Citation Nr: 22013641 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 16-37 380 DATE: March 10, 2022 ORDER Entitlement to service connection for irritable bowel syndrome (IBS) is granted. Entitlement to service connection for shortness of breath, as an undiagnosed illness, is granted. Entitlement to service connection for left hip pain, as an undiagnosed illness, is granted. Entitlement to service connection for right hip pain, as an undiagnosed illness, is granted. Entitlement to service connection for right third finger PIP [proximal interphalangeal] joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for right third finger DIP [distal interphalangeal] joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for right fourth finger PIP joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for right fourth finger DIP joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for left second finger PIP joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for left second finger DIP joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for left third finger PIP joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for left third finger DIP joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for left fourth finger PIP joint pain, as an undiagnosed illness, is granted. Entitlement to service connection for left fourth finger DIP joint pain, as an undiagnosed illness, is granted. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for chronic fatigue syndrome (CFS) is remanded. FINDINGS OF FACT 1. The Veteran, a Persian Gulf Veteran, has had IBS during the appeal period. 2. The Veteran, a Persian Gulf Veteran, has, during the appeal period, had shortness of breath that has not been attributed to any known clinical diagnosis. 3. The Veteran, a Persian Gulf Veteran, has, during the appeal period, had joint pain, specifically (1) left hip pain, (2) right hip pain, (3) right third finger PIP joint pain, (4) right third finger DIP joint pain, (5) right fourth finger PIP joint pain, (6) right fourth finger DIP joint pain, (7) left second finger PIP joint pain, (8) left second finger DIP joint pain, (9) left third finger PIP joint pain, (10) left third finger DIP joint pain, (11) left fourth finger PIP joint pain, (12) and left fourth finger DIP joint pain, that has not been attributed to any known clinical diagnosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for IBS have been met. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 2. The criteria for entitlement to service connection for shortness of breath, as an undiagnosed illness, have been met. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 3. The criteria for entitlement to service connection for (1) left hip pain, (2) right hip pain, (3) right third finger PIP joint pain, (4) right third finger DIP joint pain, (5) right fourth finger PIP joint pain, (6) right fourth finger DIP joint pain, (7) left second finger PIP joint pain, (8) left second finger DIP joint pain, (9) left third finger PIP joint pain, (10) left third finger DIP joint pain, (11) left fourth finger PIP joint pain, (12) and left fourth finger DIP joint pain, as undiagnosed illnesses, have been met. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from October 1983 to December 1991, to include service in the Southwest Asia theater of operations. He was awarded the Combat Action Ribbon. This case comes before the Board of Veterans' Appeals (Board) from August 2015 and October 2016 rating decisions. In May 2020, the Board remanded the claims on appeal. 1. Service Connection IBS Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. For a veteran who had active service in the Southwest Asia theater of operations during the Persian Gulf War (a Persian Gulf veteran), service connection may be established for a qualifying chronic disability, which specifically includes a medically unexplained chronic multisymptom illness (MUCMI). See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. IBS is noted as an example of a MUCMI under 38 U.S.C. § 1117(a)(2)(B) ("A [MUCMI] (such as...[IBS]"). In addition, functional gastrointestinal disorders are specifically listed as MUCMIs under 38 C.F.R. § 3.317(a)(2)(i)(B)(3). A Note to the cited regulation defines functional gastrointestinal disorders and states, as relevant, that "[s]pecific functional gastrointestinal disorders include, but are not limited to, [IBS]." In review, IBS is a MUCMI and a qualifying chronic disability pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The Veteran's service personnel records noted that he served in "SWA/Persian Gulf" from December 1990 to June 1991. See Individual Deployment Record. In addition, a Fitness Report for a period in 1991 noted that the Veteran "[p]erformed well while on combat operation[s] in Kuwait." As such, the Veteran had active service in the Southwest Asia theater of operations during the Persian Gulf War and he is therefore a Persian Gulf Veteran. See 38 C.F.R. § 3.317(e) (including Kuwait in the definition of the Southwest Asia theater of operations), 38 C.F.R. § 3.2(i) (defining the Persian Gulf War as from "August 2, 1990 through date to be prescribed by Presidential proclamation or law"). Accordingly, the Veteran is eligible for service connection under the provisions discussed above related to Persian Gulf veterans (i.e., 38 U.S.C. § 1117 and 38 C.F.R. § 3.317). Analysis Upon review, the Board finds that service connection is warranted for IBS. As referenced, service connection may be established pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 for a MUCMI and IBS is a MUCMI for purposes of that law and regulation. As such, a key issue is whether the Veteran has had IBS during the appeal period. After review of the evidence, the Board finds that the Veteran has had IBS during the appeal period. In this regard, the Board affords significant probative value to a March 2021 Intestinal Conditions Disability Benefits Questionnaire (DBQ), which was completed by Dr. M.B. following an in-person examination of the Veteran and review of the electronic claims file. This DBQ noted a diagnosis of IBS. The Board also notes that a June 2017 VA primary care record noted an impression of "[history consistent with IBS]." The Board acknowledges that a negative direct service connection opinion was provided in March 2021 by Dr. M.B. The Board, however, finds that this opinion is not sufficient affirmative evidence that the Veteran's IBS was not incurred during active service in the Southwest Asia theater of operations. See 38 C.F.R. § 3.317(a)(7)(i). In this regard, the Board finds this opinion inadequate. Specifically, the opinion did not clearly address whether the Veteran's IBS was directly related to the Veteran's Southwest Asia theater of operations service, to include any related environmental exposures, but rather generally addressed whether IBS was related to active service. In addition, the opinion appeared to impermissibly ignore the Veteran's lay report of the onset of symptoms being in 1991. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) ("it appears that the medical examiner impermissibly ignored the appellant's lay assertions"); Miller v. Wilkie, 32 Vet. App. 249, 260 (2020) ("The examiner must address the veteran's lay statements to provide the Board with an adequate medical opinion"). In this regard, the opinion relied, at least in part, on that "[t]he [Veteran] was never seen for any digestive changes, pain, condition, diarrhea or constipation while he was in service from 1983 to 1991," without discussing or apparently considering that the Veteran reported the onset of symptoms as occurring in 1991 (the March 2021 Intestinal Conditions DBQ stated regarding IBS that "[t]he condition started in June 1991. The condition began from being in the gulf war Theat[er]. When the condition began the symptoms were constipation, diarrhea, and abdominal pain"). As such, the Board finds this opinion inadequate and therefore that it is not sufficient affirmative evidence that the Veteran's IBS was not incurred during active service in the Southwest Asia theater of operations In sum, the Board finds that the Veteran, a Persian Gulf Veteran, has had IBS during the appeal period. As the Veteran is a Persian Gulf Veteran and has had a qualifying chronic disability of IBS, the Board concludes that the criteria for entitlement to service connection for IBS have been met and, to this extent, the Veteran's claim is therefore granted. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 2. Service Connection Shortness of Breath Procedural History and Legal Criteria In March 2014, the Veteran filed a claim (on a VA Form 21-526EZ) for "shortness of breath (Respiratory cond[ition])." A July 2014 rating decision denied service connection for "shortness of breath." In August 2016, the Veteran filed a claim (on a VA Form 21-526EZ) for "bilateral lung condition." An October 2016 rating decision stated that "[t]he claim for service connection for shortness of breath (now claimed as a bilateral lung condition) remains denied because the evidence submitted is not new and material." A May 2020 Board decision stated that "[t]he petition to reopen the previously denied claim of entitlement to service connection for a lung condition, including shortness of breath, is granted." The Board also remanded a claim of service connection for "a lung condition, including shortness of breath." As noted above, the Veteran is a Persian Gulf Veteran and is thus eligible for service connection under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. Under this law and regulation, service connection may be established for a qualifying chronic disability, which includes an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii) notes that a qualifying chronic disability is one that "[b]y history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis." 38 U.S.C. § 1117(g) outlines "signs or symptoms that may be a manifestation of an undiagnosed illness" and one listed item is "[s]igns or symptoms involving the upper or lower respiratory system." 38 C.F.R. § 3.317(a)(1) indicates that "objective indications of a qualifying chronic disability" are required for service connection in this context and 38 C.F.R. § 3.317(b) outlines a nonlimiting example list of signs or symptoms "which may be manifestations of undiagnosed illness," which includes "[s]igns or symptoms involving the respiratory system (upper or lower)." Analysis Upon review, and after resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for shortness of breath, as an undiagnosed illness, is warranted. See 38 C.F.R. § 3.102 ("When...a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant"). The evidence of record indicated that, during the appeal period, the Veteran has competently reported experiencing shortness of breath, which is a symptom related to the respiratory system. See 38 C.F.R. § 3.159(a)(2) (defining competent lay evidence). As noted, respiratory symptoms are noted under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 as manifestations of undiagnosed illness. Moreover, the evidence did not attribute the Veteran's reported shortness of breath to any known clinical diagnosis. In this regard, the Veteran was afforded a VA examination in January 2021 and a Respiratory Conditions DBQ was completed by Dr. M.B. The examiner marked no in response to a question of "[d]oes the Veteran now have or has he or she ever been diagnosed with a respiratory condition." Under the medical history section, it was stated "[f]or lung condition; shortness of breath, the history is described below: 06/1991 Persian Gulf war operation Desert Storm in Kuwait[.] After being next to the oil well fires[]it was hard to breathe[.] Not treated[.]" and "[h]ard breathing and hard to catch his breath[.] He gets out of breath more easily at work and when trying to exercise[.]" Under the remarks heading, the examiner stated "[f]or the [Veteran's] claimed condition of lung condition there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. For the [Veteran's] claimed condition of shortness of breath there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis." The Veteran was afforded another VA examination in March 2021 and a Respiratory Conditions DBQ was again completed by Dr. M.B. This DBQ contained similar information to the prior DBQ. In this regard, the examiner marked no to the same question quoted earlier regarding whether the Veteran has been diagnosed with a respiratory condition. The medical history section included similar information, to include that "[t]he condition started in June 1991" and that "[t]he current symptoms are...having a hard time catching a breath." Under the remarks heading, the examiner stated that "[f]or the [Veteran's] claimed condition of [s]hortness of breath there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis." Dr. M.B. also provided three negative direct service connection opinions: a February 2021 opinion related to shortness of breath, a February 2021 opinion related to "lung condition" and an April 2021 opinion related to shortness of breath. As relevant, the April 2021 opinion stated that "the [Veteran's] main complaint[] [is]...having a hard time catching his breath" and "the [Veteran's] "main complaint is...shortness of breath." In addition, the February 2021 lung condition opinion stated that "[c]urrent examination shows a normal PFT and chest x-ray. Therefore no diagnosis is given." See also January 2021 Chest X-Ray Report (including an impression of "[n]o acute pathology"); March 2021 Chest X-Ray Report (including an impression of "[n]o abnormality in the chest"). Upon review of the January 2021 and March 2021 VA DBQs and opinions, such essentially noted the Veteran's competent report of shortness of breath and did not attribute the reported shortness of breath to any known clinical diagnosis. The Board affords significant probative value to these examination reports, which were prepared following examinations of the Veteran specifically in the context of evaluating his claim for disability benefits. Again, the examiner did not a diagnosis related to the Veteran's shortness of breath. See Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014) (rejecting the concept "that a veteran must be subjected to all possible medical testing available and then 'diagnosed' with an 'undiagnosed illness' after all possible medical conditions have been ruled out" and "[t]he statute and regulation require only that the veteran has been evaluated and no diagnosis could be made concerning the cause of the qualifying chronic disability"). The remaining evidence of record during the appeal period did not otherwise attribute the Veteran's reported shortness of breath to any known clinical diagnosis. Overall, the Board finds that there is currently sufficient evidence to determine that the Veteran's shortness of breath, as an undiagnosed illness, is a qualifying chronic disability pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); As referenced, Dr. M.B. provided three negative direct service connection opinions. Initially, the Board notes that a direct service connection "nexus" opinion is not required pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See Gutierrez v. Principi, 19 Vet. App. 1, 8 (2004) ("Congress has decided as a matter of policy, stemming at least in part from difficulty of proof, that, even though a Persian Gulf War veteran's symptoms may not at this time be attributed to a specific disease, the symptoms may nonetheless be related to conditions in the Southwest Asia theater of operations and, for that reason, are presumed to be service connected" and that the Veteran "was not required to provide evidence linking his current conditions to events during service and the Board erred by imposing such a nexus requirement"). Moreover, the Board finds that these opinions are not sufficient affirmative evidence that the Veteran's shortness of breath was not incurred during active service in the Southwest Asia theater of operations. See 38 C.F.R. § 3.317(a)(7)(i). In this regard, the February 2021 opinions did not affirmatively attribute the Veteran's shortness of breath to a different cause, but rather essentially indicated that there was no diagnosis of shortness of breath or a lung condition. As to the April 2021 opinion, such stated that "[t]he [Veteran] is currently 56 years old, he has a history of hypertension and diabetes. He is also moderately obese" and that "[b]ased on these there are other factors that may lead to his shortness of breath and fatigue but there are no pulmonary conditions than can be attributed to his service or to any Gulf War syndrome with unexplained etiology." Based on the speculative language used ("may lead to"), the Board affords this opinion minimal probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the factually accurate, fully articulated, sound reasoning for the conclusion...that contributes probative value to a medical opinion"). Overall, the Board finds that the three 2021 negative direct service connection opinions from Dr. M.B. are not sufficient affirmative evidence that the Veteran's shortness of breath was not incurred during active service in the Southwest Asia theater of operations. In sum, the Board finds that the Veteran, a Persian Gulf Veteran, has, during the appeal period, had shortness of breath that has not been attributed to any known clinical diagnosis. As such, the Board concludes that the criteria for entitlement to service connection for shortness of breath, as an undiagnosed illness, have been met and, to this extent, the Veteran's claim is therefore granted. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 3. Service Connection Multiple Joint Pain Scope of Claim In March 2014, the Veteran filed a claim (on a VA Form 21-526EZ) for "joint pain." He also listed various other disabilities that included specific body parts: bilateral knees, left shoulder and left ankle. A July 2014 rating decision denied service connection for "joint pain." The rating decision also separately granted service connection for a left shoulder disability and a left ankle disability and denied service connection for bilateral knee disabilities. In March 2015, the Veteran filed a claim (on a VA Form 21-526EZ) for "Gulf War Syndrome/undiagnosed illnesses." On a separate VA Form 21-4138, the Veteran stated that "I have multiple joint pain, without any physical event to cause the pain. I have pain in individual joints on no particular 'schedule.'" An August 2015 rating decision denied service connection for "multiple joint pain" and "gulf war syndrome/undiagnosed illnesses." An October 2016 rating decision specifically denied service connection for a low back condition and a right ankle condition. In May 2020, the Board remanded a claim characterized as "service connection for multiple joint and muscle pain." In review, as to the claim on appeal, the Veteran generally claimed "multiple joint pain." A separate and unappealed rating decision denied service connection for a low back condition and a right ankle condition, while the Veteran has been granted service connection for a left shoulder disability and a left ankle disability. In addition, separately on appeal is a claim for service connection for left and right knee disabilities, which have been treated as separate claims by VA. As such, the Board will construe the Veteran's "joint pain" claim to relate to areas of the body distinct from those that have already been granted service connection (left shoulder and left ankle), denied service connection (low back and right ankle) or that have been treated as separate claims (bilateral knees). Legal Criteria As noted above, the Veteran is a Persian Gulf Veteran and is thus eligible for service connection under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, which allows for service connection for an undiagnosed illness. 38 U.S.C. § 1117(g) outlines "signs or symptoms that may be a manifestation of an undiagnosed illness" and two listed items are "[m]uscle pain" and "[j]oint pain." 38 C.F.R. § 3.317(b) outlines a nonlimiting example list of signs or symptoms "which may be manifestations of undiagnosed illness," which also includes "[m]uscle pain" and "[j]oint pain." Analysis Upon review, and after resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for multiple joint pains (as specifically identified further below), as undiagnosed illnesses, is warranted. See 38 C.F.R. § 3.102. The evidence of record indicated that, during the appeal period, the Veteran has competently reported experiencing joint pain. As noted, joint pain is a symptom listed under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 as manifestations of undiagnosed illness. Moreover, the evidence did not attribute the Veteran's reported joint pain to any known clinical diagnosis. In this regard, the Veteran was afforded various VA examinations in August 2015. A Hip and Thigh Conditions DBQ was completed by Dr. M.H. The examiner marked a box stating that "[t]he Veteran does not have a current diagnosis associated with any claimed condition listed above." Under the medical history section, noted was: He states he has pain in his "hips." He points to the location, which is poste[r]ior ilium bilaterally. He states pain started 1 year ago, and it feels "like a stiffness." " I try to stretch it by bending side to side." No triggers, occurs 8-12 days out of a month. He just tolerates it, it does not interfere with functional activities, and he has not sought medical attention for it. diagnosis: no diagnosis. There is insufficient evidence to warrant or confirm a diagnosis of a condition. The posterior ilium is not a joint. Location and history is suggestive of a condition. Dr. M.H. also completed a Hand and Finger Conditions DBQ. The examiner marked a box stating that "[t]he Veteran does not have a current diagnosis associated with any claimed condition listed above." Under the remarks section, noted was: He states the right 3rd and 4th fingers, and 2nd, 3rd, 4th fingers of left hand hurt. Location is PIP and DIP joints. They hurt at random times, no triggers. They hurt now, just sitting. It started 3 years ago. They hurt 10 days out of a month. He tolerates it, it does not interfere with functional activities, and he has not sought medical care. On exam, hands appeared normal, without joint deformity, without enlarge[e]ment or swelling, or erythema. Motor was normal. VA treatment notes do not mention a hand problem. diagnosis: no diagnosis. There is insufficient evidence to warrant or confirm a diagnosis of a condition. Exam, history, and documentation was not suggestive of a condition. In May 2020, the Board remanded the "multiple joint and muscle pain" claim for a new VA examination. The remand directives stated that "[t]he examiner must specifically address whether the claimed symptoms of joint pain, muscle pain...are attributable to a diagnosed condition." The Veteran was subsequently afforded multiple VA examinations. Knee and Lower Leg Conditions DBQs were completed, which will be further discussed below as part of the separate bilateral knee disabilities claims. The only other DBQ complete that potentially related to the joint and muscle pain claim remanded by the Board was a Fibromyalgia DBQ completed in March 2021 by Dr. M.B. The examiner marked a box indicating that the Veteran did not have a current diagnosis of fibromyalgia. As explanation, the examiner stated "[t]he [Veteran's] symptoms do not constitute fibro[my]algia: he complains of left shoulder pain, bilateral hand pain and bilateral knee pain. He does not have other symptoms such as lo[w] grade fever, pharyngitis, palpable cervical lymph nodes, headaches, or migratory joint pains. He does not have trigger points." Under the medical history section, it was stated that "[f]or the [m]ultiple joint pain; muscle pain condition the history is described below. The condition started in June 1991. The condition began over time. When the condition began the symptoms were joint pain. No, treatment has not been done" and that "[t]he current symptoms are pain in joints. The impact of the condition is when there is a flare up my job suffers." Under the remarks section, the examiner stated "[f]or the [Veteran's] claimed condition of muscle pain there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. For the [Veteran's] claimed condition of [m]ultiple joint pain please refer to the diagnosis section." Dr. M.B. also provided a negative direct service connection opinion in April 2021. The rationale provided stated that: Based on medical records review the patient has specific joint pains that were evaluated over time. He has had injuries to his ankle, shoulder and knee while in service. In 2010 it was noted that he had joint pains but was specified in his Gulf War registry and it was noted by the physician who examined him that it is at least as likely as not related to his age. On this examination fibromyalgia has not been diagnosed either. As noted the [Veteran's] symptoms did not constitute fibromyalgia, his main complaints include left shoulder, bilateral hand and bilateral knee pain. He has no other symptoms related or attributed to fibromyalgia and therefore there is no diagnosis of his chronic joint pains that may be associated with fibromyalgia that can be attributed to his exposure to being in the Persian Gulf from 1990 to 1991. The Board notes that the referenced 2010 Gulf War Registry note stated that the Veteran "has no specific complaints other than musculoskeletal pain but he is in his 40s and these are normal for anyone regardless of their past work or sports history." The Board observes that this note did not mention any specific musculoskeletal or joint pain and thus it is not clear that comment addressed or applied to the any joint pain noted during the current appeal. Upon review of the VA examinations conducted as part of the claim on appeal, such essentially noted the Veteran's competent reports of hip and bilateral hand/finger pain and did not attribute the reported pain to any known clinical diagnoses. The Board affords significant probative value to these examination reports, which were prepared following examinations of the Veteran specifically in the context of evaluating his claim for disability benefits. The joint pain reported by the Veteran can be a qualifying chronic disability pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014) ("We hold that the Veterans Court erred in concluding that pain cannot evidence a qualifying chronic disability under § 1117...the plain language of § 1117 makes clear that pain, such as muscle pain or joint pain, may establish an undiagnosed illness that causes a qualifying chronic disability"). Beyond the VA examinations and opinion discussed, the remaining evidence of record during the appeal period did not otherwise attribute the Veteran's reported joint pain to any known clinical diagnosis. To be sure, further development could potentially be warranted in this case, as, for example, following the May 2020 Board remand as to the general "joint and muscle" pain claim, the examiner in 2021 completed only a Fibromyalgia DBQ and did not complete a Hip and Thigh Conditions DBQ or a Hand and Fingers DBQ, like were completed in 2015. In light of the evidence obtained in the course of this claim, however, the Board will resolve reasonable doubt in the Veteran's favor and find that there is currently sufficient evidence to determine that the Veteran's joint pain, as an undiagnosed illness, is a qualifying chronic disability pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See 38 C.F.R. § 3.304(c); see also Mariano v. Principi, 17 Vet. App. 305, 312 (2003) ("it would not be permissible for VA to undertake...additional development if a purpose was to obtain evidence against an appellant's case"). With respect to what is specifically being granted service connection, the scope of the claim was discussed above. As noted, the Board will construe the Veteran's "joint pain" claim to relate to areas of the body distinct from those that have already been granted service connection (left shoulder and left ankle), denied service connection (low back and right ankle) or that have been treated as separate claims (bilateral knees). Based on the VA examinations discussed above, the remaining distinct body areas included (1) left hip pain, (2) right hip pain, (3) right third finger PIP joint pain, (4) right third finger DIP joint pain, (5) right fourth finger PIP joint pain, (6) right fourth finger DIP joint pain, (7) left second finger PIP joint pain, (8) left second finger DIP joint pain, (9) left third finger PIP joint pain, (10) left third finger DIP joint pain, (11) left fourth finger PIP joint pain, (12) and left fourth finger DIP joint pain. These specific joints have been identified during the appeal period as having joint pain and such pain has not been attributed to any known clinical diagnosis. As each item listed relates to a specific joint, the Board finds that separately characterizing the claims being granted more clearly and precisely explains the decision reached by the Board. The Board finds that this decision represents a full grant of benefits as to this claim, as all identified joint pain during the appeal period has been granted or denied service connection or is being separately addressed. In sum, the Board finds that the Veteran, a Persian Gulf Veteran, has, during the appeal period, had joint pain, specifically (1) left hip pain, (2) right hip pain, (3) right third finger PIP joint pain, (4) right third finger DIP joint pain, (5) right fourth finger PIP joint pain, (6) right fourth finger DIP joint pain, (7) left second finger PIP joint pain, (8) left second finger DIP joint pain, (9) left third finger PIP joint pain, (10) left third finger DIP joint pain, (11) left fourth finger PIP joint pain, (12) and left fourth finger DIP joint pain, that has not been attributed to any known clinical diagnosis. As such, the Board concludes that the criteria for entitlement to service connection for multiple joint pains (as specifically identified above), as undiagnosed illnesses, have been met and, to this extent, the Veteran's claims are therefore granted. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. REASONS FOR REMAND 1. Service Connection Right Knee Disability Upon review, the Board finds that remand is warranted to obtain a new VA opinion. In May 2020, the Board remanded this claim to obtain a VA examination and opinion. A portion of the remand directives stated that "[t]he examiner is advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so" (emphasis added). The Veteran was subsequently afforded VA examinations in January and March 2021, with Knee and Lower Leg Conditions DBQs completed by Dr. M.B. Diagnoses were noted of osteoarthritis and Osgood Schlatter's disease. On the January 2021 DBQ, it was stated under the medical history section "[f]or bilateral knee condition, the history is described below: 1986[.] He was in the infantry and had to carry heavy weapons and back pack[.] Knee and shin pain." On the March 2021 DBQ, it was stated under the medical history section "[t]he condition started in June 1991. The condition began around June 1991. When the condition began the symptoms were stiffness and pain in knees." In review, both DBQs documented the Veteran's report of the onset of knee symptoms as during service. Dr. M.B. also provided two negative direct service connection opinions in February 2021 and April 2021. The provided rationales, however, did not discuss or address the Veteran's report of the onset of knee symptoms as during service. This raises substantial compliance issues with respect to the May 2020 Board remand language quoted above. See Stegall v. West, 11 Vet. App. 268 (1998). Moreover, as the rationale did not address such, the opinions appeared to impermissibly ignore the Veteran's lay report of the onset of symptoms being during service. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007); Miller v. Wilkie, 32 Vet. App. 249, 260 (2020). As such, the Board finds that remand is warranted to obtain a new VA opinion, as outlined further in the remand directives below. In addition, while on remand, VA must attempt to obtain outstanding VA treatment records. See 38 U.S.C. § 5103A(c)(1)(B); 38 C.F.R. § 3.159(c)(3); see also Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) ("We hold that [38 C.F.R] § 3.159(c)(3) extends the VA's duty to assist to obtaining sufficiently identified VA medical records...regardless of their relevance"). In this regard, a June 2014 Knee and Lower Leg Conditions DBQ noted under the medical history section that "[t]he Veteran states he has a 'knot' on his right knee that hurts at times...He states that he went to the VA for this around 1994 (got out of service in 1991). He states that he got Motrin at that time and that he uses this occasionally." Copies of electronic VA treatment records are of record dating from 2010, but there does not appear to have been any attempt to obtain copies of any earlier archived/retired paper records. While the Veteran did not specifically identify a VA location for the reported treatment, the most contemporaneous (to 1994) address noted in the claims file (from an August 1992 letter) was in San Diego, California. As such, the Board will presume that the Veteran's reported treatment was at the San Diego VA Medical Center (VAMC). The Veteran is advised to inform VA if this is not the correct location of his reported 1994 treatment. In review, while on remand, the Board finds that a specific request is warranted to attempt to obtain copies of any archived/retired paper records from the San Diego VAMC from 1994. Finally, while on remand, any more recent VA outstanding VA treatment records must also be obtained (the most recent records of record are from September 2020). 2. Service Connection Left Knee Disability Upon review, the Board finds that remand is warranted to obtain a new VA opinion. In May 2020, the Board remanded this claim to obtain a VA examination and opinion. As noted, the Veteran was subsequently afforded VA examinations in January and March 2021, with Knee and Lower Leg Conditions DBQs completed by Dr. M.B. Diagnoses were noted of patellofemoral pain syndrome and "Calcific Tendinitis, Quadriceps Tendon, Left Knee." Dr. M.B. also provided two negative direct service connection opinions in February 2021 and April 2021. The rationale for the April 2021 opinion stated in part that the Veteran "has worked for physical type of job since 1993 and continues to do so...Based on these it is at least as likely as not that the [Veteran's] current left knee condition is related to his physical labor and age process over the last 30 years." The Board notes that 30 years prior to the April 2021 opinion would be April 1991, which would be during the Veteran's active service (which did not end until December 1991). As such, while this was a negative direct service connection opinion, the rationale, at least in part, related the Veteran's disability to his active service. It is not clear if this was an oversight by the examiner or purposeful. In addition, while the rationale noted the Veteran's post-service physical work, it did not specifically address the physical nature of the Veteran's active service and the Veteran has, essentially, contended that his knee disability is related to such. See February 2017 VA Form 646 (Statement of Accredited Representative in Appealed Case) ("Service connection for left knee condition, [V]eteran contends that the wear and tear on body as a US Marine caused his issues"). In light of the issues noted, the Board finds that remand is warranted to obtain a new VA opinion, as outlined further in the remand directives below. 3. Service Connection CFS The Board finds that remand is also required for this claim, as it is inextricably intertwined at this time with the bilateral knee disability claims being remanded, specifically with respect to the outstanding VA treatment records being requested. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Finally, the previous examiners were asked to opine if it was "at least as likely as not (a 50 percent or greater probability)" that the Veteran's cardiac disabilities were connected to service. This language found in the previous remands entitled the Veteran to the benefit of the doubt if the evidence was in equipoise. Following direction from the United States Court of Appeals for the Federal Circuit in Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021), the proper standard of review is whether the factors are in an "approximate balance." Lynch held that the Veteran is entitled to the benefit of the doubt when the evidence is in an approximate balance - i.e. nearly equal - and does not require the evidence to be in exact equipoise. See id. The matters are REMANDED for the following action: 1. Attempt to obtain outstanding VA treatment records, which specifically includes: (a.) VA treatment records from September 2020 to the present. (b.) Copies of any archived/retired paper records from the San Diego VAMC from 1994. See June 2014 Knee and Lower Leg Conditions DBQ ("The Veteran states he has a 'knot' on his right knee that hurts at times...He states that he went to the VA for this around 1994"). 2. Obtain an opinion from a medical professional that addresses the Veteran's left and right knee disability claims. If the medical professional determines that additional examination of the Veteran is necessary to provide an adequate opinion, such examination must be scheduled. The medical professional must provide an opinion addressing the following: (a.) Whether it is at least as likely as not (i.e., an approximate balance of positive and negative evidence) that any right knee disability had its onset during service or is otherwise related to service. (b.) Whether it is at least as likely as not (i.e.,an approximate balance of positive and negative evidence) that any left knee disability had its onset during service or is otherwise related to service. The medical professional's attention is invited to: (a.) The diagnoses noted upon prior VA examinations, which included: i. For the right knee, medial tibial stress syndrome (with a date of diagnosis noted of 1987 on the June 2014 Knee and Lower Leg Conditions DBQ); osteoarthritis and Osgood Schlatter's disease (noted on the January 2021 and March 2021 Knee and Lower Leg Conditions DBQs). ii. For the left knee, medial tibial stress syndrome (with a date of diagnosis noted of 1987 on the June 2014 Knee and Lower Leg Conditions DBQ); patellofemoral pain syndrome (noted on the January 2021 Knee and Lower Leg Conditions DBQ) and "Calcific Tendinitis, Quadriceps Tendon, Left Knee" (noted on the March 2021 Knee and Lower Leg Conditions DBQ). (b.) The contention that "the wear and tear on body as a US Marine caused his" bilateral knee disabilities. See February 2017 VA Form 646 (Statement of Accredited Representative in Appealed Case). (c.) The Veteran's report of, essentially, the in-service onset of bilateral knee symptoms, to include in: i. A January 2021 Knee and Lower Leg Conditions DBQ, which stated "[f]or bilateral knee condition, the history is described below: 1986[.] He was in the infantry and had to carry heavy weapons and back pack[.] Knee and shin pain." ii. A March 2021 Knee and Lower Leg Conditions DBQ, which stated "[t]he condition started in June 1991. The condition began around June 1991. When the condition began the symptoms were stiffness and pain in knees." (d.) STRs documenting treatment related to the left knee, to include: i. A January 1990 STR, which noted a complaint of left knee pain for approximately one month and noted an assessment of chondromalacia patella (abbreviated CMP) "mild-moderate." ii. A March 1990 STR, which noted a complaint of left knee pain, that "has been seen before for same problems and no relief" and noted an assessment of "possible meniscus injury." iii. A March 1990 STR (a Consultation Report), which noted a three month history of left knee pain and giving way and that "NSAIDs, light duty, PT have been ineffective." iv. A July 1990 Reenlistment Report of Medical History, where the Veteran reported ever having or having now "'Trick' or locked knee" and "knee giving out 'awhile' ago." For all opinions provided, the medical professional must include the underlying reasons for any conclusions reached. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Hoopengardner, 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.