Citation Nr: 21041628 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 15-27 266A DATE: July 9, 2021 ORDER Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected fibromyalgia is denied. Entitlement to service connection for a back disorder, to include as secondary to service-connected fibromyalgia, is denied. Entitlement to service connection for carpal tunnel syndrome, to include as secondary to service-connected fibromyalgia, is denied. Entitlement to service connection for vertigo, to include as secondary to service-connected fibromyalgia, is denied. Entitlement to service connection for hypothyroidism, to include as secondary to service-connected fibromyalgia is denied. Entitlement to service connection for atrial fibrillation, to include as secondary to service-connected fibromyalgia is denied. Entitlement to service connection for coronary artery disease, to include as secondary to service-connected fibromyalgia is denied. REMANDED Entitlement to service connection for a right knee disability, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for gout, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for a left hip disability, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for a right hip disability, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for a right elbow disability, to include as secondary to service-connected fibromyalgia, is remanded. FINDINGS OF FACT 1. The Veteran's cervical spine condition neither began during or was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. 2. The Veteran's back condition neither began during or was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. 3. The Veteran's carpal tunnel syndrome neither began during or was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. 4. The Veteran's vertigo neither began during or was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. 5. The Veteran's hypothyroidism neither began during or was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. 6. The Veteran's atrial fibrillation neither began during or was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. 7. The Veteran's coronary artery disease neither began during or was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected fibromyalgia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for a back disorder, to include as secondary to service-connected fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for carpal tunnel syndrome, to include as secondary to service-connected fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to service connection for vertigo, to include as secondary to service-connected fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for entitlement to service connection for hypothyroidism, to include as secondary to service-connected fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for entitlement to service connection for atrial fibrillation, to include as secondary to service-connected fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for entitlement to service connection for coronary artery disease, to include as secondary to service-connected fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1973 to April 1975. The issues of entitlement to service connection for a right knee disorder, back disorder, cervical spine disorder, carpal tunnel syndrome, and sleep apnea come before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in February 2002 and April 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in April 2019. The issues of entitlement to service connection for gout, vertigo, hypothyroidism, atrial fibrillation, coronary artery disease, left and right shoulder disabilities, left and right hip disabilities, and a right elbow disability come before the Board on appeal from a February 2018 rating decision. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. 1. & 2. Entitlement to service connection for cervical and thoracolumbar spine disorders, to include as secondary to service-connected fibromyalgia; and, The Veteran contends that his cervical (neck) and thoracolumbar (back) spine conditions were caused or aggravated by his service-connected fibromyalgia disability. In December 2001, the Veteran was afforded a VA spine examination, at which time the examiner noted an assessment of cervical multilevel degenerative joint disease (DJD) with C5-6-disc protrusion, lumbar degenerative disk disease (DDD), and thoracic spine DJD. In April 2005, the Veteran underwent another VA spine examination. At such time, the examiner noted that the Veteran had a diagnosis of chronic trunk and thoracolumbar pain secondary to myofascial pain syndrome, which was as likely as not a result of the crush injury sustained in 1973. However, the examiner provided no rationale and recommended that the Veteran be evaluated by a rheumatologist for a myofascial pain syndrome or a fibromyalgia-like syndrome. In an April 2008 private opinion, Dr. W.L. noted that the Veteran has a history of fibromyalgia, carpal tunnel syndrome, and degenerative joint diseases. Dr. W.L. opined that after reviewing the Veteran's medical records and histories, the Veteran's current medical conditions "clearly began in service as resulted from the injury he sustained on 1973". In another private medical opinion from May 2008, Dr. B.K. noted that the Veteran's medical records document extensive cervical and thoracolumbar degenerative joint disease. Dr. B.K. further stated that the medical records also show that "the treating physicians at the VA that his current conditions are clearly began in the service, as the result caused by his injuries in while in the service." Dr. B.K. stated that he agreed that the Veteran's condition "clearly as the result caused by his injury while in service in 1973." In February 2012, an opinion was obtained to determine if the Veteran's current back and neck disorders were related to his military service and/or his service-connected fibromyalgia. The examiner opined that it was less likely than not that the Veteran's current cervical spine condition was related to his in-service injury or his service-connected fibromyalgia. The examiner explained that the clinical description of the Veteran's in-service injury only noted rib discomfort and there was a lack of persistent symptoms after such injury during service. The examiner also reasoned that the Veteran's medical records indicated that he had back injuries in 1980 and 1994. The examiner concluded that there was insufficient evidence to link the Veteran's in-service injury to his current condition of degenerative joint and disc disease of the cervical or lumbar spine. Furthermore, the examiner also found that the Veteran's service-connected fibromyalgia, which was a functional condition characterized by soft tissue pain in the absence of systemic inflammation or bone/joint destruction, did not result in his current spinal degenerative joint or disc disease as these conditions were etiologically and clinically distinct. In a July 2013 statement, the Veteran stated that his cervical spine and back conditions were aggravated by his service-connected disabilities. In an August 2015 statement, the Veteran stated that he had always associated his conditions to the injury he sustained during service. The Veteran further stated that his treating physicians at the VAMC have indicated in his records that his disabilities are linked to his service-connected disabilities. In September 2017, the Veteran submitted articles noting a potential relationship between fibromyalgia and cervical stenosis. The Veteran had another examination for his cervical and thoracolumbar spine conditions in February 2020. The examiner was unable to establish a baseline level of severity for the Veteran's cervical spine condition as the medical evidence was considered insufficient for such a determination. The examiner opined that it was less likely than not that the Veteran's cervical spine and back conditions were caused or aggravated by his service-connected fibromyalgia. The examiner stated that the natural history of the Veteran's non-service-connected musculoskeletal disorders is for them to worsen with time due to repetitive trauma leading to worsening degeneration of cartilage and bone. The examiner noted that there is no plausible pathophysiologic etiology to provide an aggravation nexus between the Veteran's service-connected fibromyalgia, which is a functional disorder characterized by pain, fatigue, psychiatric symptoms and somatic symptoms, and the Veteran's degenerative joint disorders which are characterized by tissue damage, joint destruction, and sometimes inflammation. Upon review of the record, the Board finds that service connection for the cervical spine and thoracolumbar back conditions is not warranted. The Board finds the February 2012 and February 2020 examiners' medical opinions to be highly probative because they provided an adequate rationale based on the relevant evidence of record. The examiners indicated that the Veteran's service treatment records do not suggest that his neck or back conditions had onset in service, specifically noting that the medical evidence at the time only noted rib discomfort and there was a lack of persistent symptoms after such injury during service. Furthermore, the examiners noted that there is no medical evidence that the Veteran's fibromyalgia could cause or aggravate his neck or back conditions, noting that the conditions are distinct. In contrast, the Board does not find the private medical opinions from Dr. W.L. and Dr. B.K. and the April 2005 examiner's opinion to carry significant probative weight. The private medical opinions from Dr. W.L. and Dr. B.K. and the April 2005 examiner's opinion did not provide an adequate rationale in support of their conclusions. As a result, the probative medical evidence of record is against finding that the Veteran's cervical and thoracolumbar spine conditions were caused by his active duty service or was caused or aggravated by his service-connected disabilities. To the extent that the Veteran believes that his conditions are linked to his active duty service or was caused or aggravated by his service connected disabilities, principally his fibromyalgia, the Board notes that he is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007). However, the question regarding the etiology of his spine conditions is an issue of causation of a medical condition, which requires a medical determination outside the realm of common knowledge of any lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, his lay statements alone are not sufficient to establish the required nexus in this case. The Board must then rely on the available and probative medical evidence, which have found no nexus between the Veteran's cervical and thoracolumbar spine conditions and his military service and that it is less likely than not that they were caused or aggravated by his service-connected disabilities. In sum, the evidence preponderates against the claim for service connection for cervical spine and back disabilities. There is no reasonable doubt to be resolved, and the claim of entitlement to service connection, to include as secondary to service-connected fibromyalgia, must be denied. 38 C.F.R. §§ 3.303, 3.310. 3. Entitlement to service connection for carpal tunnel syndrome, to include as secondary to service-connected fibromyalgia The Veteran contends that his carpal tunnel syndrome was caused or aggravated by his service-connected fibromyalgia disability. In a December 2005 examination, the examiner noted that the Veteran had an EMG that showed that he had carpal tunnel syndrome in the past but apparently refused to have the needle examination for nerve conduction study which would have been useful for diagnosis of whether he had a nerve root compressions anywhere. In an April 2008 private opinion, Dr. W.L. noted that the Veteran has a history of fibromyalgia, carpal tunnel syndrome, and degenerative joint diseases. Dr. W.L. opined that after reviewing the Veteran's medical records and histories, the Veteran's current medical conditions "clearly began in service as resulted from the injury he sustained on 1973". In another private medical opinion from May 2008, Dr. B.K. noted that the Veteran has carpal tunnel syndrome. Dr. B.K. further stated that the medical records also show that the treating physicians at the VA state that his current conditions clearly began in the service, as the result caused by his injuries in while in the service. Dr. B.K. stated that he agreed that the Veteran's condition is shown "clearly as the result caused by his injury while in service in 1973." In a July 2013 statement, the Veteran stated that his carpal tunnel syndrome was aggravated by his service-connected disabilities. In an August 2015 statement, the Veteran stated that he had always associated his condition to the injury he sustained during service. The Veteran further stated that his treating physicians at the VAMC have indicated in his records that his disabilities are linked to his service-connected disabilities. Additionally, the Veteran stated that he has had hand surgery and not has carpal tunnel syndrome. The Veteran had an examination for his carpal tunnel syndrome in February 2020. The examiner opined that it was less likely than not that the Veteran's carpal tunnel syndrome was incurred in or caused by his active service. The examiner noted that the Veteran reported that in 1973 he got caught between two gangplanks, and that his whole body was pinned, and he was sent to sick bay. The Veteran further reported that his hands and wrist were crushed together causing pain and numbness in his wrists and hands. Furthermore, the Veteran stated that he did not mention it until after he got out of the Navy. The examiner noted that the Veteran's service treatment records note that the Veteran was pinned on sides by the gangplank on the bow in July 1973. It was reported that he was not in any apparent distress and had some discomfort in both upper portions of his rib cage, and that his arms were also down to his sides when pinned, but no x-rays were ordered of the arms, wrist, or hand. The examiner noted that the service treatment records do not mention any complaints of pain, numbness, or dysfunction in the Veteran's wrists or hands. Furthermore, the examiner noted that there was no evidence that the Veteran complained of any wrist or hand pain or numbness while on active duty or within a year of his discharge from service. Finally, the examiner noted that the Veteran was not diagnosed with carpal tunnel syndrome until 28 years after his discharge from service. Additionally, the examiner opined that it was less likely than not that the Veteran's carpal tunnel syndrome was caused or aggravated by his service-connected disabilities, to include fibromyalgia. The examiner stated that fibromyalgia is a functional disorder of unknown etiology, characterized by pain, fatigue, psychiatric symptoms and somatic symptoms in the absence of demonstrable inflammation or tissue damage. Additionally, the examiner noted that to be diagnosed with fibromyalgia, you must have had at least 3 months of widespread pain and pain and tenderness in at least 11 of 18 areas. The examiner indicated that trigger point areas of pain do not include the wrists or hands. The examiner further indicated that the pathology of carpal tunnel syndrome is increased pressure within the carpal tunnel and the median nerve segment leading to ischemia and scarring of the nerve. The examiner stated that fibromyalgia does not cause or contribute to median nerve compression, ischemia and scarring of the nerve. Upon review of the record, the Board finds that service connection for carpal tunnel syndrome is not warranted. The Board finds the February 2020 examiner's medical opinion to be highly probative because the examiner provided an adequate rationale based on the relevant evidence of record. The examiner indicated that the Veteran's service treatment records do not suggest that his carpal tunnel syndrome had onset in service, specifically noting that the medical evidence at the time did not mention any complaints of pain, numbness, or dysfunction in the Veteran's wrists or hands, and that the Veteran was not diagnosed until 28 years after separation from service. Furthermore, the examiner noted that there is no medical evidence that the Veteran's fibromyalgia could cause or aggravate his carpal tunnel syndrome, noting that the conditions are distinct. In contrast, the Board does not find the private medical opinions from Dr. W.L. and Dr. B.K. to carry significant probative weight. The private medical opinions from Dr. W.L. and Dr. B.K. did not provide an adequate rationale in support of their conclusions. As a result, the probative medical evidence of record is against finding that the Veteran's carpal tunnel syndrome was caused by his active duty service or was caused or aggravated by his service-connected disabilities. To the extent that the Veteran believes that his carpal tunnel syndrome is linked to his active duty service or was caused or aggravated by his service connected disabilities, principally his fibromyalgia, the Board notes that he is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. However, the question regarding the etiology of his carpal tunnel syndrome is an issue of causation of a medical condition, which requires a medical determination outside the realm of common knowledge of any lay person. Therefore, his lay statements alone are not sufficient to establish the required nexus in this case. The Board must then rely on the available and probative medical evidence, which has found no nexus between the Veteran's carpal tunnel syndrome and his military service and that it is less likely than not that his carpal tunnel syndrome was caused or aggravated by his service-connected disabilities. In sum, the evidence is predominantly against the claim for service connection carpal tunnel syndrome. There is no reasonable doubt to be resolved, and the claim of entitlement to service connection for carpal tunnel syndrome, to include as secondary to service-connected fibromyalgia must be denied. 38 C.F.R. §§ 3.303, 3.310. 4. Entitlement to service connection for vertigo, to include as secondary to service-connected fibromyalgia The Veteran contends that his vertigo was caused or aggravated by his service-connected fibromyalgia disability. In September 2017, the Veteran submitted articles noting a potential relationship between fibromyalgia and vertigo. The Veteran had an examination for his vertigo in November 2017. After a review of the pertinent medical records and the current peer reviewed medical literature, the examiner opined that it was less likely than not that the Veteran's vertigo was proximately due to or the result of his fibromyalgia. The examiner stated that the Veteran is currently experiencing signs of vertigo, which arise upon movement of the neck. The examiner noted that fibromyalgia is a musculoskeletal disorder with pain as its main symptom. The examiner indicated that there is no established medical evidence that correlated fibromyalgia to any vestibular pathology that may cause vertigo. The Veteran had another examination for his vertigo in July 2019. The examiner opined that it was less likely than not that the Veteran's vertigo was caused by his service-connected fibromyalgia. The examiner stated that fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Further, the examiner noted that researchers believe that fibromyalgia amplifies painful sensations by affecting the way the brain processes pain signals. The examiner stated that this is a separate and distinct condition from cervical vertigo which is dizziness that is provoked by a particular neck posture no matter what the orientation of the head is to gravity. The examiner noted that dizziness can be provoked by turning the head about the vertical axis, while sitting upright. The examiner also stated that there is no medical literature published in reputable journals to provide a nexus between fibromyalgia and cervical vertigo. Additionally, the examiner opined that it was less likely than not that the Veteran's vertigo was aggravated by his fibromyalgia disability. The examiner reiterated that cervical vertigo and fibromyalgia are distinct conditions and that there is no medical literature published in reputable journals to provide a nexus between fibromyalgia and cervical vertigo. Upon review of the record, the Board finds that entitlement to service connection for vertigo is not warranted. The Board finds the November 2017 and July 2019 examiners' medical opinions to be highly probative because they provided an adequate rationale based on the relevant evidence of record. The examiners indicated that vertigo and fibromyalgia are separate and distinct conditions that do not affect each other. Furthermore, the examiners specifically indicated that there is no medical literature published in reputable journals that would indicate a connection between vertigo and fibromyalgia. As the relationship between vertigo and fibromyalgia is medically complex, the Veteran is not competent to offer an opinion on the matter. The Board must then rely on the available and probative medical evidence. In sum, the evidence preponderates against the claim for service connection for vertigo. There is no reasonable doubt to be resolved, and the claim of entitlement to service connection for vertigo, to include as secondary to service-connected fibromyalgia must be denied. 38 C.F.R. §§ 3.303, 3.310. 5. Entitlement to service connection for hypothyroidism, to include as secondary to service-connected fibromyalgia The Veteran contends that his hypothyroidism was caused or aggravated by his service-connected fibromyalgia disability. In September 2017, the Veteran submitted articles noting a potential relationship between fibromyalgia and thyroid conditions. The Veteran had an examination for his hypothyroidism in November 2017. After a review of the pertinent medical records and the current peer reviewed medical literature, the examiner opined that it was less likely than not that the Veteran's hypothyroidism was proximately due to or the result of his fibromyalgia. The examiner stated that hypothyroidism is a condition marked by a decrease in thyroid gland function, and fibromyalgia is a musculoskeletal disorder with pain as its main symptom. The examiner indicated that these conditions are two separate entities with no current medical evidence associating hypothyroidism development with the presence of fibromyalgia. The Veteran had another examination for his hypothyroidism in July 2019. The examiner opined that it was less likely than not that the Veteran's hypothyroidism was caused by his service-connected fibromyalgia. The examiner stated that fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Further, the examiner noted that researchers believe that fibromyalgia amplifies painful sensations by affecting the way the brain processes pain signals. The examiner stated that this is a separate and distinct condition from hypothyroidism which is a condition in which the thyroid gland is not able to produce enough thyroid hormone which results in a slow metabolism and symptoms associated with it including fatigue, weight gain, fatigue, mood swings, and hair/skin changes. The examiner also stated that there is no medical literature published in reputable journals to provide a nexus between fibromyalgia and hypothyroidism. Additionally, the examiner opined that it was less likely than not that the Veteran's hypothyroidism was aggravated by his fibromyalgia disability. The examiner reiterated that hypothyroidism and fibromyalgia are distinct conditions and that there is no medical literature published in reputable journals to provide a nexus between fibromyalgia and hypothyroidism. Upon review of the record, the Board finds that service connection for hypothyroidism is not warranted. The Board finds the November 2017 and July 2019 examiners' medical opinions to be highly probative because they provided an adequate rationale based on the relevant evidence of record. The examiners indicated that hypothyroidism and fibromyalgia are separate and distinct conditions that do not affect each other. Furthermore, the examiners specifically indicated that there is no medical literature published in reputable journals that would indicate a connection between hypothyroidism and fibromyalgia. As the relationship between hypothyroidism and fibromyalgia is medically complex, the Veteran is not competent to offer an opinion on the matter. The Board must then rely on the available and probative medical evidence. In sum, the evidence preponderates against the claim for service connection for hypothyroidism. There is no reasonable doubt to be resolved, and the claim of entitlement to service connection for hypothyroidism, to include as secondary to service-connected fibromyalgia must be denied. 38 C.F.R. §§ 3.303, 3.310. 6. & 7. Entitlement to service connection for atrial fibrillation and coronary artery disease, to include as secondary to service-connected fibromyalgia The Veteran contends that his atrial fibrillation and coronary artery disease were caused or aggravated by his service-connected fibromyalgia disability. In September 2017, the Veteran submitted articles noting a potential relationship between fibromyalgia and heart conditions such as atrial fibrillation and coronary artery disease. The Veteran had an examination for his heart conditions in November 2017. The examiner noted that the Veteran had diagnoses of acute, subacute, or old myocardial infarction; coronary artery disease; and supraventricular arrhythmia. After a review of the pertinent medical records and the current peer reviewed medical literature, the examiner opined that it was less likely than not that the Veteran's coronary artery graft bypass with atrial fibrillation was proximately due to or the result of his fibromyalgia. The examiner stated that fibromyalgia is a musculoskeletal condition that manifests mainly as pain. Additionally, the examiner noted that the Veteran had a history of atrial fibrillation and coronary artery disease/myocardial infarction for which he underwent coronary artery graft bypass in 2009. The examiner stated that medical research has failed to show any links of ischemic heart disease, coronary artery disease, or atrial fibrillation with fibromyalgia. Additionally, the examiner opined that the Veteran's METs score is solely based on cardiac functioning. The Veteran had another examination for his heart conditions in July 2019. The examiner opined that it was less likely than not that the Veteran's atrial fibrillation and coronary artery disease were caused by his service-connected fibromyalgia. The examiner stated that fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Further, the examiner noted that researchers believe that fibromyalgia amplifies painful sensations by affecting the way the brain processes pain signals. The examiner stated that this is a separate and distinct condition from atrial fibrillation which is a disruption in cardiac conduction between the pacemaker cells of the heart that leads to irregular firing and subsequent irregularly irregular heartbeat. Additionally, the examiner stated that fibromyalgia is also a separate and distinct condition from coronary artery disease which is a disease causing narrowing or blockage of the coronary arteries, usually caused by atherosclerosis. The examiner noted that atherosclerosis is the buildup of cholesterol and fatty deposits or plaques on the inner walls of the arteries. The examiner also stated that there is no medical literature published in reputable journals to provide a nexus between fibromyalgia and heart conditions such as atrial fibrillation and coronary artery disease. Additionally, the examiner opined that it was less likely than not that the Veteran's atrial fibrillation and coronary artery disease were aggravated by his fibromyalgia disability. The examiner reiterated that heart conditions such as atrial fibrillation and coronary artery disease are distinct conditions from fibromyalgia and that there is no medical literature published in reputable journals to provide a nexus between fibromyalgia and heart conditions such as atrial fibrillation and coronary artery disease. Upon review of the record, the Board finds that entitlement to service connection for atrial fibrillation and coronary artery disease is not warranted. The Board finds the November 2017 and July 2019 examiners' medical opinions to be highly probative because they provided an adequate rationale based on the relevant evidence of record. The examiners indicated that heart conditions such as atrial fibrillation and coronary artery disease are separate and distinct conditions from fibromyalgia and do not affect each other. Furthermore, the examiners specifically indicated that there is no medical literature published in reputable journals that would indicate a connection between fibromyalgia and heart conditions such as atrial fibrillation and coronary artery disease. As the relationship between the Veteran's heart disabilities and his fibromyalgia is medically complex, the Veteran is not competent to offer an opinion on the matter. The Board must then rely on the available and probative medical evidence. In sum, the evidence preponderates against the claims for entitlement to service connection for atrial fibrillation and coronary artery disease. There is no reasonable doubt to be resolved, and the claims of entitlement to service connection for atrial fibrillation and coronary artery disease, to include as secondary to service-connected fibromyalgia must be denied. 38 C.F.R. §§ 3.303, 3.310. REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability, to include as secondary to service-connected fibromyalgia, is remanded. The Veteran contends that his right knee condition was caused or aggravated by his service-connected disabilities, to include fibromyalgia. The Veteran most recently had an examination for his right knee condition in February 2020. The examiner opined that it was less likely than not that the Veteran's right knee condition was related to his active service. The examiner stated that the Veteran's service treatment records indicated that he was pinned on sides by the gangplank on the brow but did not mention any complaints of his legs or knees being pinned or crushed. The examiner further noted that there is no evidence that the Veteran complained of any knee pain while on active duty or within one year of separation. Additionally, the examiner opined that it was less likely than not that the Veteran's right knee condition was caused or aggravated by his fibromyalgia. The examiner stated that fibromyalgia is a functional disorder characterized by pain, fatigue, psychiatric symptoms and somatic symptoms in the absence of demonstrable inflammation or tissue damage, and it is not associated with osteoarthritis of the knee and it does not cause worsening osteoarthritis. The Board finds the February 2020 examiner's opinion to be inadequate. It is not clear whether the examiner fully considered medical evidence of record from March 2018 stating that due to fibromyalgia, the Veteran's knee pain has been aggravated and worsened to the point that he now needs a brace to support his knees. Accordingly, the Board finds that remand is appropriate for an addendum medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for sleep apnea, to include as secondary to service-connected fibromyalgia, is remanded. The Veteran contends that his sleep apnea was caused or aggravated by his service-connected disabilities, to include fibromyalgia. The Veteran most recently had an examination for his sleep apnea in December 2019. The examiner opined that it was less likely than not that the Veteran's sleep apnea was aggravated by his fibromyalgia. The examiner stated that fibromyalgia does not cause obstructive airway accentuation by virtue of mere muscle aches and joint pains. The examiner noted that the pathology of obstructive sleep apnea is obstruction of the airways during sleep by relaxation of the oropharyngeal muscles. The examiner stated that the presence of fibromyalgia causing muscle aches and pain during the day does not affect the relaxation of the oropharyngeal muscles which occur at night during sleep and concluded that fibromyalgia cannot aggravate sleep apnea. The Board finds the December 2019 examiner's opinion to be inadequate. It is not clear whether the examiner fully considered medical evidence of record from June 2010 noting that the Veteran has poor sleep efficiency due to his fibromyalgia, as well as medical evidence from April 2012 noting that has difficulty using CPAP due to his fibromyalgia. Accordingly, the Board finds that remand is appropriate for an addendum medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 3. Entitlement to service connection for gout, to include as secondary to service-connected fibromyalgia, is remanded. The Veteran contends that his gout condition was caused or aggravated by his service-connected disabilities, to include fibromyalgia. The Veteran had an examination for his gout condition in November 2017. The examiner opined that it was less likely than not that the Veteran's gout was proximately due to or the result of his fibromyalgia. The examiner stated that gout is an inflammatory joint condition due to high or fluctuating levels of uric acid. Accordingly, the examiner noted that there is therefore no association between the development of gout and fibromyalgia, the latter being a musculoskeletal condition that manifests mainly as pain. Additionally, the examiner stated that there is no medical evidence correlating one entity to the other. The Board finds the November 2017 examiner's opinion to be inadequate. The examiner did not adequately address whether the Veteran's service-connected disabilities aggravated his gout condition. An opinion that something "is not related to" or "is not due to" does not answer the question of aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Accordingly, remand is appropriate for an addendum medical opinion to adequately address whether the Veteran's gout condition was aggravated by his service-connected disabilities. 4. & 5. Entitlement to service connection for left and right shoulder disabilities, to include as secondary to service-connected fibromyalgia, is remanded. The Veteran contends that his left and right shoulder conditions were caused or aggravated by his service-connected disabilities, to include fibromyalgia. The Veteran had an examination for his left and right shoulder conditions in November 2017. The examiner opined that it was less likely than not that the Veteran's left and right shoulder conditions were proximately due to or the result of his fibromyalgia. The examiner stated that the Veteran currently has a diagnosis of AC osteoarthritis. The examiner noted that fibromyalgia is a condition of the musculoskeletal system that manifests as pain. Additionally, the examiner noted that there is no current medical evidence that supports a correlation between fibromyalgia and the development of osteoarthritis which is a degenerative condition due to constant strain and overuse of a joint. The Board finds the November 2017 examiner's opinion to be inadequate. The examiner did not adequately address whether the Veteran's service-connected disabilities aggravated his left and right shoulder conditions. An opinion that something "is not related to" or "is not due to" does not answer the question of aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Accordingly, remand is appropriate for an addendum medical opinion to adequately address whether the Veteran's left and right shoulder conditions were aggravated by his service-connected disabilities. 6. & 7. Entitlement to service connection for left and right hip disabilities, to include as secondary to service-connected fibromyalgia, is remanded. The Veteran contends that his left and right hip conditions were caused or aggravated by his service-connected disabilities, to include fibromyalgia. The Veteran had an examination for his left and right hip conditions in November 2017. The examiner opined that it was less likely than not that the Veteran's left and right hip conditions were proximately due to or the result of his fibromyalgia. The examiner stated that the Veteran currently has a diagnosis of degenerative arthritis of both hips with right hip tendinitis. The examiner further noted that fibromyalgia is a condition that affects the musculoskeletal system with the main symptom being pain. Additionally, the examiner indicated that there was no current medical consensus indicating that fibromyalgia can result in the development of a degenerative arthritis. The Board finds the November 2017 examiner's opinion to be inadequate. The examiner did not adequately address whether the Veteran's service-connected disabilities aggravated his left and right hip conditions. An opinion that something "is not related to" or "is not due to" does not answer the question of aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Accordingly, remand is appropriate for an addendum medical opinion to adequately address whether the Veteran's left and right hip conditions were aggravated by his service-connected disabilities. 8. Entitlement to service connection for a right elbow disability, to include as secondary to service-connected fibromyalgia, is remanded. The Veteran contends that his right elbow condition was caused or aggravated by his service-connected disabilities, to include fibromyalgia. The Veteran had an examination for his right elbow condition in November 2017. The examiner opined that it was less likely than not that the Veteran's right elbow was proximately due to or the result of his fibromyalgia. The examiner stated that the Veteran is currently diagnosed with right elbow bursitis and osteoarthritis. The examiner noted that fibromyalgia is a condition that involves the musculoskeletal system with the main symptom being pain. The examiner noted that there was no clear established medical correlation between fibromyalgia and the development of bursitis. Furthermore, the examiner stated that, since the Veteran has a history of gout and a current diagnosis of osteoarthritis, it is more likely that bursitis would be the result of these inflammatory conditions rather than fibromyalgia. The Board finds the November 2017 examiner's opinion to be inadequate. The examiner did not adequately address whether the Veteran's service-connected disabilities aggravated his right elbow condition. An opinion that something "is not related to" or "is not due to" does not answer the question of aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Accordingly, remand is appropriate for an addendum medical opinion to adequately address whether the Veteran's right elbow condition was aggravated by his service-connected disabilities. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current right knee condition is related to his military service and/or secondary to his service-connected disabilities to include his service-connected fibromyalgia disability. The record must be made available to and reviewed by the VA examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, the examiner should address the following: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right knee condition had its onset in, or is otherwise related to his period of active duty service, to include his 1973 in-service gangplank incident? The examiner must consider and discuss the lay statements of record regarding the onset of the Veteran's right knee disorder and the continuity of symptomatology of the claimed disorder. b) Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right knee condition was caused by his service-connected disabilities, to include his fibromyalgia? c) Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that the Veteran's right knee condition is aggravated by his service-connected disabilities, to include his fibromyalgia? The examiner must discuss the pertinent medical evidence of record, including a March 2018 medical treatment record stating that due to fibromyalgia, the Veteran's knee pain has been aggravated and worsened to the point that he now needs a brace to support his knees. See VBMS, document labeled Medical Treatment Record - Government Facility, receipt date 01/07/2019. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 2. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current sleep apnea condition is related to his military service and/or secondary to his service-connected disabilities to include his service-connected fibromyalgia disability. The record must be made available to and reviewed by the VA examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, the examiner should address the following: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's sleep apnea condition had its onset in, or is otherwise related to his period of active duty service? b) Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's sleep apnea condition was caused by his service-connected disabilities, to include his fibromyalgia? c) Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea condition is aggravated by his service-connected disabilities, to include his fibromyalgia? The examiner must discuss the pertinent medical evidence of record, including a June 2010 treatment record noting that the Veteran has poor sleep efficiency due to his fibromyalgia, as well as medical evidence from April 2012 noting that has difficulty using CPAP due to his fibromyalgia. See VBMS, document labeled VAMC Other Output / Reports, receipt date 03/17/2014. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 3. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current gout condition is related to his military service and/or secondary to his service-connected disabilities to include his service-connected fibromyalgia disability. The record must be made available to and reviewed by the VA examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, the examiner should address the following: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's gout condition had its onset in, or is otherwise related to his period of active duty service? b) Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's gout condition was caused by his service-connected disabilities, to include his fibromyalgia? c) Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that the Veteran's gout condition is aggravated by his service-connected disabilities, to include his fibromyalgia? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 4. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current left and right shoulder conditions are related to his military service and/or secondary to his service-connected disabilities to include his service-connected fibromyalgia disability. The record must be made available to and reviewed by the VA examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, the examiner should address the following: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left and right shoulder conditions had their onset in, or are otherwise related to his period of active duty service? b) Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left and right shoulder conditions were caused by his service-connected disabilities, to include his fibromyalgia? c) Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that the Veteran's left and right shoulder conditions were aggravated by his service-connected disabilities, to include his fibromyalgia? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 5. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current left and right hip conditions are related to his military service and/or secondary to his service-connected disabilities to include his service-connected fibromyalgia disability. The record must be made available to and reviewed by the VA examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, the examiner should address the following: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left and right hip conditions had their onset in, or are otherwise related to his period of active duty service? b) Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left and right hip conditions were caused by his service-connected disabilities, to include his fibromyalgia? c) Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that the Veteran's left and right hip conditions were aggravated by his service-connected disabilities, to include his fibromyalgia? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 6. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current right elbow condition is related to his military service and/or secondary to his service-connected disabilities to include his service-connected fibromyalgia disability. The record must be made available to and reviewed by the VA examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, the examiner should address the following: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right elbow condition had its onset in, or is otherwise related to his period of active duty service? b) Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right elbow condition was caused by his service-connected disabilities, to include his fibromyalgia? c) Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that the Veteran's right elbow condition is aggravated by his service-connected disabilities, to include his fibromyalgia? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David M. Sebstead, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.