected herniated disc. In 1987, he reentered active service. In June 2020, the Veteran testified that during this second period of active service he performed a great deal of physical training and he operated heavy equipment, including bulldozers, which caused intense vibrations in his back. Records of an October 1983 hospitalization at the Akron General Medical Center are included in the claims file. They document the Veteran was admitted to the hospital and treated for back pain and right leg sciatica. Degenerative disc disease of the lumbar spine and acute right sciatica were diagnosed. The October 1983 hospital records include a lumbar spine x-ray which showed degenerative changes with minor disc narrowing at L5 and sclerosis at L5. The Veteran also reported receiving treatment for his back from Dr R. B. from 1984 to 1987. In August 2010, Dr. R. B.'s office responded to a VA request for records with a note stating the records were no longer available. Although there is medical evidence of a back condition in 1983, at the time of the Veteran's entry into his second period of service in 1987, the examiner noted back pain on only one occasion and a 1983 hospitalization for a back infection with "no trouble since." Thus, the Board finds that the presumption of soundness with respect to the Veteran's back for his second period of active duty has not been rebutted as there is not clear and unmistakable evidence of a pre-existing back disability. In July 2017, a VA back conditions examination was provided. The examiner diagnosed lumbosacral strain and degenerative arthritis of the spine. She opined the back disability was less likely than not incurred in or caused by injury during the first period of active service because this injury "appeared to be self limited." The examiner did not provide any reason for describing the injury as self limiting. The opinion is not supported by a complete rationale and it is inadequate to determine whether the current back condition is causally related to an injury during the first period of active service. See Stefl, supra. The examiner also opined that the back condition diagnosed in 1983 (between periods of active service) was less likely than not aggravated beyond its normal progression during the second period of active service. However, as the Board finds that the Veteran was presumed sound with respect to his spine at the time he entered his second period of active duty, this opinion is inadequate because it is based on an inaccurate factual premise. 4. Entitlement to service connection for a right knee disability is remanded. 5. Entitlement to service connection for a left knee disability is remanded. The Veteran seeks service connection for left and right knee disabilities. In February 2009 and June 2010 statements he recounted his knee problems were onset in 1987 during basic training where he ran and marched on hard surfaces. Service treatment records include a November 1987 record of treatment for right knee pain. During an October 1994 separation examination, the Veteran reported swollen or painful joints and the examiner noted bilateral knee pain. A July 2017 VA knee conditions examination was provided to evaluate the Veteran's claim. The examiner diagnosed bilateral knee arthritis. In the medical history portion of the examination report, she noted the in-service report of right knee pain, the separation examination documentation of bilateral knee pain, and post service treatment records of left knee pain in March and April 2016. She did not describe any discussion with the Veteran about his experience of knee pain or other knee symptoms. The examiner opined the current knee arthritis was less likely than not related to the Veteran's active service because there was no evidence of continuity of care, chronicity of the condition, or onset of arthritis within one year of the Veteran's active service. Her opinion appears to be based solely on the lack of medical records documenting knee treatment following the Veteran's separation from service. This rationale is insufficient to support her opinion. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). A new examination must be provided. 6. Entitlement to service connection for a right heel spur disability is remanded. The Veteran seeks service connection for a right heel disability. Service connection for a left heel spur is established. In February 2009 and June 2010, he provided statements recounting heel problems were onset in 1987 during basic training where he ran and marched on hard surfaces. The Veteran testified that he received treatment, including injections, for his left and right heels during active service. As a layperson, the Veteran is competent to report his experience of pain and his receipt of medical treatment. A January 1990 "Over 40" examination documents a heel spur, without indicating whether the condition is in the right or right foot. Other service treatment records confirm January 1990 in-service treatment for a left heel spur. During his October 1994 exit examination, the Veteran reported foot trouble. A July 2017 VA foot conditions examination was provided to evaluate the Veteran's claim. The examiner diagnosed bilateral heel spurs. She noted the service treatment records confirmed a left heel spur but did not indicate treatment for a right heel spur. She opined the current right heel spur was less likely than not incurred in or caused by running and marching in service because right heel pain and treatment were not documented in the service treatment records. She stated the right heel spur was more likely related to years of working as a manual laborer and obesity. The examiner did not discuss the Veteran's reports of in-service right heel pain and right heel treatment. She did not provide any reason for dismissing the Veteran's contentions. Accordingly, her opinion is not based on consideration of the complete medical history. It is inadequate to evaluate the claim. Id.; see also Stefl, supra. A new examination must be provided. 7. Entitlement to service connection for an acquired psychiatric disorder, however diagnosed, is remanded. In June 2008, the Veteran filed a claim seeking service connection for posttraumatic stress disorder (PTSD). A July 2017 VA initial PTSD examination was provided to evaluate the Veteran's claim. The examiner diagnosed unspecified depressive disorder and found the Veteran did not meet the diagnostic criteria for PTSD. Thus, the Board has recharacterized the Veteran's claim as one for any acquired psychiatric disorder, however diagnosed, in accordance with Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). The July 2017 examiner stated the Veteran's "recent symptoms" did not meet the diagnostic criteria for PTSD and it is not clear that his symptoms over the entire appeal period were considered in this evaluation. He opined the unspecified depressive disorder was less likely than not due to the Veteran's active service. The examiner explained that the condition was more likely due to bereavement following the Veteran's wife's death in 2012 death and chronic pain. VA treatment records include July 2008 psychiatry consult note which documents reports of depression and a diagnosis of adjustment disorder with mixed anxiety and depressed mood. Therefore, the examiner's rationale that the depression is related to bereavement following his wife's death in 2012 is based on an incorrect factual premise as there is evidence of depressive symptoms years before the Veteran's wife's death. Moreover, the examiner indicated that the depression was also due to chronic pain but failed to address whether the chronic pain stemmed from his service-connected disabilities. Therefore, the Board finds that the etiology opinion is inadequate to evaluate the claim. See Stefl, supra. The Board also notes, the Veteran testified that he received all psychiatric treatment through the VA. VA treatment records after August 2017 are not yet associated with the claims file. The most recent VA treatment records must be obtained. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). 8. Entitlement to service connection for fingernail and toenail disorder, including as due to a qualifying chronic disability, is remanded. 9. Entitlement to service connection for a rash on the neck, including as due to a qualifying chronic disability, is remanded. The Veteran seeks service connection for a fingernail and toenail disorder. In a February 2009 statement he described his nails as deformed and split. He also reported receiving treatment for his nails in the 1990's from Dr. G. M. In June 2010, he provided a statement claiming his thumbnail and toenail condition was related to his service in Southwest Asia. In June 2020, he testified that his nail condition was onset shortly after he separated from active service in January 1995. In his June 2010 statement, the Veteran claimed he had an unexplained rash on his neck related to his service in Southwest Asia. In June 2020, the Veteran testified that he did not currently have any rash on his neck. He recalled that the rash was very bothersome, but it just went away. Signs or symptoms involving the skin may indicate an undiagnosed illness or MUCMI subject to service connection under the presumptions afforded to Persian Gulf War Veterans. 38 C.F.R. § 3.317(b). In July 2017, a VA Gulf War illness examination and a VA skin conditions examination were provided to evaluate the Veteran's claims. The VA examiner indicated rash on the neck had resolved. She did not include any further discussion of this rash or any etiology opinion for the condition. Although the Veteran may not have had a neck rash at the time of the examination, if the Veteran has had a neck rash at any point during the appeal period, this would constitute a current disability and an etiology opinion would be necessary. The examiner diagnosed tinea ungum of the toenails and thumbnails. She described the Veteran's toenails as yellowed and thickened. She observed his thumbnails were yellowed with ridging and splits down the center. She did not provide any opinion as to whether the tinea ungum was directly related to the Veteran's service. She noted that as tinea ungum was a diagnosed condition, there was no undiagnosed illness and no diagnosable but medically unexplained chronic multi symptom illness with unknown or partially explained etiology. She stated the disability pattern was not related to service in Southwest Asia. However, the examiner did not address both the etiology and pathophysiology of the diagnosed condition in the context of the claimant's unique circumstances, thus, she has not adequately addressed whether the condition could be considered a MUCMI. Therefore, the etiology opinions are inadequate to evaluate the claims. See Stefl, supra; see also Stewart, supra. In addition, it appears there may be outstanding medical records from Dr. G. M. The Veteran stated Dr. G. M. provided treatment for his nail condition in the 1990's. While some medical records from Dr. G. M. are associated with the claims file, they do not include any records of treatment of this treatment. VA must make reasonable efforts to assist the Veteran in obtaining outstanding records from Dr. G. M. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). 10. Entitlement to service connection for a digestive disorder, including as due to a qualifying chronic disability, is remanded. In February 2009, the Veteran filed a claim form and statement asserting he had a digestive disorder, with bloating and gas, related to his Persian Gulf War service. A May 2003 VA Gulf War examination diagnosed a small hiatal hernia with mild gastroesophageal reflux (GERD). VA treatment records document treatment for GERD over the current appeal period. In June 2020, the Veteran testified that his digestive problems were present "all along" and he used TUMS for most of his adult life. He recalled diverticulitis was diagnosed in 2010. He was hospitalized for this condition and surgery was performed to remove a portion of his colon. Gastrointestinal signs or symptoms may indicate an undiagnosed illness or MUCMI subject to service connection under the presumptions afforded to Persian Gulf War Veterans. 38 C.F.R. § 3.317(b). In July 2017, a VA Gulf War exam and a VA intestinal conditions examination was provided. The examiner diagnosed diverticulosis, colon polyps and GERD. She did not provide any opinion as to whether the diagnosed digestive conditions were directly related to the Veteran's active service. She noted that as diverticulosis, colon polyps and GERD were a diagnosed condition, there was no undiagnosed illness and no diagnosable but medically unexplained chronic multi symptom illness with unknown or partially explained etiology. She stated the disability patterns were not related to service in Southwest Asia. However, the examiner did not address both the etiology and pathophysiology of diverticulosis, colon polyps, and GERD in the context of the claimant's unique circumstances. The examination and etiology opinions are inadequate to evaluate the claims. See Stefl, supra; see also Stewart, supra. In addition, the records of the Veteran's 2010 hospitalization for diverticulitis are not associated with the claims file. VA treatment records after August 2017 are not associated with the claims file. Additional efforts are required to obtain these outstanding treatment records. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). 11. Entitlement to service connection for teeth degeneration, including as due a qualifying chronic disability, is remanded. In a June 2010 statement, the Veteran asserted that his teeth were degenerating due to his service in Southwest Asia. He reported having more than 20 root canals and/or crowns. In July 2017, a VA dental conditions examination was provided to evaluate the claim. The VA dentist found no diagnosed dental condition; but he observed the Veteran had a high rate of dental decay. The signs and symptoms of an undiagnosed disease or MUCMI are not limited to those listed in the regulation. Accordingly, a high rate of dental decay might be a sign or symptom of a qualifying chronic disability. 38 C.F.R. § 3.317(b). Thus, an additional opinion to evaluate whether a high rate of dental decay is a sign or symptom of such a condition must be provided. 12. Entitlement to service connection for memory loss, including as due to a qualifying chronic disability, is remanded. 13. Entitlement to service connection for lack of concentration, including as due to a qualifying chronic disability, is remanded. In February 2009 and June 2010 statements, the Veteran asserted he experiences memory loss and a lack of concentration related to his service in Southwest Asia. As a layperson, he is competent to report his experience of memory loss and lack of concentration. Neuropsychological signs or symptoms may indicate an undiagnosed disease or MUCMI which are presumed to be causally related to service in Persian Gulf Veterans. 38 C.F.R. § 3.317(b). Although a July 2017 VA Gulf War examination was provided, the examiner did not address these reported difficulties. These symptoms were not described in a July 2017 VA PTSD examination or in a July 2017 VA chronic fatigue syndrome examination. An examination to evaluate the Veteran's reported memory loss and lack of concentration must be provided. See McLendon, supra. 14. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. During the July 2017 VA PTSD examination, the Veteran reported that he was unable to work due to his health issues. The issue of TDIU has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 454-455 (2009). This matter is remanded for appropriate development. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from August 2017 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for any private treatment provider who may have records related to the appealed claims, including records from any private podiatrist, records of a hospitalization and treatment for diverticulitis, and records of fingernail and toenail treatment from Dr. G. M. Make two requests for the authorized records from any treatment provider identified, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA examination for his back disability. The examiner must review the claims file, including the medical records, the Veteran's statements and claims, and the June 2020 testimony. The examiner is asked to provide a response to the following: Is current back disability at least as likely as not related to injury or injuries incurred during the Veteran's initial period of active service, including a 1969 incident where the Veteran was stuck in the back while taking down bunkers in Vietnam or in 1970 where he pulled his back while changing a tire. The examiner is advised that the Veteran is competent to report occasions when he injured his back and observable symptoms. A complete rationale must be provided for dismissing any such report from the Veteran. The absence of contemporaneous treatment records is insufficient reason to dismiss the Veteran's reports. The examiner should answer the following question only if the examiner finds that the current back disability is less likely than not related to his first period of active service: Is the Veteran's current spine disability at least as likely as not related to his second period of service starting in 1987, including the Veteran's participation in physical training or his duties operating heavy equipment? Please note that as the Board has found the presumption of soundness has attached for the Veteran's spine with respect to the second period of active duty, the question is one of direct service connection and the examiner must ignore any suggestion of a pre-existing back disability. 4. Schedule the Veteran for a VA examination for right and left knee disabilities. The examiner must review the claims file, including the Veteran's written statements of February 2009 and June 2010 and his June 2020 testimony. The examiner is asked to provide a response to the following: Is a right knee or left knee disability at least as likely as not related to the Veteran's active service, including running and marching on hard surfaces, a November 1987 record of treatment for right knee pain, or bilateral knee pain noted on the October 1994 exit examination? The examiner is advised that the Veteran is competent to report occasions when he injured his knees and his observable symptoms. A rationale must be provided for dismissing any such report from the Veteran. The absence of contemporaneous treatment records by itself is insufficient reason to dismiss the Veteran's reports. 5. Schedule the Veteran for a VA examination for right heel disability. The examiner must review the claims file, including the Veteran's written statements of February 2009 and June 2010 and his June 2020 testimony. The examiner is asked to provide a response to the following: Is a right heel disability at least as likely as not related to the Veteran's active service, including running and marching on hard surfaces, a January 1990 "over 40" examination indicating heel spur, or foot trouble reported during an October 1994 exit examination? The examiner is advised that the Veteran is competent to report occasions when he injured his knees and his observable symptoms. A rationale must be provided for dismissing any such report from the Veteran. The absence of contemporaneous treatment records by itself is insufficient reason to dismiss the Veteran's reports 6. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of acquired psychiatric disability, to include PTSD and depressive disorder. If the Veteran is diagnosed with PTSD, the examiner must clearly identify the stressor or stressors upon which the diagnosis is made. If any other acquired psychiatric disabilities are diagnosed, to include a depressive disorder, the examiner must opine whether each disability is at least as likely as not related to an in-service injury, event, or disease. If the Veteran's depressive disorder is not found to be directly related to military service, the examiner must also opine whether it is at least as likely as not proximately due to or aggravated (worsened beyond its natural progression) by pain due to a service-connected disability. The opinion must address both causation and aggravation to be deemed adequate. The clinician must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. 7. Schedule the Veteran for a VA examination to evaluate the nature and etiology of any fingernail, toenail, and skin disability (to include a neck rash). The examiner must review the entire claims file. The examiner must identify all diagnosed fingernail, toenail, and skin disabilities present over the appeal period. For each diagnosed condition, the examiner must answer the following: Is the etiology of the diagnosed condition at least partially understood in the context of the Veteran's specific circumstances? Is the pathophysiology of the diagnosed condition at least partially understood in the context of the Veteran's circumstances? For each diagnosed fingernail, toenail, and skin disability identified where BOTH the etiology and pathophysiology are at least partially understood in the context of the Veteran's circumstances, the examiner must opine as to whether the disability is at least as likely as not (a degree of probability of 50 percent or higher) related to the Veteran's military service, to include the Veteran's reports of fingernail, toenail, or skin condition associated with his service in Southwest Asia. The Veteran is competent to report his observable symptoms and any treatment received. If the examiner rejects any report from the Veteran, a complete rationale for doing so must be provided. A complete rationale must be provided for all opinions expressed. 8. Schedule the Veteran for a VA examination to evaluate the nature and etiology of any digestive disability including diverticulitis, colon polyps, and GERD. The examiner must review the entire claims file. The examiner must identify all diagnosed digestive disabilities present over the appeal period. For each diagnosed digestive disability identified, the examiner must opine: As to whether the etiology of the diagnosed condition is at least partially understood in the context of the Veteran's circumstances. As to whether the pathophysiology of the diagnosed condition is at least partially understood in the context of the Veteran's circumstances. For each diagnosed digestive disability identified where BOTH the etiology and pathophysiology are at least partially understood in the context of the Veteran's circumstances, the examiner must opine as to whether the disability is at least as likely as not (a degree of probability of 50 percent or higher) related to the Veteran's military service, to include the Veteran's reports of digestive problems associated with his service in Southwest Asia. The Veteran is competent to report his observable symptoms and any treatment received. If the examiner rejects any report from the Veteran, a complete rationale for doing so must be provided. A complete rationale must be provided for all opinions expressed. 9. Schedule the Veteran for a VA examination to evaluate the nature and etiology of any dental disability. The examiner must review the entire claims file. The examiner must identify all diagnosed dental disabilities present over the appeal period. For each diagnosed dental disability identified, the examiner must opine: As to whether the etiology of the diagnosed condition is at least partially understood in the context of the Veteran's circumstances. As to whether the pathophysiology of the diagnosed condition is at least partially understood in the context of the Veteran's circumstances. For each diagnosed dental disability identified where BOTH the etiology and pathophysiology are at least partially understood in the context of the Veteran's circumstances, the examiner must opine as to whether the disability is at least as likely as not (a degree of probability of 50 percent or higher) related to the Veteran's military service, to include the Veteran's reports of a dental condition associated with his service in Southwest Asia. The Veteran is competent to report his observable symptoms and any treatment received. If the examiner rejects any report from the Veteran, a complete rationale for doing so must be provided. A complete rationale must be provided for all opinions expressed. 10. Schedule the Veteran for a VA examination to evaluate the nature and etiology of any loss of memory or lack of concentration disability. The examiner must review the entire claims file. The examiner must identify all diagnosed loss of memory or lack of concentration disabilities present over the appeal period. For each diagnosed loss of memory or lack of concentration disability identified, the examiner must opine: As to whether the etiology of the diagnosed condition is at least partially understood in the context of the Veteran's circumstances. As to whether the pathophysiology of the diagnosed condition is at least partially understood in the context of the Veteran's circumstances. For each diagnosed loss of memory or lack of concentration disability identified where BOTH the etiology and pathophysiology are at least partially understood in the context of the Veteran's circumstances, the examiner must opine as to whether the disability is at least as likely as not (a degree of probability of 50 percent or higher) related to the Veteran's military service, to include the Veteran's reports of loss of memory or lack of concentration condition associated with his service in Southwest Asia. The Veteran is competent to report his observable symptoms and any treatment received. If the examiner rejects any report from the Veteran, a complete rationale for doing so must be provided. If no loss of memory or lack of concentration disability is diagnosed during the appeal period, the examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a loss of memory or lack of concentration disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) If the Veteran's objective indications of a loss of memory or lack of concentration cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. The examiner is advised that the Veteran is competent to report his experience of observable symptomatology. If the examiner dismisses any reported observable symptomatology, a complete rationale for doing so must be provided. The absence of contemporaneous medical records, without additional rationale, is insufficient to support dismissing the Veteran's lay repots of observable symptomatology A complete rationale must be provided for all opinions expressed. 11. Develop and adjudicate the issue of entitlement to a TDIU. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.