Citation Nr: 21048717 Decision Date: 08/10/21 Archive Date: 08/10/21 DOCKET NO. 13-11 461 DATE: August 10, 2021 ORDER Service connection for chronic fatigue as secondary to posttraumatic stress disorder (PTSD) is granted. Service connection for degenerative arthritis of the right foot is granted. Service connection for degenerative arthritis of the left foot is granted. Service connection for degenerative arthritis of the right ankle is granted. Service connection for degenerative arthritis of the right knee is granted. Service connection for degenerative arthritis of the left knee is granted. REMANDED The issue of service connection for a skin disability is remanded. The issue of service connection for degenerative arthritis of the right elbow is remanded. The issue of service connection for degenerative arthritis of the left elbow is remanded. The issue of service connection for degenerative arthritis of the right hand is remanded. The issue of service connection for degenerative arthritis of the left hand is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his chronic fatigue was caused by his service-connected PTSD. 2. Resolving reasonable doubt in the Veteran's favor, the Veteran has experienced right foot pain related to degenerative arthritis of the right foot since his separation from service. 3. Resolving reasonable doubt in the Veteran's favor, the Veteran has experienced left foot pain related to degenerative arthritis of the right foot since his separation from service. 4. Resolving reasonable doubt in the Veteran's favor, the Veteran has experienced right ankle pain related to degenerative arthritis of the right ankle since his separation from service. 5. Resolving reasonable doubt in the Veteran's favor, the Veteran has experienced right knee pain related to degenerative arthritis of the right knee since his separation from service. 6. Resolving reasonable doubt in the Veteran's favor, the Veteran has experienced left knee pain related to degenerative arthritis of the left knee since his separation from service. CONCLUSIONS OF LAW 1. The criteria to establish service connection for chronic fatigue are met. 38 U.S.C. § 1131; 38 C.F.R. § 3.310. 2. The criteria for service connection for degenerative arthritis of the right foot are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for degenerative arthritis of the left foot are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for degenerative arthritis of the right ankle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for degenerative arthritis of the right knee are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for degenerative arthritis of the left knee are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1976 to May 1992, to include service in the Southwest Asia Theater of operations during the Persian Gulf War. The Veteran is also rated as totally disabled due to service-connected disorders ("TDIU") effective March 2012. This matter came before the Board of Veterans' Appeals (Board) on appeal from July 2011, November 2011, and January 2012 rating decisions of a Department of Veteran Affairs (VA) Regional Office (RO). In July 2018, the Board remanded the appeal to the RO for additional action. The Board directed the RO to obtain outstanding VA and/or private treatment records, scheduled new medical examinations and obtain adequate medical opinions. There has not been substantial compliance with previous remand directives regarding the remanded claims of service connection for a skin disability, bilateral elbows, and hands. Stegall v. West, 11 Vet. App. 268 (1998). 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). Certain chronic diseases will be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Service connection for chronic fatigue The Veteran's PTSD is service connected and is evaluated as 70 percent disabling. He has chronic fatigue that is related to service-connected PTSD and the claim will be granted. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.310. Service treatment records are silent as to complaints or treatment for fatigue. However, post service treatment records reflect the Veteran's reports of fatigue beginning as early as 1999 through 2020. Throughout this time, the Veteran's fatigue was thought to be associated with various conditions to include his mental disorders. A November 2019 infectious disease VA examination report notes the Veteran reported having chronic fatigue that began in 1993. The examiner opined that the Veteran did not meet the criteria for a diagnosis of chronic fatigue syndrome but opined that the Veteran's chronic fatigue was more likely than not due to his PTSD. An additional VA medical opinion was obtained in November 2020. The examiner also opined that the Veteran's chronic fatigue was effected by his PTSD and other conditions. The Board will grant the claim based on the benefit-of-the-doubt doctrine. 2. Service connection for arthritis of the right foot 3. Service connection for arthritis of the left foot The Veteran has current right and left foot disabilities that are related to service and the claims will be granted. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A November 2019 foot VA examination noted the Veteran has current diagnoses of degenerative arthritis of the right and left foot. The question becomes whether the current disabilities are related to service. The evidence in favor of the claims include service treatment records from October 1983 and January 1986 that document the Veteran's reports of pain in the right and left foot following injury. Service treatment records also note the Veteran sustained a severe sprain to his left ankle which caused pain in his left foot. Post-service treatment records beginning in 1999 continued to note the Veteran's reports of pain and swelling of the feet and noted that Veteran had early arthritis of the right foot in 2001. The Veteran has reported that he continued to have the same symptoms of foot pain and swelling during and since service. The Veteran is competent to report that he has and had foot pain. His reports are credible and entitled to probative weight, as they are internally consistent and consistent with other evidence of record. Service connection for right and left foot degenerative arthritis is warranted and the appeal is allowed. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Below, the Board is also granting service connection for a right ankle disorder. The Board expresses no opinion regarding the severity of the right and left foot arthritis disorders. The RO will assign an appropriate disability rating on receipt of this decision. Ferenc v. Nicholson, 20 Vet. App. 58 (2006) (discussing the distinction in the terms "compensation," "rating," and "service connection" as although related, each having a distinct meaning as specified by Congress). In determining an appropriate disability rating, the RO will determine whether the right foot and right ankle disorders involve the same or different symptoms, as opposed to the Board's current determination that they were incurred during or because of military service. Compare 38 C.F.R. § 4.14 (the evaluation of the " same disability " or the " same manifestation " under various diagnoses is to be avoided) and Esteban v. Brown, 6 Vet. App. 259 (1994) (while pyramiding of disabilities is to be avoided pursuant to 38 U.S.C. § 1155 and 38 C.F.R. § 4.14, it is possible for a veteran to have separate and distinct manifestations from the same injury permitting two different disability ratings). 4. Service connection for a right ankle disability The Veteran has a current right ankle disability that is related to service and the claim will be granted. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A November 2019 ankle VA examination noted the Veteran has a current diagnosis of degenerative arthritis of the right ankle. The question becomes whether the current disability is related to service. The evidence in favor of the claim includes service treatment records from September 1986 that note the Veteran was involved in a motor vehicle accident that caused severe body trauma. Post service treatment records beginning in 1999 continued to note the Veteran's reports of swelling of the ankles The Veteran has reported that he continues having right ankle pain and swelling during and since service. The Veteran is competent to report that he has ankle pain. His reports are credible and entitled to probative weight, as they are internally consistent and consistent with other evidence of record, which shows the Veteran's right ankle pain was attributable to the Veteran's degenerative arthritis. Service connection for right ankle degenerative arthritis is warranted and the appeal is allowed. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Service connection for right knee arthritis 6. Service connection for left knee arthritis The Veteran has current right and left knee disabilities that are related to service and the claims will be granted. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A November 2019 knee VA examination noted the Veteran has current diagnoses of degenerative arthritis of the right and left knee. The question becomes whether the current disabilities are related to service. The evidence in favor of the claims include service treatment records from December 1980 that document the Veteran's reports of pain in the left knee after a piece of metal lodged into his left thigh while chopping wood. The Veteran had surgery to remove the metal lodged just above the left knee. Service treatment records also note the Veteran sustained injury to his right knee after falling and was diagnosed with a right knee strain and placed on a limited profile for 90 days. As noted above, the Veteran had severe body trauma following a September 1986 motor vehicle accident. Post service treatment records beginning in 1999 continued to note the Veteran's reports of pain and swelling of the knees. The Veteran has reported that he had and has knee pain and swelling during and since service. The Veteran is competent to report these symptoms. His reports are credible and entitled to probative weight, as they are internally consistent and consistent with other evidence of record, which shows the Veteran's right and left knee pain were attributable to the Veteran's degenerative arthritis. Service connection for right and left knee degenerative arthritis is warranted and the appeal is allowed. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. The issue of service connection for a skin disability is remanded. 2. The issues of service connection for degenerative arthritis of the right and left elbows are remanded. 3. The issues of service connection for degenerative arthritis of the right and left hands are remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran contends service connection is warranted for these disabilities as they are a result of his service, to include his service in Southwest Asia. There has not been substantial compliance with the Board's July 2018 remand directives. The RO was instructed to obtain adequate medical opinions that addressed the Veteran's contentions of in-service occurrences and exposures to determine whether theses disabilities were related to service to include toxin exposure in Southwest Asia. Regarding the skin disability, the examinations conducted in November 2019, September and November 2020 are inadequate. The November 2019 and September 2020 examiners noted there were no reports of a skin condition during service which is contrary to service treatment records that note the Veteran was treated for skin conditions. Additionally, the November 2019 examiner noted further examination should be conducted by a dermatologist. The September and November 2020 examiners were not dermatologist and did not provide adequate rationale for the opinions rendered. Regarding the elbows and hands, the November 2019 and November 2020 VA medical opinions note there were no reports of complaints or treatment for the elbows or hands during service. However, service treatment records note the Veteran's reports of right elbow and hand pain following repeated right shoulder and arm injuries. Service treatment records also note the Veteran injured his finger of his left hand and that he sustained severe trauma to his upper body following a motor vehicle accident. As the evidence of in-service occurrence of skin treatment, elbow and hand pain were not taken into consideration as instructed in the Board's July 2018 decision, a remand is required. The remand directives follow. 2. Schedule the Veteran for a VA examination by a dermatologist to determine the etiology of any skin disabilities. The electronic file, including a copy of the Remand, must be reviewed by, the VA examiner. All appropriate tests, studies, and consultations must be done, and all clinical findings must be reported in detail. 3. Schedule the Veteran for a VA examination by a suitable clinician to determine the etiology of any bilateral elbow and hand disabilities. The electronic file, including a copy of the Remand, must be reviewed by, the VA examiner. All appropriate tests, studies, and consultations must be done, and all clinical findings must be reported in detail. 4. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinions: (a.) Whether the Veteran's skin, bilateral elbow and hand disabilities were caused by or aggravated by any in-service event, injury, or disease, to include toxin exposure during his service in Southwest Asia. (b.) Whether the Veteran's bilateral elbow and hand disabilities were caused by or aggravated by any service-connected disability. The examiner is advised: 5. He/she must fully explain the opinions. A summary conclusion is not sufficient under the law and the opinion will be returned for further clarification. THE EXAMINER MUST ALSO EXPRESS AN OPINION OF WHETHER THE VETERAN'S ACCOUNT OF THE DEVELOPMENT OF THE DISABILITIES IS CONSISTENT WITH THE MEDICAL EVIDENCE AND THE EXAMINER'S KNOWLEDGE AND PRACTICE EXPERIENCE. The examiner must review the entire record in conjunction with making the requested opinions. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner's attention is drawn to the following: *In September 1977, the Veteran was seen for complaints of a skin condition around his fingernails. He was diagnosed with perinicium and warts of the hands. *In March 1980 the Veteran was seen for reports of a skin rash on the face, arms, knees, crotch, and sides. The Veteran was thought to have a poison oak infection. *In December 1980, service treatment records note the Veteran was seen for an injury to his left thigh after a piece of metal was lodged into it while he chopped wood and the skin around the area developed cellulitis. *A June 2009 VA treatment record reflected objective findings of multiple erythematous plaques with thick scale and crust on the trunk, arms, legs, buttocks, hands, and feet and noted psoriasis was the most likely diagnosis considering his joint pain. *A July 2009 VA treatment record reflects that a June 2009 punch biopsy of the back and chest revealed the differential diagnosis of allergic contact dermatitis, nummular dermatitis, ID reaction, or pityriasis rubra pilaris. *The Veteran has confirmed Southwest Asia service and was possibly exposed to the nerve agents sarin and cyclo sarin. *In May 1984, the Veteran was noted to have a foreign body in his right elbow. *In January 1986, the Veteran was seen for injury to his left first finger. *In September 1986 the Veteran was involved in a motor vehicle accident and sustained severe upper body trauma. *In 1988, the Veteran sustained repeated injury to his right arm and shoulder while playing racquet ball and doing pushups. The Veteran also fell a few times during service injuring his right arm. It was noted on occasion that the pain from his right shoulder would radiate down to his right elbow and hand. *In December 1999 VA treatment records note the Veteran reported another episode of swelling of his hands. *Service connection is in effect for posttraumatic arthritis of the right shoulder, PTSD, chronic headaches, left ankle degenerative joint disease, tinnitus, and bilateral hearing loss and per this decision, chronic fatigue and degenerative arthritis of the feet, right ankle, and knees. (CONTINUED ON NEXT PAGE) 6. After completing the requested actions, and any additional actions considered warranted, readjudicate the claims on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be given a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDuffie, 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.