Citation Nr: 21032162 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 16-09 577 DATE: May 26, 2021 ORDER Entitlement to service connection for an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI), to include muscle and joint pain, and a fatigue disorder, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has had muscle and joint pain, a fatigue disorder, or other symptoms due to an undiagnosed illness or MUCMI at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for an undiagnosed illness or MUCMI are not met. 38 U.S.C. §§ 1110, 1117, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1983 to October 1987 and from December 1987 to July 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in November 2018 to afford the Veteran a new VA examination and opinion to address whether he has an undiagnosed illness or MUCMI. Specifically, the Board noted the Veteran's reports of several signs and symptoms identified to establish presumptive service connection including morning fatigue, chronic joint pain, and pain in his hands, elbow, shoulders, and knees. As a final initial matter, the Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that VA must review the entire record but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the analysis will focus specifically on what the evidence shows, or fails to show, as to the issue on appeal. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability 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) (VA has issued an interim final rule extending this date to December 31, 2021). Service records show that the Veteran had service in the Southwest Asia theatre of operations and, in turn, is considered a Persian Gulf War veteran pursuant to 38 C.F.R. § 3.317. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to service connection for an undiagnosed illness or MUCMI, to include muscle and joint pain, and a fatigue disorder The Veteran contends that he has a chronic multi-symptom illness due to his Gulf War service. See, e.g., December 2016 Statement of Accredited Representative, May 2013 Notice of Disagreement and September 2010 Statement in Support of Claim. The Board concludes that, while the Veteran reported in-service symptoms of joint and muscle pain, sleep disturbances, and fatigue, the preponderance of the evidence weighs against finding that he has a qualifying chronic disability as he is not shown to have either an undiagnosed illness or MUCMI, fibromyalgia, or CFS. 38 U.S.C. §§ 1117, 5107(b); 38 C.F.R. § 3.317. For purposes of 38 C.F.R. § 3.317, a qualifying chronic disability is either: (1) an undiagnosed illness or (2) a medically unexplained chronic multi symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. An "undiagnosed illness" is defined as a disability that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 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 (such as CFS, fibromyalgia, or irritable bowel syndrome) 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). Objective indications of "chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Here, the medical evidence does not establish the presence of any qualifying chronic disability under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. As pertinent to this appeal, the Veteran is currently service connected for disabilities of the lower back, bilateral shoulders, bilateral elbows, all digits of his bilateral hands, bilateral knees, and left foot, as well as tension headaches, bilateral lower side sciatic nerve involvement, and major depressive disorder. The Veteran's service treatment records (STRs) reflect that he endorsed symptoms of muscle aches, headaches, respiratory symptoms, gastrointestinal symptoms, exhaustion, painful joints, back pain, and sleeping difficulties. April 1987 STRs reveal that the Veteran complained of sleeping poorly and stomach aches, which the in-service care provider assessed as situational reaction and associated with job-related stress and depression. A March 1993 VA examination reported shows a diagnosis of major depressive disorder with symptoms including chronic sleep impairment and mild memory loss. An April 2015 VA treatment record notes the Veteran began using Ambien for depression-associated sleep disturbance, and a July 2018 VA treatment record shows a diagnosis of mild obstructive sleep apnea. September and October 1993 VA examination reports reflect that the Veteran complained of back and foot pain, unexplained headaches, and bilateral hand weakness. The examiners noted diagnoses lower back pain secondary to mild degenerative joint disease and probable somatoform pain disorder. March 2013 VA examination reports reflect diagnoses of contact dermatitis, moderate osteoarthritis of the knees and shoulders, moderate osteoarthritis of the right acromioclavicular joint, and major depressive disorder. The examiner noted that the Veteran's bilateral shoulder, elbow, hand/fingers, and knee pain was attributable to arthritis, and that his contact dermatitis was presumed to result from direct skin contact with an irritant on a periodic basis. The Veteran's post-service treatment records reflect occasional complaints of muscle pain associated with a viral syndrome in June 2008, and further reveal that in August 2012, the Veteran's cholesterol medication was switched from Pravastatin to Simvastatin due to muscle aches, which resolved after the Veteran stopped taking Pravastatin. March 2019 and December 2020 VA muscle examination reports also show that the Veteran did not have any cardinal signs and symptoms of muscle injury. March 2019 and December 2020 VA muscle examination reports shows normal muscle strength and no muscle atrophy, and during the December 2020 VA muscle examination, the Veteran denied muscular pain of his left leg that stemmed from service. His post-service VA and private treatment records show that the Veteran regularly denied muscle aches. See, e.g., June 2020 and May 2019 VA Treatment Records and December and October 2015 Private Medical Treatment Records. In addition, a March 2019 VA fibromyalgia examination report reflects that the Veteran denied any history of a muscle injury during service or in the year following separation. A review of the record reveals that STRs and post-service VA and private medical treatment records are silent for a diagnosis of CFS and/or fibromyalgia. The March 2013 examiner stated that the Veteran did not have any diagnosed illnesses for which no etiology was established. October and December 2020 VA examiners agreed. Although the March 2013 VA examination report shows the examiner marked that the Veteran has been diagnosed with CFS, the examiner also marked that depression was the only disorder present and did not mark that CFS was diagnosed. Additionally, the examiner noted the Veteran did not then or in the past have any findings, signs, and symptoms attributable to CFS. The March 2019 VA fibromyalgia examination report also reflects that the Veteran does not now have and has never been diagnosed with fibromyalgia and a May 2019 VA rheumatology consultation record notes that the suspicion of fibromyalgia is very low. The VA rheumatologist noted the Veteran's complaints of muscle pain were localized around the joints, with some muscle involvement in his shoulders and quadriceps, but that his bilateral shoulder pain is most consistent with a rotator cuff tendinopathy. The rheumatologist also found his lower back pain consistent with his lumbar degenerative joint disease, his bilateral elbow pain consistent with medical epicondylitis and left lateral epicondylitis, and his wrist and hand pain suggestive of overuse associated with his job as a cook. The rheumatologist concluded that a diagnosis of fibromyalgia was very unlikely. A March 2019 VA examiner opined that the Veteran's current symptoms can be attributable to the known disabilities of osteoarthritis, medial epicondylitis, degenerative disc disease, sciatica, and patellofemoral pain syndrome. The October and December 2020 examiners agreed and opined that the Veteran did not have any diagnosed illnesses for which no etiology was established and did not have any additional signs and/or symptoms that may represent and undiagnosed illness or MUCMI. Both the March 2019 and October 2020 VA examiners opined that the Veteran's back and bilateral knee disabilities were as likely as not caused by hard landings during his in-service parachutist training and a review of the Veteran's STRs shows that the Veteran injured his lower back during a parachute jump in 1984. The December 2020 VA examiner opined that the Veteran's bilateral shoulder and bilateral elbow disabilities were as likely as not due chronic overuse as a cook, which he continues to perform on a daily basis. The Veteran's DD 214 shows a military occupational specialty of food service specialist. Additionally, a December 2020 VA hand and finger examination report shows that the Veteran reported bilateral hand pain secondary to chronic overuse as a cook. With respect to gastrointestinal signs or symptoms, the Board notes that while the record reflects the Veteran has a current diagnosis of gastroesophageal reflux disease (GERD), GERD cannot be considered a MUCMI under 38 C.F.R. § 3.317. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The Board acknowledges the Veteran and his wife's contentions that he has symptoms of an undiagnosed illness due to exposure to environmental hazards during his Persian Gulf service while deployed in Saudi Arabia. See, e.g., May 2013 Notice of Disagreement, May 2013 Correspondence from the Veteran's wife, and January 1997 Statement in Support of Claim. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428 (2011), the specific issue being decided here falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran and his wife have not been shown to possess the requisite medical training, expertise, or credentials needed to render an opinion on this matter before the Board. Nothing in the record demonstrates that either he or his wife have received any special training, or acquired any medical expertise, in evaluating complex medical disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the Veteran and his wife's statements are lay evidence that do not constitute competent medical evidence and thus lack probative value. Therefore, the most probative evidence of record are the VA medical opinions of record. The Board assigns greater probative value to the medical evidence as the VA medical opinions were prepared by skilled, neutral medical professionals after examining the Veteran and reviewing his claims file. The March 2013, March 2019, October 2020 and December 2020 VA examinations are more probative in this matter as they reflect comprehensive examinations and reviews of the claims file, including the Veteran's subjective reports of muscle aches, painful joints, back pain, and sleeping difficulties, in reaching the conclusion that the Veteran does not have an undiagnosed illness or MUCMI. As such, the Board assigns more probative weight to the VA examinations of record than the Veteran's subjective reports. Additionally, the record shows that the Veteran was afforded dozens of VA exams from 1993 through 2020, including general Gulf War, back, muscle, elbow, knee, fibromyalgia, muscle, chronic fatigue syndrome, hip, shoulder, hand and finger, orthopedic, and psychiatric examinations, yet none of the examiners found an undiagnosed illness or MUCMI. In sum, the preponderance of the evidence is against finding that the Veteran has or had disability due to undiagnosed illness or MUCMI. Based on a thorough review of the evidence of record, the Board concludes that the preponderance of the evidence is against finding that the Veteran has a chronic disability manifested by symptoms of muscle and joint pain and fatigue as a result of or due to an in-service injury or disease, for which he is not already service-connected. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The appeal is denied. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Battaile 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.