Citation Nr: 21040900 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 14-24 653A DATE: July 7, 2021 ORDER New and material evidence having been received, the previously denied claim of entitlement to service connection for a right knee disability is reopened. New and material evidence having been received, the previously denied claim of entitlement to service connection for a left knee disability is reopened. New and material evidence having been received, the previously denied claim of entitlement to service connection for sinusitis is reopened. Entitlement to service connection for a low back disability is granted. Entitlement to service connection for chronic fatigue syndrome is denied. 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 sinusitis is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a right wrist disability is remanded. Entitlement to service connection for a right hand disability is remanded. Entitlement to service connection for irritable bowel syndrome is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for rheumatoid arthritis is remanded. Entitlement to service connection for fibromyalgia is remanded. FINDINGS OF FACT 1. A September 2004 rating decision, in pertinent part, denied entitlement to service connection for right and left knee disabilities and sinusitis. The appellant was informed of the RO's decision and her appellate rights in an October 2004 letter and filed a Notice of Disagreement (NOD) received in October 2004, but she withdrew her claim in written correspondence received in May 2005. 2. Evidence received since the final September 2004 rating decision denying entitlement to service connection for a right knee disability relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the claim of service connection for a right knee disability. 3. Evidence received since the final September 2004 rating decision denying entitlement to service connection for a left knee disability relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the claim of service connection for a left knee disability. 4. Evidence received since the final September 2004 rating decision denying entitlement to service connection for sinusitis relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the claim of service connection for sinusitis. 5. The evidence is in relative equipoise as to whether the appellant's current low back disability, to include lumbar strain, spinal stenosis, status post back fusion, and degenerative disc disease, was incurred in or is otherwise causally related to her active service. 6. The most probative evidence establishes that the appellant does not currently have a separate and distinct disability characterized by fatigue, to include chronic fatigue syndrome. CONCLUSIONS OF LAW 1. The September 2004 rating decision which denied entitlement to service connection for right and left knee disabilities and sinusitis is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. New and material evidence has been received with respect to the previously denied claim of entitlement to service connection for a right knee disability. 38 U.S.C. §§ 5107, 5108; 38 C.F.R. § 3.156. 3. New and material evidence has been received with respect to the previously denied claim of entitlement to service connection for a left knee disability. 38 U.S.C. §§ 5107, 5108; 38 C.F.R. § 3.156. 4. New and material evidence has been received with respect to the previously denied claim of entitlement to service connection for sinusitis. 38 U.S.C. §§ 5107, 5108; 38 C.F.R. § 3.156. 5. The criteria for entitlement to service connection for a low back disability have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for entitlement to service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.14. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the U.S. Army from April 1980 to January 1988. The appellant also had service in the Army National Guard from May 2005 to May 2006. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). An April 2012 rating decision, in pertinent part, denied entitlement to service connection for right shoulder, right elbow, right wrist, and right hand disabilities, determined that new and material evidence had not been received with respect to the previously denied claims of entitlement to service connection for right and left knee disabilities, and confirmed and continued the previous denial of entitlement to service connection for sinusitis. An October 2013 rating decision, in pertinent part, denied entitlement to service connection for migraine headaches, chronic fatigue syndrome, irritable bowel syndrome, a low back disability, fibromyalgia, and rheumatoid arthritis. The appellant was afforded a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in November 2017. A transcript is of record. In an August 2018 decision, the Board, in pertinent part, remanded the issues set forth above. Supplemental Statements of the Case (SSOC) were issued in September 2020 and January 2021. New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. See 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims such as this one, filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 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. 38 C.F.R. § 3.156. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist. Id. at 118; but see Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). A September 2004 rating decision, in pertinent part, denied entitlement to service connection for right and left knee disabilities and sinusitis. The appellant was informed of the RO's decision and her appellate rights in an October 2004 letter and filed a Notice of Disagreement (NOD) received in October 2004, but she withdrew her claim in written correspondence received in May 2005 and did not subsequently reinstate the appeal within the appeal period, nor was new and material received within one year of notification of the rating decision. As such, the September 2004 decision is final and not subject to revision on the same factual basis. Despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. The Board has therefore reviewed the entire record, with particular attention to the additional evidence received since the last final decision discussed above. 1. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for a right knee disability. 2. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for a left knee disability. Evidence received since the final September 2004 rating decision denying service connection for right and left knee disabilities includes an April 2021 clinical note from A.K., M.D., the appellant's treating physician. Dr. A.K. examined the appellant and noted that she reported that Dr. S. wanted her to have injections of both knees. Dr. A.K. also provided a medical opinion in which he stated that the appellant recently sent him forms regarding her active service and that: we noted that it is more likely than not that she suffered from the diagnoses of rheumatoid arthritis and the complications of joint problems, including her back, neck, her lower extremities[,] her elbows[,] hands[,] shoulders and pain due to fibromyalgia and sleep problems and fatigue and irritable bowel syndrome while she was serving in the Army. Dr. A.K. then stated that the had reviewed the appellant's Army service medical records and Army National Guard document DA Form 3349 and that he believes that "it is more likely than not that the conditions that's in her service medical records are the same conditions and symptoms that I treat her for now." This evidence is new, as the evidence of record at the time of the last final decision did not include any indication of a nexus between current right and left knee disabilities and the appellant's active service, described here as joint problems of the lower extremities. Further, this additional evidence, when presumed credible, relates to unestablished facts necessary to substantiate the claims and triggers VA's duty to provide a medical examination. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing the four elements to consider in determining whether a VA medical examination should be provided). Under these circumstances, the Board finds that new and material evidence has been presented. Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Accordingly, the Board finds that the appellant's previously denied claims of service connection for right and left knee disabilities are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Although the record is sufficient to warrant reopening of the claims, it is not sufficient to allow the grant of the benefits sought. Once a claim is reopened, the statutory duty to assist is triggered. See 38 U.S.C. § 5103. For reasons explained below, additional development is necessary before the Board may proceed with a decision on the merits. 3. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for sinusitis. VA medical records created and associated with the claims file since the final September 2004 rating decision include a current diagnosis of chronic sinusitis. Indeed, a May 2016 clinical note states that the appellant complained of sinus symptoms. She uses a nasal steroid but still has more than three sinus infections per year, for which she uses Abx. The VA physician diagnosed chronic sinusitis. See also June 2016 and August 2016 VA clinical notes. This evidence is new, as, when read with the appellant's previous private medical records showing numerous complaints and treatment for upper respiratory infections, emerging sinusitis, and possible underlying chronic allergic rhinitis, see 2003 clinical notes from WellStar Powder Springs Medical Center, and VA medical records including an August 2004 assessment of "acute on chronic sinusitis," it suggests that the appellant has experienced a continuity of symptomatology regarding sinusitis in the form of numerous bouts each year. The claim was denied in the September 2004 rating decision because there was no evidence of a nexus between a current sinus disability and an in-service injury or disease, as there was no chronic in-service diagnosis, simply acute episodes of associated symptoms. As such, this evidence is also material, because it indicates that there may be a nexus between the appellant's current chronic sinusitis disability and her active service. Under these circumstances, the Board finds that new and material evidence has been presented. Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Accordingly, the Board finds that the appellant's previously denied claim of service connection for sinusitis is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Although the record is sufficient to warrant reopening of the claim, it is not sufficient to allow the grant of the benefits sought. Once a claim is reopened, the statutory duty to assist is triggered. See 38 U.S.C. § 5103. For reasons explained below, additional development is necessary before the Board may proceed with a decision on the merits. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. "To establish a right to compensation for a present disability, a Veteran must show: '(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'the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Pyramiding, that is, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 4. Entitlement to service connection for a low back disability. For the following reasons, the Board finds that entitlement to service connection for a back disability, to include lumbar strain, spinal stenosis, status post back fusion, and degenerative disc disease, is warranted. The appellant contends that her current lumbar spine disability is causally related to a 1985 in-service lifting injury and that she has experienced symptoms since such time. Service treatment records reveal that the appellant sought treatment for back pain following heavy lifting in February 1985. See April 1985 treatment note. The appellant was assessed with muscle strain and placed on light duty for five days. In January 1988, the appellant declined to undergo a separation examination. Her records were reviewed and it was determined that such an examination was not required. A June 2005 DA Form 3349 from the appellant's National Guard service indicates that she was placed on profile for bilateral shoulder, back, and knee pain. The appellant complained of low back pain during an August 2008 VA clinical visit. The impression was chronic back pain. Tenderness of L4-L5 just left of midline was noted to be an old finding. Received in March 2013 was a statement from the appellant's sister detailing her recollections of the appellant telling her that she strained her back in or about 1983 or 1984. The March 2013 VA examiner did not offer a nexus opinion because there was no pathology upon which to render a diagnosis during such examination. However, the VA examiner noted that there were no post-service records regarding back pain until 2011 and that the appellant's reduced range of motion was of uncertain etiology but may be related to her BMI. Notwithstanding the fact that the appellant later was diagnosed with back disabilities, this is an inaccurate factual premise regarding the existence of back-related post-service records prior to 2011 and it does not take the appellant's lay contentions into consideration. The appellant underwent elective lumbar spine decompression for her diagnosed spinal stenosis in April 2017. Records from St. Vincent Medical Center have been associated with the claims file. An April 2019 imaging study of the lumbar spine revealed moderate to severe multilevel degenerative disc disease and spondylosis, and degenerative changes of the right sacroiliac joint. The appellant was afforded a contracted back examination in October 2019. The claims file was reviewed. Following examination of the appellant and review of the claims file, lumbosacral strain was diagnosed. The examiner offered a negative etiological opinion because "[t]here are no records that support the right wrist and back condition in the [V]eteran's records." The Board affords minimal probative weight to this October 2019 etiological opinion because it is conclusory in nature. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The appellant was afforded a contracted back examination in November 2020. The claims file was reviewed. Following examination of the appellant and review of the claims file, status post back fusion, degenerative disc disease, and bilateral lower extremity radiculopathy were diagnosed. The appellant reported that her back pain began in 1982 while stationed in Korea. She was lifting heavy boxes and started having pain after doing that all day. The examiner opined that it was less likely than not that a back disability had its onset or was otherwise causally related to the appellant's active service. The opinion was based on a January 1984 report of medical examination showing normal upper extremities, April 1985 complaints of back pain from heavy lifting but no diagnosis rendered at that time, and a normal examination of the lumbar spine in January 2013. Curiously, although the examiner noted that the appellant's active service was from April 1980 to January 1988, the examiner described the January 1984 examination as the separation examination. However, the appellant's reports of continuity of symptomatology were not considered. The Federal Circuit has held that a medical opinion which relies on the absence of contemporaneous medical evidence, and fails to consider whether lay statements present sufficient support of the etiology of the claimed disability, is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In April 2021, T.S., M.D., the appellant's treating physician, opined that the appellant's current lumbar spine disability "is related to a pre-existing conditions since the 1980s" [sic]. Dr. T.S. noted that the appellant complained of similar low back pains radiating to the right calf when she first presented to his office and that she seemed to have had complained of these symptoms since the 1980s. Further, Dr. T.S. reviewed the appellant's service treatment records, and noted that such include a note that the appellant sought treatment for low back pain radiating to the hips in April 1985. Although the opinion is inartfully worded, essentially, Dr. T.S. appears to have determined that the appellant's current lumbar spine disability is consistent with the April 1985 in-service injury, and that the appellant's reports of continuity of symptomatology are consistent with the development of the current disability. The Board finds that the April 2021 opinion of Dr. T.S. is at least as probative as the October 2019 and November 2020 negative opinions, if not more so. This places the evidence at least in equipoise on the crucial question of nexus. Andrews v. McDonough, No. 19-0352, (U.S. Vet. App. June 22, 2021). As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in her favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award entitlement to service connection for a lumbar spine disability. 5. Entitlement to service connection for chronic fatigue syndrome. The Board finds that the preponderance of the evidence is against the claim of service for chronic fatigue syndrome, or any disability or functional impairment in earning capacity characterized by fatigue. The appellant contends that she has a disability manifested by chronic fatigue. She has reported that fatigue began in service, and has continued since. She has also contended that her fatigue is due to fibromyalgia. Service treatment records are negative for pertinent complaints or observations. On her January 1984 Report of Medical History, the appellant reported that she was in good health and denied frequent trouble sleeping. of chronic fatigue. She declined a separation examination in January 1988. Her records were reviewed and it was determined that a medical examination for separation was not required. In June 2012, the appellant contended that she experienced headaches, chronic fatigue, problems going to sleep and staying asleep, and irritable bowel syndrome as the result of her fibromyalgia. A November 2012 VA clinical note states that the appellant reported continuing nonrestorative sleep which leads to fatigue and FMS (fibromyalgia syndrome). The assessment was fibromyalgia syndrome and osteoarthritis, particularly of the knees. In an April 2014 email to the appellant, N.H., M.D., a VA physician, stated that the appellant's rheumatoid arthritis was a systemic inflammatory condition and was likely the cause of her multiple joint pain and generalized fatigue. The appellant was afforded a contracted chronic fatigue syndrome examination in October 2019. The claims file was reviewed. The October 2019 contracted examiner explained that the appellant did not meet the criteria for a diagnosis of chronic fatigue syndrome, but other clinical conditions which may produce similar symptoms had not been included, namely a "poss[ible] psych[iatric] condition or sleep apnea." The Board notes that service connection is in effect for posttraumatic stress disorder (PTSD) with persistent depressive disorder and that one of the symptoms is chronic sleep impairment. See e.g. November 2018 rating decision. As such, to the extent that the appellant is already being compensated for chronic sleep impairment and resulting fatigue as part of her disability rating for PTSD with persistent depressive disorder, to assign a separate evaluation for the same symptoms would constitute impermissible pyramiding. 38 C.F.R. § 4.14. During the appellant's September 2018 VA psychiatric examination, she reported that she is easily distracted by unpleasant memories and rarely gets much sleep, so she suffers from fatigue. It was noted that chronic sleep impairment was a symptom of the appellant's PTSD with persistent depressive disorder. Chronic sleep impairment was again noted as a symptom of her PTSD with persistent depressive disorder in the January 2020 contracted psychiatric examination. The appellant reported restless sleep and when she is unable to sleep she gets "triggered" and starts to "think about the why." She also stated that pain impedes her sleep. A medical opinion from A.K., M.D., the appellant's treating physician, was rendered in April 2021. Dr. A.K. stated that the appellant recently sent him forms regarding her active service and that: we noted that it is more likely than not that she suffered from the diagnoses of rheumatoid arthritis and the complications of joint problems, including her back, neck, her lower extremities[,] her elbows[,] hands[,] shoulders and pain due to fibromyalgia and sleep problems and fatigue and irritable bowel syndrome while she was serving in the Army. Dr. A.K. then stated that the had reviewed the appellant's Army service medical records and Army National Guard document DA Form 3349 and that he believes that "it is more likely than not that the conditions that's in her service medical records are the same conditions and symptoms that I treat her for now." As best the Board can discern, Dr. A.K.'s reference to sleep problems and fatigue is meant to denote symptoms, rather than diagnoses. Moreover, this interpretation is consistent with the competent evidence of record, which is wholly negative for a diagnosis of chronic fatigue, but includes multiple notations of symptoms of fatigue and difficulty sleeping. To the extent that fatigue is a symptom of rheumatoid arthritis or fibromyalgia, as discussed in detail infra, the claims of service connection for such are being remanded. Should service connection eventually be granted for either and/or both disabilities, any attributable fatigue would be contemplated in the ratings assigned. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Indeed, the rating criteria for rheumatoid arthritis contemplates constitutional manifestations, impairment of health, and incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5002. Although the rating criteria was recently amended, effective February 7, 2021, both versions contemplate constitutional manifestations, impairment of health, and incapacitating exacerbations. The rating criteria for fibromyalgia contemplates fatigue and sleep disturbance explicitly. 38 C.F.R. § 4.71a, DC 5025. On the appellant's July 2014 substantive appeal regarding chronic fatigue syndrome, it was argued that service connection for obstructive sleep apnea was warranted and that the claim of service connection for chronic fatigue should have been sympathetically inferred as a claim for sleep apnea. Also received in July 2014 was a VA Form 21-526EZ, upon which entitlement to service connection for obstructive sleep apnea was claimed. The contention that the claim of chronic fatigue should be broadened to include sleep apnea was repeated in a VA Form 9 received in January 2015. However, this has not been argued since the appellant appointed a new representative. Indeed, during the November 2017 hearing, the appellant's current representative simply characterized the matter as a claim of service connection for chronic fatigue syndrome. Entitlement to service connection for obstructive sleep apnea was denied in a January 2015 rating decision. The appellant and her then-representative were notified of the RO's decision and appellate rights in a January 2015 letter, but did not appeal, nor was new and material evidence received within the applicable period. As such, the decision is final and not subject to revision on the same factual basis. Even assuming arguendo that the claim of service connection for chronic fatigue currently before the Board includes sleep apnea, there is no competent evidence of the presence of any sleep apnea. VA and private medical records are negative for diagnoses of sleep apnea. Notably, an April 2017 note from Cedars-Sinai Medical Group states that sleep apnea was not present. As such, expanding the claim to service connection for sleep apnea would not avail the appellant due to the lack of a current disability. The appellant is certainly competent to report symptoms regarding difficulty sleeping and fatigue because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the appellant is not competent to determine the cause of her symptoms or opine as to the presence of a separate disability of fatigue because there is no adequate foundation in the current record to establish that she has the education, training, or clinical experience to do so. Again, service connection is in effect for PTSD with persistent depressive disorder, which is manifested by, inter alia, chronic sleep impairment. The appellant's service-connected PTSD with persistent depressive disorder has been assigned a 70 percent evaluation, effective October 27, 2011, and a 100 percent evaluation, effective June 20, 2018, under DC 9411, which uses the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. The General Rating Formula for Mental Disorders contemplates occupational and social impairment, such as chronic sleep impairment. As such, to assign a separate rating for symptoms of fatigue caused by the appellant's service-connected PTSD with persistent depressive disorder would constitute impermissible pyramiding. 38 C.F.R. § 4.14. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). The Board notes that "disability" as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and that pain alone can reach the level of a functional impairment of earning capacity. Saunders v. Wilkie, 866 F.3d 1356 (2018). In this case, however, there is no indication that the appellant experiences any symptoms of fatigue which are not part and parcel of fibromyalgia, rheumatoid arthritis, or service-connected PTSD with persistent depressive disorder which cause a functional impairment in earning capacity. The appellant has not shown or specifically alleged that she has manifestations of similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). In summary, the Board finds that the most probative evidence shows that the appellant does not currently have a separate disability of fatigue and the record contains no indication that any currently claimed fatigue was incurred in active service or is otherwise causally related to active service. Indeed, there is no competent diagnosis of such. The appellant's fatigue- and sleep-related symptoms, such as chronic sleep impairment, which are causally related to service-connected PTSD with persistent depressive disorder, have been contemplated in the rating assigned for such. Again, to the extent that rheumatoid arthritis and/or fibromyalgia cause symptoms of fatigue, should service connection eventually be awarded for either or both, the ratings assigned would contemplate the resulting functional impairment. Thus, the claim of service connection for chronic fatigue must be denied at this time. See 38 C.F.R. §§ 3.102, 3.303; McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present 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... even though the disability resolves prior to the Secretary's adjudication of the claim."); Brammer, supra. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. The appellant contends that she developed bilateral knee disabilities as a result of physical activity while on active duty, specifically running regularly in 1985 at which time she began to experience aches and pains. She also contends that her right knee disability caused her to fall and injure her left knee, resulting in additional disability of the left knee. See e.g. March 2012 and May 2012 VA clinical notes. In a May 2004 statement, the appellant indicated that she went to sick call while on active duty for lower extremity pain, including aching knees, after running during physical training. Although the appellant appears to have crossed out "shin splints," the Board observes that service treatment records include notations of right leg pain in the hip and calf in June 1983, and, an assessment of shin splints in a note where the date is difficult to read but appears to be 1983. During a June 2004 VA physical therapy visit, the appellant reported that her bilateral knee pain began 18 years prior while on active duty, but it had worsened in the past two years. July 2004 VA imaging studies revealed low-grade degenerative arthritis of both knees. During a May 2012 VA rheumatology consult, the appellant reported that, while stationed at Fort Campbell in 1985, she ran five miles a day three days a week, and developed severe aches and pains in the muscles and joints and believes that her current severe aches and pains are related to such running activity. The instant visit was focused on more recent aches and pains which began in July 2011 when she fell and dislocated her left knee. While recuperating, the appellant noticed that her aches and pains were generalizing and involved more and more joints and she now has symptoms in almost all joints. The impression was fibromyalgia syndrome. Imaging studies revealed mild degenerative changes of the bilateral knees and an old avulsion fracture fragment of left femur. See e.g. March 2018 VA clinical note. As noted above, the duty to assist has been triggered by the reopening of the claims of service connection for right and left knee disabilities. On a March 2004 VA Form 21-4142, the appellant stated that Dr. M.D. told her that her knee disabilities could have been caused by military activities. It is well established that medical opinions that are inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor's opinion that "it is possible" and "it is within the realm of medical possibility" too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the words "could not rule out" was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that a physician's statement that a service-connected disorder "may or may not" have prevented medical personnel from averting a Veteran's death was not sufficient). Given the applicable standard of proof, the Board finds that such statement is insufficient to support an award of service connection. A medical opinion from A.K., M.D., the appellant's treating physician, was rendered in April 2021. Dr. A.K. stated that the appellant recently sent him forms regarding her active service and that: we noted that it is more likely than not that she suffered from the diagnoses of rheumatoid arthritis and the complications of joint problems, including her back, neck, her lower extremities[,] her elbows[,] hands[,] shoulders and pain due to fibromyalgia and sleep problems and fatigue and irritable bowel syndrome while she was serving in the Army. Dr. A.K. then stated that the had reviewed the appellant's Army service medical records and Army National Guard document DA Form 3349 and that he believes that "it is more likely than not that the conditions that's in her service medical records are the same conditions and symptoms that I treat her for now." Unfortunately, this opinion is insufficient to support an award of the benefits sought. The opinion of Dr. A.K. is conclusory and does not adequately address which disabilities Dr. A.K. is linking to active service, such as whether the joint references are meant as individual disabilities of each joint or as manifestations of rheumatoid arthritis or fibromyalgia. Additionally, the phrasing of the opinion suggests that it is based at least in part on the appellant having been diagnosed with various disabilities while on active duty, including rheumatoid arthritis, fibromyalgia, and irritable bowel syndrome, which would be an inaccurate factual premise. Further, Dr. A.K. referenced a DA Form 3349 from the appellant's National Guard service. To the extent that the opinion is based on this form, regarding being placed on profile for bilateral shoulder, back, and knee pain in June 2005, such is inadequate because it was not from a period when the appellant was on active duty, active duty for training (ACDUTRA), or inactive duty for training (INACDUTRA). As such, the appellant should be afforded appropriate examination(s) to determine the nature and etiology of her right and left knee disabilities. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Etiological opinions should be obtained regarding whether such right and left knee disabilities were incurred in or are otherwise causally related to the appellant's active service; and whether a left knee disability was caused or aggravated by a right knee disability. 3. Entitlement to service connection for sinusitis. The appellant contends that she first developed sinusitis while on active duty and that she has experienced chronic sinus infections multiple times a year since. In a statement received in May 2004, the appellant reported that she first experienced sinus symptoms while at Fort McPherson between 1985 and 1987. She was cleaning and loading printers in the data center and has been to three doctors since separation for her symptoms. Service treatment records reveal that the appellant was seen for sinus congestion in May 1985. A September 2001 private clinical note from C.H., C.N.P., states that the appellant was seen for headache and nasal congestion productive of green mucus with scratchy cough and frontal sinus pain. Over-the-counter medications have not provided much relief. The assessment was maxillary sinus cavity tenderness. L.N., C.F.N.P., assessed pharyngitis in July 2002. Private medical records from WellStar Powder Springs Medical Center include multiple 2003 clinical notes regarding complaints and treatment for upper respiratory infections, emerging sinusitis, and possible underlying chronic allergic rhinitis. VA medical records include an August 2004 assessment of "acute on chronic sinusitis." At that time, the appellant reported resolving symptoms of an upper respiratory infection with cough and sputum production. She endorsed continuing hoarseness, mucus production, and thick and clear sputum. During a November 2007 medical appointment, the appellant reported that she experienced chronic sinus problems and associated headaches approximately two to three times a year. The VA R.N. included chronic sinusitis in the assessment, and the VA M.D. assessed chronic sinus problems and recommended a CT scan of the sinuses to determine the extent of the disease. Clinical records from Lawrence Joel Army Health Clinic include complaints, treatment, and assessments of acute sinusitis in November 2005 and March 2006. A February 2012 VA primary care note states that the appellant complained of sinus drainage, slightly sore throat, and frequent cough for a few days. The assessment was pharyngitis, upper respiratory infection, persistent cough, "likely allergic vs etio?" The appellant was afforded a VA examination in April 2012. The claims file was reviewed. The appellant reported that she first experienced sinusitis in 1981 or 1982 and it has recurred at least three to four times per year, associated with season changes. She also endorsed accompanying headaches. Following examination of the appellant and review of the claims file, the VA clinician determined that, while the appellant had acute sinusitis with no residual and no functional impairment, a diagnosis of chronic sinusitis was not warranted because there was no evidence to support such a diagnosis. The VA examiner noted that the December 2007 CT scan of the sinuses was essentially normal and that April 2012 X-rays revealed suspicion of mucosal thickening of the right maxillary sinus, but the frontal ethmoid left maxillary sinus and sphenoid were essentially normal. However, since this time, the appellant has been diagnosed with chronic sinusitis. Indeed, a May 2016 clinical note states that the appellant complained of sinus symptoms. She uses a nasal steroid but still has more than three sinus infections per year, for which she uses Abx. The VA physician diagnosed chronic sinusitis. See also June 2016 and August 2016 VA clinical notes. The appellant is competent to describe what she experienced, such as sinus congestion, mucus and sputum production, cough, sore throat, sinus pain, and headaches. See Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398,403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify"). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, the Board finds that remand is warranted in order to obtain an adequate etiological opinion regarding the appellant's diagnosed chronic sinusitis. 4. Entitlement to service connection for a right shoulder disability. 5. Entitlement to service connection for a right elbow disability. 6. Entitlement to service connection for a right wrist disability. 7. Entitlement to service connection for a right hand disability. The appellant asserts that right shoulder, right elbow, right wrist, and right hand disabilities were incurred in during active service. See November 2017 hearing transcript. Notably, post-service treatment records include diagnoses of degenerative arthritis of the right shoulder, multiple joint arthralgias, rheumatoid arthritis, and fibromyalgia. See October 2011, May 2012, and November 2017 VA treatment records; see also February 2014, May 2014, September 2014, and October 2014 private treatment records. The appellant has also been diagnosed with right wrist ganglion cyst during the period on appeal. See February 2014 private treatment records. April 2014 VA medical records reveal that the appellant complained that her right wrist ganglion cyst precluded her from having full flexibility of the wrist. An October 2017 private note states that ultrasound imaging of the right wrist and hand did not support the long history of rheumatoid arthritis. In accordance with the Board's remand instructions, the appellant was afforded examinations in October 2019. Following diagnoses of, inter alia, fibromyalgia, right elbow strain, right hand strain, and right shoulder strain, and a determination that there was no right wrist pathology other than fibromyalgia upon which to render a diagnosis, the October 2019 contracted clinician offered negative etiological opinions, primarily based upon a lack of diagnoses while on active duty or within a year of discharge. In October 2020, the RO discovered this inadequacy and ordered new examinations and opinions. The appellant was afforded contracted examinations in November 2020. The claims file was reviewed. Following examination of the appellant and review of the claims file, inter alia, right shoulder arthritis and right hand arthritis were diagnosed, and it was determined that there was no right wrist or right elbow pathology other than fibromyalgia upon which to render a diagnosis. The contracted examiner offered negative etiological opinions because a January 16, 1984, separation examination revealed that upper extremities were normal and the appellant denied having painful or "trick" shoulders at the time, although the examiner also noted that the appellant served on active duty for four more years, until January 1988. The examiner also noted that service treatment records were negative for complaints or treatment regarding the right hand or right wrist. These opinions, too, are inadequate. They are based primarily on a lack of evidence of treatment in service, although the instructions provided to the contracted examiner requested that the examiner "note that the absence of evidence of treatment for a disability in the Veteran's service treatment records should not serve as the sole basis for a negative opinion." Indeed, the Federal Circuit has held that a medical opinion which relies on the absence of contemporaneous medical evidence, and fails to consider whether lay statements present sufficient support of the etiology of the claimed disability, is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Additionally, even if the appellant did not have a current right wrist or right elbow disability at the time of the November 2020 examination, she has been diagnosed with right wrist and right elbow disabilities during the period on appeal. The current disability element of the claims of service connection had been met by virtue of the disabilities of right wrist ganglion cyst and right elbow strain having been present during the period on appeal. As discussed in detail above, the April 2021 positive medical opinion of A.K., M.D., the appellant's treating physician, is inadequate to support an award of the benefits sought. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, new opinions should be obtained upon remand. 8. Entitlement to service connection for irritable bowel syndrome. The appellant contends that she developed a gastrointestinal disability, including irritable bowel syndrome, while on active duty. Alternatively, she contends that such a disability was caused or aggravated by medications taken for pain from other disabilities, or by fibromyalgia. Indeed, in June 2012, the appellant contended that she experienced headaches, chronic fatigue, problems going to sleep and staying asleep, and irritable bowel syndrome as the result of her fibromyalgia. The appellant was afforded a VA examination in March 2013. The claims file was reviewed. Following examination of the appellant and review of the claims file, the VA examiner determined that the appellant did not meet the criteria for a diagnosis of irritable bowel syndrome. However, the appellant did have constipation which was medically managed and caused no functional limitations. The examiner opined that such was not the same as, or related to, in-service complaints of abdominal cramping. These in-service events were associated with known etiologies, such as menstrual cycle pain, viral enteritis, ectopic, pregnancy, intrauterine pregnancy, etc. The VA examiner noted that the appellant had not been given a formal diagnosis for her current symptoms, which also included abdominal cramping and bloating. No specific work-up had been performed to find any potential underlying etiology for the appellant's constipation, but a physician noted that risk factors included poor diet, limited fluid intake, and sedentary lifestyle. The VA examiner also noted that the appellant was prescribed narcotic medication. However, the appellant has been diagnosed with IBS during the period on appeal. Indeed, an August 2016 VA clinical note states that the appellant was diagnosed with IBS-C (constipation). She was prescribed medication for such. As discussed in detail above, the April 2021 positive medical opinion of A.K., M.D., the appellant's treating physician, is inadequate. As the appellant has been diagnosed with IBS during the period on appeal, a new medical opinion should be obtained. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 9. Entitlement to service connection for headaches. The appellant contends that she developed a disability manifested by headaches while on active duty which has continued since. She has also contended that such are the result of her fibromyalgia. Additionally, the evidence of record indicates that headaches may be caused or aggravated by chronic sinusitis. In June 2012, the appellant contended that she experienced headaches, chronic fatigue, problems going to sleep and staying asleep, and irritable bowel syndrome as the result of her fibromyalgia. Both the October 2019 and November 2020 contracted examiners diagnosed migraine headaches and offered negative etiological opinions. The October 2019 opinion was based on a lack of service treatment records noting migraines while on active duty. The November 2020 opinion is based upon service treatment records including a January 1984 denial of headaches, December 1985 complaints of headache, chills, and head cold assessed as flu, and August 1987 complaints of stomach cramps, headache, and diarrhea, and VA medical records including a June 2007 complaint of sinus drainage and congestion with frontal headaches which occur two to three times per year. As best the Board can discern, the examiner's negative opinion is based upon a lack of nexus between the in-service complaints and a current disability, but the opinion is very unclear and does not consider the appellant's competent lay reports. The October 2019 opinion also did not consider the appellant's competent lay reports. As such, the Board finds that a new medical opinion should be obtained as to the nature and etiology of the appellant's migraine headaches. Additionally, should a positive opinion be returned for sinusitis and/or fibromyalgia, this headache opinion should also address whether a headache disability was caused or aggravated by sinusitis and/or fibromyalgia. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 10. Entitlement to service connection for rheumatoid arthritis. 11. Entitlement to service connection for fibromyalgia. The negative etiological opinions obtained from contracted clinicians in October 2019 and November 2019 regarding fibromyalgia and rheumatoid arthritis are inadequate. The October 2019 negative fibromyalgia opinion is simply based upon the disability not being diagnosed while on active duty or within one year of discharge. Although the October 2019 contracted examiner determined that a diagnosis of rheumatoid arthritis was not warranted, the appellant has been diagnosed with rheumatoid arthritis multiple times during the period on appeal. Indeed, VA medical records indicate that the appellant has a history of both seronegative and seropositive rheumatoid arthritis. See e.g. March 2018 and March 2019 clinical notes. The November 2020 negative fibromyalgia and rheumatoid arthritis opinions are based upon a lack of in-service diagnoses, the January 1984 examination report, referred to as a separation examination, despite the appellant serving four additional years thereafter, and the fact that fibromyalgia and rheumatoid arthritis were first diagnosed between 2010 and 2012, leading the examiner to conclude that neither had any bearing on service. The Federal Circuit has held that a medical opinion which relies on the absence of contemporaneous medical evidence, and fails to consider whether lay statements present sufficient support of the etiology of the claimed disability, is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). As discussed in detail above, the April 2021 positive medical opinion of A.K., M.D., the appellant's treating physician, is inadequate. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, remand is warranted to obtain new etiological opinions regarding fibromyalgia and rheumatoid arthritis. Additionally, the appellant contends that her generalized joint pain began while recovering from a left knee injury in approximately 2012. Thus, if a positive opinion regarding a left knee disability is returned, an opinion as to whether fibromyalgia and/or rheumatoid arthritis was caused or aggravated by such should also be obtained. The matters are REMANDED for the following action: 1. Schedule the appellant for an examination with an appropriate clinician to determine the nature and etiology of the appellant's right and left knee disabilities. Access to the claims file should be made available to the examiner for review. After examining the appellant and reviewing the claims file, the examiner should delineate all right and left knee disabilities. For each identified disability, the examiner should opine as to the following: Is it at least as likely as not that any current right or left knee disability had its onset in service or is otherwise related to the appellant's active service? If not, is it at least as likely as that any current right or left knee disability was proximately due to or the result of service-connected low back disability? If neither, is it at least as likely as not that a right or left knee disability was aggravated (made worse) by a low back disability? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. If a positive opinion regarding the right knee is returned, but not for the left, is it at least as likely as that a left knee disability was proximately due to or the result of a right knee disability? If a positive opinion regarding the right knee is returned, but not for the left, is it at least as likely as not that a left knee disability was aggravated (made worse) by a right knee disability? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) service treatment records regarding right leg pain in the hip and calf and an assessment of shin splints; (b) the appellant's reports of continuity of symptomatology since active service and that her left knee injury was the result of the right knee disability; (c) July 2004 imaging studies revealing bilateral low-grade degenerative arthritis; (d) the May 2012 VA rheumatology consult note; and (e) the April 2021 opinion of Dr. A.K. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that physical training including running caused or aggravated a right or left knee disability, this should be noted. Stated another way, do the appellant's reports about her activities and symptoms align with how the current right and/or left knee disabilities are known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? 2. Obtain a medical opinion from an appropriate clinician to determine the nature and etiology of the appellant's diagnosed chronic sinusitis. Access to the claims file should be made available to the examiner for review. The need for examination of the appellant is left to the discretion of the clinician rendering the requested opinion. After reviewing the record, the examiner should provide an opinion, with supporting rationale, as to the following: Is it at least as likely as not that chronic sinusitis had its onset in service or is otherwise related to the appellant's active service? In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) service treatment records which include treatment for sinus congestion; (b) the appellant's lay statements of continuity of symptomatology in the form of multiple sinus infections annually since they began on active duty; (c) the August 2004 assessment of acute on chronic sinusitis; (d) the inadequate April 2012 VA medical opinion; and (e) the May 2016 diagnosis of chronic sinusitis. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant's reported symptoms in service and thereafter represented the onset of her current sinusitis, this should be noted. Stated another way, do the appellant's reports about her symptoms in service and thereafter align with how chronic sinusitis is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? 3. Obtain medical opinions from an appropriate clinician or clinicians as to the nature and etiology of the appellant's right hand, right wrist, right elbow, and right shoulder disabilities. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that any identified right hand, right wrist, right elbow, and right shoulder disability had its onset in service or is otherwise related to the appellant's active service? In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) the current diagnoses during the period on appeal of degenerative arthritis of the right shoulder and hand, multiple joint arthralgias, rheumatoid arthritis, fibromyalgia, right elbow strain, right hand strain, right shoulder strain, and right wrist ganglion cyst; (b) the inadequate October 2019 and November 2020 medical opinions; (c) the April 2021 opinion of Dr. A.K.; and (d) the appellant's reports of in-service onset and continuity of symptomatology. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that that the appellant's reported symptoms in service and thereafter represented the onset of her current disabilities, this should be noted. Stated another way, do the appellant's reports about her in-service activities and subsequent symptoms align with how any current right hand, right wrist, right elbow, or right shoulder disability are known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? If the clinician determines that an examination of the appellant is necessary, one should be scheduled. 4. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's diagnosed IBS-C. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that diagnosed IBS had its onset in service or is otherwise related to the appellant's active service? If not, is it at least as likely as that diagnosed IBS was proximately due to or the result of fibromyalgia and/or prescribed medications for pain? If neither, is it at least as likely as not that IBS was aggravated (made worse) by fibromyalgia and/or prescribed medications for pain? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) the appellant's lay contentions regarding in-service onset; (b) the March 2013 VA examination report and opinion; (c) the August 2016 diagnosis of IBS-C; and (d) the April 2021 opinion of Dr. A.K. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant's reported symptoms in service and thereafter represented the onset of her current IBS, this should be noted. Stated another way, do the appellant's reports about her symptoms align with how IBS is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? If the clinician determines that an examination of the appellant is necessary, one should be scheduled. 5. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's headaches. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that the appellant's current headache disability had its onset in service or is otherwise related to the appellant's active service? If not, and a positive opinion regarding sinusitis and/or fibromyalgia is returned, is it at least as likely as that the appellant's current headache disability is proximately due to or the result of sinusitis and/or fibromyalgia? If neither, and a positive opinion regarding sinusitis and/or fibromyalgia is returned, is it at least as likely as not that a headache disability was aggravated (made worse) by sinusitis and/or fibromyalgia? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) the appellant's contentions that she has experienced headaches since active service and experiences headaches in conjunction with her sinusitis and fibromyalgia; and (b) the October 2019 and November 2020 examination reports. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant's reported symptoms in service and thereafter represented the onset of her current headache disability, this should be noted. Stated another way, do the appellant's reports about her symptoms align with how any current headache disability is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? If the clinician determines that an examination of the appellant is necessary, one should be scheduled. 6. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's diagnosed fibromyalgia and rheumatoid arthritis. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that fibromyalgia and/or rheumatoid arthritis had its onset in service or is otherwise related to the appellant's active service? In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) the inadequate October 2019 and November 2020 medical opinions; (b) the March 2018 and March 2019 diagnoses of both seronegative and seropositive rheumatoid arthritis; and (c) the appellant's contentions that her generalized joint pain began while recovering from a left knee injury in approximately 2012. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. (Continued on the next page) If there is any medical reason to accept or reject the proposition that the appellant's reported symptoms in service and thereafter represented the onset of her current fibromyalgia and/or rheumatoid arthritis, this should be noted. Stated another way, do the appellant's reports about her symptoms align with how fibromyalgia and/or rheumatoid arthritis is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? If the clinician determines that an examination of the appellant is necessary, one should be scheduled. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Behlen, 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.