Citation Nr: 21031399 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 16-34 431 DATE: May 21, 2021 REMANDED Entitlement to service connection for joint pain is remanded. Entitlement to service connection for muscle pain is remanded. Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for hypertension, including as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a heart disability, including as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran had active duty service from July 1989 to July 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, denied service connection for fatigue, headaches, cardiovascular signs, muscle pain, joint pain, and hypertension. The Board notes that these matters were denied in April and November 2009 rating decisions. However, the RO withdrew the Veteran's Notice of Disagreement (NOD) in a May 2010 letter and reprocessed the claims under Gulf War procedures. These matters were before the Board in December 2018, at which time they were remanded for additional evidentiary development. 1. Entitlement to service connection for joint pain is remanded; 2. Entitlement to service connection for muscle pain is remanded; 3. Entitlement to service connection for chronic fatigue syndrome is remanded; 4. Entitlement to service connection for hypertension, including as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded; 5. Entitlement to service connection for a heart disability, including as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded; 6. Entitlement to service connection for headaches is remanded. At the outset, the Board notes that the Veteran's military personnel records reveal that he enlisted in the Army National Guard in July 1993 and had various periods of active service from 1993 to 1996, including as a combat engineer in 1994 and 1995. See 08/01/2014, Military Personnel Record, pp. 4-5. Accordingly, the Board finds that a remand is necessary in order for the RO to obtain and provide information regarding the Veteran's period(s) of active duty, including active duty for training (ACDUTRA), active duty for special work, and/or IDT. Moreover, while the Veteran's VA treatment records are associated with the claims file, the associated VistA images are not. See e.g., CAPRI, 10/02/2019. Thus, the Board finds that the RO should obtain and associate his complete treatment records, including VistA images, on remand. The Veteran asserts that his joint pain, muscle pain, hypertension, fatigue, chest pain, and headaches commenced in service and have continued to the present day. He had active service during the Persian Gulf War in the Southwest Asia theatre of operations and asserts these disabilities are related to his required vaccinations and/or exposures in Kuwait, Saudi Arabia, and Iraq, including depleted uranium, burning oil wells, biological weapons, and various chemical agents. He submitted articles regarding oil well fires and chemical and biological weapons used during the Gulf War. The Veteran's treatment records reveal that he was diagnosed with hypertension in 2003. He was assessed with atypical chest pain, arrythmia, and systemic hypertension in November 2006. In January 2007, he was assessed with hypertension, headaches, foot pain, insomnia, and gout. During a July 2010 VA examination, the Veteran was assessed with headaches and generalized fatigue. A CT [computed tomography] scan and x-rays of the cervical spine revealed osteoarthritis in January and February 2019. In January 2019, x-rays of the bilateral shoulders revealed acromioclavicular joint degenerative disease. X-rays of the left foot in May 2017 revealed degenerative changes of the talonavicular joint. Pursuant to the Board's prior remand instructions, VA examinations were performed in July 2019. The examiner concluded that the Veteran's joint pain was related to his newly diagnosed degenerative joint disease and not to military service given that there was no evidence of injuries in service or evidence of chronicity of care. Moreover, the examiner indicated that his hypertension was not related to service or proximately due to or aggravated by his PTSD given that his hypertension diagnosis was made in 2008. After a review of the evidence, the Board finds that the July 2019 VA examinations are insufficient to determine the present claims. In this regard, the Veteran's hypertension was diagnosed in 2003, not in 2008 as noted by the examiner. Moreover, the examiner failed to take into account the Veteran's statements indicating that his joint pain commenced in service and continued to the present day. Lastly, there has been no opinion indicating whether his degenerative joint disease, joint pain, muscle pain, hypertension, fatigue, chest pain, and/or headaches are directly related to his required in-service vaccinations and/or exposures in the Southwest Asia theatre of operations. Accordingly, the Board finds that new VA examinations are warranted on remand in order to assess the nature and etiology of any degenerative joint disease, joint pain, muscle pain, hypertension, fatigue, chest pain, and headaches. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records from May 2020 to the present. 2. Obtain and associate with the claims file the VistA images associated with the Veteran's VA treatment records. 3. Take all necessary steps to verify the Veteran's period(s) of active duty, including active duty for special work, active duty for training (ACDUTRA), and inactive duty training (IDT) for his Army National Guard service from 1993 to December 1996. Reserve retirement point sheets are not adequate for this purpose; rather, the specific dates of the Veteran's active duty for special work, ACDUTRA, and/or IDT service are required. If this information or documentation is unavailable this fact should be documented and a formal finding of unavailability should be made with notice to the Veteran and his representative and they should be given an opportunity to respond. 4. After completion of #1, #2, and #3, schedule the Veteran for appropriate VA examinations to determine the nature and etiology of his degenerative joint disease, joint pain, muscle pain, hypertension, fatigue, chest pain, and headaches. The examiner(s) should review the claims file, including a copy of this remand, and respond to the following: A. Please state whether the symptoms such as joint pain, muscle pain, chest pain, fatigue, and/or headaches are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had such disability, when did that disability resolve? Please note that the Veteran filed his claim in January 2009 and any such disability from January 2009, or shortly prior to that date, to the present is considered a current disability. B. For any diagnosed disability, including hypertension, arthritis, and headaches, is it at least as likely as not (probability of at least 50 percent) that any diagnosed disorder had its onset during and/or is otherwise related to the Veteran's period(s) of active service, including environmental exposures (such as depleted uranium, burning oil, smoke) and/or any vaccinations or pills given to the Veteran during service? C. With regard to hypertension and/or a heart disability, if not directly related to service, is it at least as likely as not (probability of at least 50 percent) that the Veteran's hypertension and/or heart disability was caused by his service-connected PTSD? If not, is it at least as likely as not (probability of at least 50 percent) that his hypertension and/or heart disability has been aggravated (any incremental increase in disability) as a result of his service-connected PTSD? If aggravation is found, is there evidence created prior to the aggravation or between the aggravation and hypertension and/or heart disability that shows a baseline of his hypertension and/or heart disability prior to aggravation? If so, please identify. D. If any of the above symptoms (such as joint pain, muscle pain, chest pain, fatigue, and/or headaches) are not attributable to a known clinical diagnosis, then is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? E. With regard to the complaints of joint pain, chest pain, muscle pain, and/or fatigue, if there is no diagnosed disability, is it at least as likely as not (a 50 percent probability or more) that any pain reaches the level of a functional impairment of earning capacity? Describe the impairment caused. If so, is it at least as likely as not (a 50 percent probability or more) that this pain had its onset during and/or is otherwise etiologically related to the Veteran's period(s) of active service? (Continued on the next page) The examiner should provide a comprehensive rationale for each opinion provided. Specifically, the examiner should discuss the Veteran's and his wife's statements of record, including statements submitted in August 2009, September 2009, July 2010, March 2012, April 2020, and August 2020 and the correlating articles regarding oil well fires and chemical and biological weapons during the Gulf War. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. (Hurley) Merrick 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.