Citation Nr: 21042582 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-47 279 DATE: July 13, 2021 ORDER The claim of entitlement to service connection for major depressive disorder is dismissed. Entitlement to service connection for hypertension is granted. Entitlement to service connection for orthostatic hypotension, claimed as dizziness with loss of balance, is granted. Entitlement to service connection for a heart condition is denied. Entitlement to service connection for irritable bowel syndrome (IBS) is granted. Entitlement to service connection for memory loss is denied. Entitlement to service connection for sleeping problems is denied. REMANDED Entitlement to service connection for left ulnar neuropathy, claimed as a wrist condition, is remanded. Entitlement to service connection for skin rashes is remanded. Entitlement to service connection for severe joint pain, to include fibromyalgia and rheumatoid arthritis, is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to a rating in excess of 10 percent for residuals of a left knee injury is remanded. Entitlement to service connection for muscle pain is remanded. Entitlement to service connection for weakness is remanded. Entitlement to service connection for fatigue is remanded. Entitlement to service connection for a right ankle disability is remanded. FINDINGS OF FACT 1. Service connection is already in effect for major depressive disorder. 2. Hypertension was noted during service, and there is continuity of symptomatology from service to the present. 3. The Veteran's orthostatic hypotension, claimed as dizziness with loss of balance, is secondary to his service-connected hypertension. 4. A coronary artery disease did not first manifest in service and has not been linked to service; there is no cardiac symptom that has not already been attributed to a service-connected disability. 5. The Veteran had active service in the Southwest Asia Theater of Operations during the Persian Gulf War. 6. The Veteran has been diagnosed with IBS. 7. The Veteran's memory loss has been evaluated as a symptom of his service-connected PTSD with major depressive disorder, alcohol use disorder, and cannabis use disorder; a separate and distinct disability manifested by memory loss has not been diagnosed; there is no memory loss that has not already been attributed to a service-connected disability. 8. The Veteran's sleeping problems have been evaluated as a symptom of his service-connected PTSD with major depressive disorder, alcohol use disorder, and cannabis use disorder; a separate and distinct disability manifested by sleeping problems has not been diagnosed; there are no sleeping problems that have not already been attributed to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for dismissal of the claim of entitlement to service connection for major depressive disorder have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 2. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 3. The criteria for entitlement to service connection for orthostatic hypotension, claimed as dizziness with loss of balance, have 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 a heart condition have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 5103, 5103A; 38 C.F.R. §§ 3.303, 3.317. 5. The criteria for entitlement to service connection for IBS have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 5103, 5103A; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. 6. The criteria for entitlement to service connection for memory loss have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.317, 4.130, Diagnostic Code 9411. 7. The criteria for entitlement to service connection for sleeping problems have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.317, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1974 to February 1978, from April 1979 to October 1980, from October 1980 to October 1986, and from November 1990 to May 1991. He had subsequent periods of active duty for training and inactive duty training that lasted to January 1997. This matter comes before the Board on appeal from a May 2013 Regional Office (RO) rating decision. In January 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Dismissed Claim 1. The claim of entitlement to service connection for major depressive disorder is dismissed. The claim of entitlement to service connection for major depressive disorder has been certified to the Board. However, service connection is already in effect for "Posttraumatic Stress Disorder with Major Depressive Disorder, Alcohol Use Disorder and Cannabis Use Disorder." Thus, the claim that is currently before the Board has already been granted in full. As such, this claim is dismissed as a matter of law, as there is no case or controversy, or dispute of fact or law, regarding this issue. See U.S.C. § 7105. The claim is therefore dismissed. Service Connection Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as hypertension, if such are shown to have been manifested to a compensable degree within a presumptive period (usually one year) following separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). A nexus to service may be presumed when "a chronic disease is 'shown in service (or within the presumptive period under § 3.307).'" Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013). In order to be "shown in service," there must be "a reliable diagnosis of the chronic disease while in service.... [T]he disease identity must be established and the diagnosis not be subject to legitimate question." Id. In such cases, the claimant need not demonstrate nexus, "so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. Alternatively, continuity of symptomatology may be used in place of nexus "[i]f evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported.'" Walker, 708 F.3d at 1336; 38 C.F.R. § 3.303(b). Under 38 C.F.R. § 3.317, service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (MUCMI) (such as chronic fatigue syndrome, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). In the case at hand, the Veteran has qualifying service under 38 C.F.R. § 3.317(e). 2. Entitlement to service connection for hypertension is granted. In the case at hand, the Board finds that hypertension has been "noted during service" rather than "shown in service." A November 1985 service treatment record notes a blood pressure reading of 140/100. A January 1986 service treatment record notes, in relevant part, a blood pressure reading of 154/108 and an assessment of "R/O Fluid retention / Initial Hypertension." A follow-up record from three days later notes blood pressure of 148/100 and deferred making an assessment. A record from the following day notes blood pressure of 140/88. A record from two days later notes an assessment of "Hypertension, diuretic controlled (Stage I)." A February 1986 record notes an assessment of "R/O Hypertension." The Veteran reported a history of, or current, high blood pressure on his July 1986 medical history report. The Veteran's service treatment records thus reflect that hypertension was noted during service, but the Veteran was not given a diagnosis of chronic hypertension while in service. With respect to a current disability, the Veteran has a current diagnosis of hypertension. (See, e.g., April 2012 VA medical record.) The Veteran testified at his Board hearing that he has been treated for hypertension since 1980 (in service). (See Board hearing transcript, pages 34-35.) This suggests continuity of symptomatology since service. The Board acknowledges that the earliest in-service notations of hypertension treatment are dated in early 1986 and not 1980. The Board notes, however, that the Veteran was on active duty service at both times and that he has testified to a continuity of symptomatology since service. The fact that the Veteran estimated at his January 2021 hearing, approximately 35 years after the occurrences at issue, that he was first treated for hypertension six years earlier than the earliest indications of hypertension of record does not contradict his essential testimony: that he first received treatment for hypertension in service and has been treated for it ever since. In short, the Board finds that the Veteran has a current diagnosis of hypertension that was first noted during service, and that the Veteran has credibly testified that he has had hypertension ever since the initial in-service treatment. Therefore, the Board finds that entitlement to service connection for hypertension is warranted, and the issue on appeal is granted. 3. Entitlement to service connection for orthostatic hypotension, claimed as dizziness with loss of balance, is granted. The Veteran does not contend, and the evidence does not demonstrate, that he had dizziness during service. He testified at his Board hearing that his dizziness began in approximately 2000. (See Board hearing transcript, page 30.) Therefore, entitlement to service connection is not warranted on a primary basis. The January 2012 VA examination report notes that the Veteran's dizziness with loss of balance "is likely to be secondary to orthostatic hypotension." "Orthostatic hypotension" or "postural hypotension" is defined as a "fall in blood pressure associated with dizziness, blurred vision, and sometimes syncope, occurring upon standing or when standing motionless in a fixed position." Dorland's Illustrated Medical Dictionary 899 (30th ed. 2003). The Board notes that a layperson, such as the Veteran in this case, is considered to be competent to describe experiencing dizziness with loss of balance. His dizziness with loss of balance has been attributed by a medical professional to orthostatic hypotension. The Board has thus recharacterized this issue as being one of entitlement to service connection for orthostatic hypotension, which is the underlying disability that has manifested in dizziness with loss of balance. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may adequately identify the disability for which compensation benefits are sought by referring to a body part or system that is disabled, or by describing the symptoms of that disability). The January 2012 VA examination report further notes that the Veteran's orthostatic hypotension is "likely secondary to his diabetes and hypertension." Entitlement to service connection for hypertension has been granted, above. Therefore, the Board finds that the Veteran has a current disability (orthostatic hypotension) that is etiologically linked to a service-connected disability (hypertension). Entitlement to service connection for orthostatic hypotension, claimed as dizziness with loss of balance, is warranted, and the issue on appeal is granted. 4. Entitlement to service connection for a heart condition is denied. Aside from the hypertension, the Veteran has claimed entitlement to service connection for a heart condition. With respect to a current disability, he testified at his Board hearing that he has had a total of 11 stents. (See Board hearing transcript, page 33.) It was noted that he has a diagnosis of coronary artery disease. (See Board hearing transcript, page 33.) The Veteran's service treatment records reflect that he did not complain of, and was never treated for, symptoms that have been associated with coronary artery disease. The January 2012 VA examination report lists a diagnosis of coronary artery disease. It notes that "This is a diagnos[ed] illness which he had after the service." The VA examiner thus attributed all of the Veteran's heart-related symptoms to a diagnosed illness, and entitlement to service connection for a heart condition as due to an undiagnosed illness is not warranted. No competent medical expert has attributed the Veteran's coronary artery disease to service, and his VA and private medical records do not otherwise suggest that his coronary artery disease is linked to service. The Veteran himself has not even suggested that he believes his diagnosed coronary artery disease is related to service. When asked at his Board hearing what he believed has caused his coronary artery disease, he stated "I don't know, diet, bad genes." (See Board hearing transcript, page 34.) The Veteran and his representative then proceeded to discuss his hypertension, for which service connection has been granted, above. In short, the Board finds that entitlement to service connection for a heart condition is not warranted, as a heart condition did not arise during service and has not otherwise been etiologically linked to service. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 5. Entitlement to service connection for IBS is granted. The Veteran contends, in part, that he suffers from IBS due to his service in Saudi Arabia in the early 1990s. (The exact dates of this service are unclear from the service personnel records.) This service qualifies for the presumptions for Gulf War veterans. The record reflects that the Veteran has been diagnosed with IBS. (See January 2012 VA examination report.) This diagnosis has been made by a physician who has reviewed the record and interviewed and examined the Veteran. This physician possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). The Board finds that the requirements for presumptive service connection for IBS, as listed above, have been satisfied. Therefore, entitlement to service connection for IBS is warranted. 6. Entitlement to service connection for memory loss is denied. With respect to memory loss, the January 2012 VA examination report notes that the Veteran "stated that he had some difficulty with his memory lately he was not evaluated or diagnosed with this." The examiner further noted that the Veteran reported that "His primary care doctor thought it could be from the hydrocodone he takes, or some his obstructed or blocked carotid arteries in the neck, no definite diagnoses of memory loss has been established." The examiner then stated that the Veteran "is not on treatment for memory loss, and there is no evidence of gross memory loss on gross examination today, the Veteran has not been diagnosed or treated for memory loss." The Veteran underwent a VA posttraumatic stress disorder (PTSD) examination in March 2020. The examination report directs the examiner to "check all symptoms that actively apply to the Veteran's diagnoses." Among the responses, the examiner checked the box indicating "Mild memory loss, such as forgetting names, directions or recent events." The January 2020 rating decision that granted entitlement to service connection for PTSD with major depressive disorder, alcohol use disorder, and cannabis use disorder assigned a 70 percent rating and cited "Mild memory loss" and "Forgetting recent events" as two bases for the assignment of this rating. In short, service connection is in effect for an acquired psychiatric disorder that manifests in memory loss, and the Veteran has not been diagnosed with a distinct memory loss disability. Nor is there a suggestion that the Veteran has additional memory loss that is due to undiagnosed illness and for which he is not being compensated. Therefore, while the Board must deny the claim of entitlement to service connection for memory loss, it does consider the Veteran's memory loss to be a symptom that is part of his service-connected PTSD with major depressive disorder, alcohol use disorder, and cannabis use disorder. 7. Entitlement to service connection for sleeping problems is denied. With respect to the Veteran's sleeping problems claim, the Board notes that the January 2012 VA examination report states that his "sleeping problem appears to be secondary to pain from his generalized rheumatoid arthritis." Service connection is not currently in effect for rheumatoid arthritis or other joint pain, and that claim is being remanded for additional development. The Board has considered whether the claim of entitlement to service connection for sleeping problems should be remanded as intertwined with the joint pain claim. The Board finds, however, that service connection is already in effect for a disability that is manifested by sleeping problems. Furthermore, the January 2012 VA examiner did not diagnose a distinct sleep disorder, but rather has suggested that the sleeping problem is a symptom rather than a distinct disability. Therefore, remand of the claim of entitlement to service connection for the symptom of sleeping problems based on a potential link to the Veteran's joint pain claim is not warranted. As noted above, the Veteran underwent a VA PTSD examination in March 2020. The examination report directs the examiner to "check all symptoms that actively apply to the Veteran's diagnoses." Among the responses, the examiner checked the box indicating the presence of "Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep)." In addition, the January 2020 rating decision cites "Chronic sleep impairment" as one of the bases for the assigned 70 percent acquired psychiatric disability rating. The rating criteria for that disability (his acquired psychiatric disability) thus expressly contemplate his sleeping problems. Therefore, the Veteran is already receiving compensation for his sleeping problems. In short, service connection is in effect for an acquired psychiatric disorder that manifests in sleeping problems, and the record does not reflect a distinct sleeping problems disability. Nor is there a suggestion that the Veteran has uncompensated sleeping problems that are due to an undiagnosed illness. Therefore, while the Board must deny the claim of entitlement to service connection for sleeping problems, it does consider the Veteran's sleeping problems to be a symptom that is part of his service-connected PTSD with major depressive disorder, alcohol use disorder, and cannabis use disorder. REASONS FOR REMAND 1. Entitlement to service connection for left ulnar neuropathy, claimed as a wrist condition, is remanded. The Veteran has stated that "the initial injury happened while I was a civilian, but it was causing me problems during my Desert Storm vacation." (See Board hearing transcript, page 44.) His representative agreed with the characterization that "it looks like you were injured in 1987 from being hit by a steel bar and then so basically it's your contention that due to your in-service duties that it aggravated this preexisting [condition]." (See Board hearing transcript, page 44.) Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of entry. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). To be "noted" within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304(b); see also 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994). History of pre-service existence of a disease does not constitute a notation of such condition. See id. at 240 (holding that "asthma" was not noted where, although the veteran checked a box indicting that he had a history of the disease, a clinical evaluation detected no abnormalities of the lungs). The presumption of soundness also attaches when an entrance examination is lost or missing. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). In the case at hand, the October 1989 enlistment examination report notes that the Veteran's upper extremities were clinically normal. Therefore, the presumption of soundness attaches in this case. The burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that a disability both (1) existed prior to service and (2) was not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). To satisfy this second prong, the government must show by clear and unmistakable evidence that either (1) there was no increase in disability during service or (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). If VA fails to rebut the presumption of soundness, the claim becomes one for service connection. If VA rebuts the presumption of soundness, then the claim must be denied. In the case at hand, an April 1991 service treatment record notes that the Veteran has "Painful hyperextended L wrist ulnar 2 fingers hyposthetic. Entrapment ulnar [illegible] Guyan's canal.... Recommend ... release ulnar [illegible] Guyon's canal L hand." Another April 1991 service treatment record notes a diagnosis of "ulnar neuropathy L hand" and that a left wrist x-ray was normal. The Board notes that these April 1991 service treatment records were associated with the claims file in April 2021, following the issuance of the statement of the case in July 2017. (There has been no subsequent supplemental statement of the case.) Given that the October 1989 reflects that the Veteran's left wrist was clinically normal when examined and that service treatment records that have newly been associated with the claims file reflect that the Veteran sought treatment for left ulnar nerve entrapment in service, the Board finds it necessary to remand this claim for a new VA examination and medical opinion. 2. Entitlement to service connection for skin rashes is remanded. The Veteran reported that he was treated for "[t]inea or a fungal infection" "all the way back to my days in the Coast Guard in Atlantic City." (See Board hearing transcript, page 39.) (He served in the Coast Guard from February 1974 to February 1978 and from April 1979 to October 1980.) He stated that "[W]e used to wear these exposure suits. You're on duty for 72 hours, and the exposure suits were basically a diving wet suit." (See Board hearing transcript, pages 39-40.) He stated: [T]he only time you could actually wash it and hang it up to dry was when you were off duty. So you would spend like a three-day tour you'd wear that thing maybe a dozen times going out on the boat, and so I was getting these boils on my skin and rashes back then, and now at the current time, I've got fungal rashes that cover[] my entire body. (See Board hearing transcript, page 40.) He noted that "[S]ome of that is exacerbated by the fact that they're giving me prednisone and all this stuff for the rheumatoid arthritis, which restricts my immune response." (See Board hearing transcript, page 40.) He reported that a rheumatologist whom he saw thought this condition was psoriatic arthritis, but the Veteran himself believes it is a fungal rash, as "I can put fungal cream on there, and it'll disappear for a while." (See Board hearing transcript, pages 40-41.) He also reported that "I've gotten from basically from head to toe, and some of those rashes have turned into diabetic ulcers." (See Board hearing transcript, page 42.) The service treatment records contain a November 1981 record of treatment for allergic dermatitis. (The handwriting on this notation is difficult to read, but it may indicate that the allergic dermatitis was on the Veteran's trunk and arm.) A May 1985 service treatment record notes that the Veteran sought treatment for athlete's foot that he had noticed one week earlier. These records had not been associated with the claims file at the time of the January 2012 VA examination. A June 2011 private medical record states that the Veteran "comes referred for evaluation for rheumatoid arthritis." It notes that, initially, the Veteran's "local rheumatologist thought this condition could be palindromic rheumatism, then psoriatic arthritis, since he was having some lesions in the skin that they thought could be psoriatic." It was noted that the Veteran "states that he applies antifungal cream to these lesions and they improve." The June 2011 rheumatology record states that the Veteran has a superficial fungal infection. The January 2012 VA medical examiner stated that the Veteran's skin rashes are "likely fungus rash or dermatophytosis." It was noted that these are "the diagnoses of his dermatologist, it is a diagnosed illness." Given that the Veteran has been diagnosed with current fungal conditions and that service treatment records and the Veteran's personal testimony have been added to the claims file since the January 2012 VA examination, the Board finds it necessary to remand this claim so that the Veteran may undergo a VA examination and an etiology opinion may be obtained. 3. Entitlement to service connection for severe joint pain, to include fibromyalgia and rheumatoid arthritis, is remanded. The Veteran contends that his joint pain is due to exposures during his Persian Gulf service. The January 2012 VA examination report notes that the Veteran has been diagnosed with rheumatoid arthritis. The examiner opined that the Veteran's joint pain and muscle pain "are likely to be secondary to the diagnosed illness of rheumatoid arthritis, and degenerative joint disease, unlikely to be symptoms of undiagnosed illness." The Board notes that no opinion has been obtained with respect to whether the Veteran's rheumatoid arthritis or degenerative joint disease is directly related to service. Furthermore, no opinion has been obtained with respect to whether the Veteran's rheumatoid arthritis at least as likely as not qualifies as a medically unexplained chronic multisymptom illness (MUCMI) that is related to his Persian Gulf service. Pursuant to Goodman v. Shulkin, 870 F.3d 1383, 1387 (Fed. Cir. 2017), a case in which the claimant was seeking entitlement to service connection for rheumatoid arthritis, "VA adjudicators may rely on a medical examiner's evaluation of whether a veteran's condition qualifies as a MUCMI pursuant to § 3.317(a)(2)(ii)." It is ultimately "'the authority of the VA adjudicator to determine on a case-by-case basis whether additional diseases meet the criteria' for a MUCMI." See Stewart v. Wilkie, 30 Vet. App. 383, 391 (2018) (quoting Goodman v. Shulkin, 870 F.3d 1383 (Fed. Cir. 2017)). Furthermore, "'the VA adjudicator may consider evidence of medical expert opinions and all other facts of record to make the final determination of whether a claimant has proven, based on the claimant's unique symptoms, the existence of a MUCMI stated." See Stewart v. Wilkie, 30 Vet. App. 383, 391 (2018) (quoting Goodman v. Shulkin, 870 F.3d 1383, 1388 (Fed. Cir. 2017)). [Emphasis in original.] An illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Conversely, an illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). Thus, when an examiner undertakes to opine whether a MUCMI exists, the examiner must address both the etiology and pathophysiology of the claimed illness, and the opinion is inadequate if it does not do so. See Id. at 392. In light of the above, the Board finds it necessary to remand this claim to obtain an opinion with respect to whether the Veteran's rheumatoid arthritis in this case may be considered a MUCMI. In addition, the examiner should determine whether a diagnosis of fibromyalgia is warranted. Furthermore, the record reflects that not all pertinent evidence has been requested. An April 2012 VA medical record notes that the Veteran "goes to a private pain physician (Dr Tracy at Oak Hill Hospital)." A June 2011 Mayo Clinic record notes that the Veteran sees a private rheumatologist for his painful joints. On remand, the appropriate attempts should be made to obtain pertinent medical records from any relevant source. In addition, it appears that at least one page in the June 2011 Mayo Clinic record is missing. Furthermore, a July 2012 VA medical record notes that the Veteran "was in Mayo clinic in June." This latter record suggests that the Veteran may have visited the Mayo Clinic in connection with his joint pain on more than one occasion. On remand, attempts should be made to obtain the Veteran's Mayo Clinic records. 4. Entitlement to service connection for a left shoulder disability is remanded. The Board notes that this claim must be remanded as inextricably intertwined with the claim of entitlement to service connection for joint pain. It must also be remanded to determine whether entitlement to service connection for a left shoulder disability is warranted on a direct basis. VA received some of the Veteran's service treatment records in April 2021. These records reflect that the Veteran injured his left shoulder in the line of duty in June 1995. A June 1995 Emergency Medical Care / Incapacitation Data Report notes that the Veteran "was lifting a Tool Box into the back of a vehicle when he heard a popping sound and pain in his left shoulder." He was diagnosed with a pulled muscle in his left shoulder. A June 2011 private medical record notes that the Veteran was having some shoulder swelling. An April 2012 VA medical record notes that the Veteran has had a left shoulder injection. The Veteran testified at his hearing that VA has x-rayed his shoulders and that he has a torn rotator cuff. (See Board hearing transcript, page 19.) On remand, an opinion should be obtained with respect to whether the Veteran has a current left shoulder disability that is related to service. 5. Entitlement to service connection for a right shoulder disability is remanded. The Board notes that this claim must be remanded as inextricably intertwined with the claim of entitlement to service connection for joint pain. It must also be remanded to determine whether entitlement to service connection for a right shoulder disability is warranted on a direct basis. The Veteran's service treatment records from June 1995 reflect that he may have also injured his right shoulder in the same accident in which he injured his left shoulder. The Veteran himself has testified that he injured both of his shoulders at that time. (See Board hearing transcript, pages 18-19.) A record from two days following the left shoulder injury report reflects that he sought treatment for his right shoulder. This record notes that the Veteran "c/o poss sprained R shoulder while performing tasks at work." It notes that he "was lifting a tool box yesterday heard a pop in R shoulder & let box fall. C/o pain constant unable to dress up usually." Following examination, an assessment of "Bursitis with poss stress fx in clavicle" was made. He received an individual sick slip a few days later prohibiting him, in relevant part, from "lifting with R arm." The Veteran's service treatment records clearly and legibly reflect that the Veteran was seeking treatment for his right shoulder at those times, while earlier records clearly and legibly reflect he was being treated for his left shoulder. Given the detail and clarity of these records and the Veteran's hearing testimony, the Board concludes that both shoulders were injured in that accident, rather than that some of his service treatment records mistakenly identified the wrong shoulder. The Veteran testified at his Board hearing that his right shoulder has been x-rayed by VA and that "my right shoulder is bone-on-bone." (See Board hearing transcript, page 19.) On remand, an opinion should be obtained with respect to whether the Veteran has a current right shoulder disability that is related to service. 6. Entitlement to service connection for a right knee disability is remanded. 7. Entitlement to a rating in excess of 10 percent for residuals of a left knee injury is remanded. The Board notes that the right knee disability claim must be remanded as inextricably intertwined with the claim of entitlement to service connection for joint pain. It must also be remanded to determine whether entitlement to service connection for a right knee disability is warranted on a direct basis. The January 2012 VA examination report diagnosed right knee degenerative joint disease/rheumatoid arthritis. The examiner opined that "The veteran's right knee condition, or right knee [degenerative joint disease], is less likely as not (less than 50/50 probability) to have been incurred in or caused by an unknown event in service." The rationale was that "There is no evidence in the service records of right knee injury or of any chronic right knee condition or [degenerative joint disease] of the right knee." Relevant service treatment records have been added to the record since this opinion was obtained. These records include a November 1985 record reflecting that the Veteran suffered a right knee injury when he "fell today on the flight deck striking his right patella on a still 'mushroom.' Pain and swelling now considerable. Tenderness and edema prevent thorough exam." An assessment of "Pre patellar bursitis? R/O fracture" was made. Therefore, on remand, a new VA examination and an opinion that considers this new information is required. Because the right knee examination is likely to contain evidence that is relevant to the service-connected left knee disability, the Board will remand the left knee claim as well. 8. Entitlement to service connection for muscle pain is remanded. 9. Entitlement to service connection for weakness is remanded. 10. Entitlement to service connection for fatigue is remanded. 11. Entitlement to service connection for a right ankle disability is remanded. The Board notes that these claims must be remanded as inextricably intertwined with the claim of entitlement to service connection for joint pain. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran's records were last obtained. In particular, ask the Veteran to fill out the appropriate authorization to allow VA to obtain any outstanding private medical records that have been identified in his claims file. Specifically, please request authorization to obtain treatment records from the following: (a) A private pain physician (identified in a record as "Dr. Tracy at Oak Hill Hospital") who was noted in an April 2012 record to have been treating the Veteran; (b) The Mayo Clinic, where he was treated in June 2011 and may have had additional later appointments. Notify the Veteran that he may submit these records himself. 2. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of any current left wrist disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed, and all findings should be reported in detail. The examiner should diagnose any current left wrist disability. The examiner must opine as to whether any such disability clearly and unmistakably preexisted the Veteran's service period of service that began in November 1990 and ended in May 1991. For any disability that did clearly and unmistakably preexist that period of service, the examiner must opine whether any such disability clearly and unmistakably WAS NOT aggravated by service. For any disability that did not clearly and unmistakably preexist service, the examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability is related to an in-service injury, event, or disease. In addressing these questions, the examiner should discuss the Veteran's service treatment records. In particular, the examiner should discuss the October 1989 enlistment examination report noting that the Veteran's upper extremities were clinically normal. The examiner should also discuss the April 1991 service treatment records. One such record notes that the Veteran has "Painful hyperextended L wrist ulnar 2 fingers hyposthetic. Entrapment ulnar [illegible] Guyan's canal.... Recommend ... release ulnar [illegible] Guyon's canal L hand." Another April 1991 notes a diagnosis of "ulnar neuropathy L hand" and that a left wrist x-ray was normal. Any opinion rendered should be accompanied by a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 3. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of any current skin rash disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed, and all findings should be reported in detail. The examiner should diagnose any current skin rash disability. For any diagnosed skin rash disability, the examiner should render an opinion with respect to whether it is at least as likely as not (a 50 percent probability or greater) that any current skin rash disability began during service or is otherwise related to service. In rendering this opinion, the examiner should discuss the service treatment records reflecting that the Veteran was treated for allergic dermatitis in November 1981 and for athlete's foot in May 1985. In providing this opinion, the examiner should discuss whether any current skin disability is consistent with the history, symptoms, and treatment that the Veteran described at his Board hearing. Specifically, he reported that he was treated for "[t]inea or a fungal infection" "all the way back to my days in the Coast Guard in Atlantic City." (See Board hearing transcript, page 39.) (He served in the Coast Guard from February 1974 to February 1978 and from April 1979 to October 1980.) He stated that "[W]e used to wear these exposure suits. You're on duty for 72 hours, and the exposure suits were basically a diving wet suit." (See Board hearing transcript, pages 39-40.) He stated that: [T]he only time you could actually wash it and hang it up to dry was when you were off duty. So you would spend like a three-day tour you'd wear that thing maybe a dozen times going out on the boat, and so I was getting these boils on my skin and rashes back then, and now at the current time, I've got fungal rashes that cover[] my entire body. (See Board hearing transcript, page 40.) He noted that "[S]ome of that is exacerbated by the fact that they're giving me prednisone and all this stuff for the rheumatoid arthritis, which restricts my immune response." (See Board hearing transcript, page 40.) He reported that a rheumatologist that he saw thought this condition was psoriatic arthritis, but the Veteran himself believes it is a fungal rash, as "I can put fungal cream on there, and it'll disappear for a while." (See Board hearing transcript, pages 40-41.) He also reported that "I've gotten from basically from head to toe, and some of those rashes have turned into diabetic ulcers." (See Board hearing transcript, page 42.) Any opinion must contain a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 4. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of any current joint pain. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed, and all findings should be reported in detail. The examiner should diagnose any current disability that manifests in joint pain. The examiner should specifically determine whether a diagnosis of fibromyalgia is warranted. For any diagnosed disability, the examiner should render an opinion with respect to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability began during service or is otherwise related to service. For the Veteran's diagnosed rheumatoid arthritis, the examiner should evaluate the Veteran's individual rheumatoid arthritis etiology and pathophysiology for purposes of determining whether the Veteran's rheumatoid arthritis is a medically explained diagnosed illness/disability. In so doing, please respond to the following: (a.) Is the etiology of the Veteran's rheumatoid arthritis completely or partially understood? (b.) Is the pathophysiology of the Veteran's rheumatoid arthritis completely or partially understood? For the purposes of this opinion, the examiner is advised that pathophysiology is defined as "the physiology of abnormal states; spec[ifically]: the functional changes that accompany a particular syndrome or disease. Webster's Third New International Dictionary of the English Language Unabridged 1655 (1966)." Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). If the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. In rendering these opinions, the examiner is advised that discussing general risk factors for rheumatoid arthritis does not qualify as conclusive etiology or pathophysiology as it pertains to the Veteran's individual disability. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of any current left and right shoulder disabilities. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed, and all findings should be reported in detail. The examiner should diagnose any current left and right shoulder disabilities. For any diagnosed left and right shoulder disability, the examiner should render an opinion with respect to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability began during service or is otherwise related to service. In rendering this opinion, the examiner should specifically discuss the June 1995 service treatment records reflecting that the Veteran injured his left and right shoulders in June 1995. The record contains a line of duty determination for his left shoulder. A June 1995 Emergency Medical Care / Incapacitation Data Report notes that the Veteran "was lifting a Tool Box into the back of a vehicle when he heard a popping sound and pain in his left shoulder." He was diagnosed with a pulled muscle in his left shoulder. A June 1995 record notes that the Veteran "c/o poss sprained R shoulder while performing tasks at work." It notes that he "was lifting a tool box yesterday heard a pop in R shoulder & let box fall. C/o pain constant unable to dress up usually." Following examination, an assessment of "Bursitis with poss stress fx in clavicle." He received an individual sick slip a few days later prohibiting him, in relevant part, from "lifting with R arm." Even though the record does not contain a line of duty determination for the Veteran's right shoulder, for purposes of this opinion, the examiner should presume that the right shoulder injury did occur in the line of duty. Any opinion must contain a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 6. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of any current right knee disability and the severity of his left knee disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed, and all findings should be reported in detail. Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion (1) on BOTH active and passive motion, (2) in weight-bearing and non-weight-bearing, AND (3) with the range of the opposite undamaged joint. If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. The examiner must note whether the Veteran demonstrates objective evidence of pain on motion and, if so, at what degree of motion he demonstrates such objective evidence (e.g., 0 to 90 degrees with pain at 80 degrees). (b) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups assessed in terms of the degree of additional range of motion loss. In regard to flare-ups, if the Veteran is not currently experiencing a flare-up and if he reports that he does experience flare-ups, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran's functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. [The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran.] The examiner should diagnose any current right knee disability. For any diagnosed right knee disability, the examiner should render an opinion with respect to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability began during service or is otherwise related to service. In rendering this opinion, the examiner should specifically discuss the November 1985 record reflecting that the Veteran suffered a right knee injury when he "fell today on the flight deck striking his right patella on a still 'mushroom.' Pain and swelling now considerable. Tenderness and edema prevent thorough exam." An assessment of "Pre patellar bursitis? R/O fracture." Any opinion must contain a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 7. Following completion of the above, readjudicate the issues on appeal, to include the issues of entitlement to service connection for muscle pain, weakness, fatigability, and right ankle disability. If any requested benefit remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, 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.