Citation Nr: 22014058 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 16-08 625 DATE: March 11, 2022 ORDER Service connection for a thoracolumbar spine disability is granted. REMANDED Entitlement to service connection for residuals of frostbite of the right lower extremity is remanded. Entitlement to service connection for residuals of frostbite of the left lower extremity is remanded. Entitlement to service connection for a right trench foot. Entitlement to service connection for a left trench foot. Entitlement to service connection for bilateral plantar fasciitis. FINDING OF FACT The Veteran's a thoracolumbar spine disability had its onset in service. CONCLUSION OF LAW The criteria for service connection a thoracolumbar spine disability have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 1154(a), (b), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Marine Corps from October 2007 to December 2011, including service in Iraq. This matter is before the Board of Veterans' Appeals (Board) on appeal of an April 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that denied service connection for a thoracolumbar spine disability (listed as a slipped disc, back); residuals of frostbite of the right lower extremity (listed as a cold injury of the right lower extremity, claimed as frostbite of the bilateral feet); residuals of frostbite of the left lower extremity (listed as a cold injury of the left lower extremity, claimed as frostbite of the bilateral feet); right trench foot (listed trench foot, right foot, claimed as bilateral trench foot); for left trench foot (listed trench foot, left foot, claimed as bilateral trench foot); and for bilateral plantar fasciitis. In July 2019, the Board remanded the issues of service connection for a thoracolumbar spine disability (listed as a back disorder, claimed as a slipped disc in the back); residuals of frostbite of the right lower extremity (listed as frostbite of the right lower extremity); residuals of frostbite of the left lower extremity (listed as frostbite of the left lower extremity); right trench foot (listed as trench foot, right foot) left trench foot (listed as trench foot, left foot), and for bilateral plantar fasciitis, for further development. Thoracolumbar Spine Disability Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. 38 U.S.C. § 1110. Therefore, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest 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, 2026. 38 C.F.R. § 3.317(a)(1). Under 38 C.F.R. § 3.317, compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illness as well as medically unexplained chronic multisymptom illnesses. See 38 C.F.R. § 3.317 (a). This means that even if a Veteran's symptoms are attributed to a known clinical diagnosis, the presumptive provisions related to Gulf War service still apply. In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b), and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b);38 C.F.R. § 3.304(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that in the case of a combat Veteran not only is the combat injury presumed, but so is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish service connection, however, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Service connection is in effect for posttraumatic stress disorder (PTSD), with an unspecified depressive disorder and an alcohol use disorder, and for tinnitus. The Veteran contends that he has a thoracolumbar spine disability that is related to service. He specifically maintains that while serving at Camp Pendleton in South Carolina, he had x-rays and a magnetic resonance imaging (MRI) study performed, which showed that his T5 to L2 vertebrae were out of place. The Veteran states that his thoracolumbar spine problems during service affected his job performance every day and that he performed physical therapy. He also reports that he had lower back problems during service, which may be a result of overuse. The Veteran indicates that he had seen a private chiropractor for back pain since approximately 2008 or 2009. The Veteran essentially asserts that he suffered from thoracolumbar spine problems during service and since service. The Veteran served on active duty in the Marine Corps from October 2007 to December 2011, including service in Iraq. His DD Form 214 lists his occupational specialty as a rifleman for three years and nine months. The Veteran's service treatment records show that he was treated for thoracolumbar spine problems on numerous occasions. A May 2011 accident/injury notification report notes that the Veteran was skateboarding and that he crashed into a parked car. The diagnosis was low back pain. A May 2011 treatment entry, two days later, notes that the Veteran presented with complaints of back pain for twenty-four hours, which he described as a four out of ten at rest, and an eight out of ten with motion. The Veteran described the pain as tightening, and he stated that it went down his left leg. The Veteran related that he was going down a hill on a skateboard and that he bailed off the skateboard before hitting the car, but that he failed, and still hit the car. The examiner reported results of an inspection of the Veteran's back, but a diagnosis was not specifically provided. Another May 2011 entry, on that same day, indicates that the Veteran had left lower and mid back tenderness for one day after jumping off of a skateboard and hitting a car. The Veteran stated that he hit the car on his left back. The examiner reported that x-rays show L5-S1 spondylosis, bilaterally, with Grade I spondylolisthesis. The assessment was soft tissue bruising, with the x-ray results as noted. The examiner stated that the Veteran would be followed up with an MRI study, and that physical therapy should be considered if there was no improvement. The examiner indicated that the Veteran was to rest his back and be assigned to light duty, with precautions. A June 2011 treatment entry reflects that the Veteran was not liking the Robaxin that he was prescribed, and that his medication would be changed to Flexeril. It was noted that the Veteran would be followed-up after his MRI study. A June 2011 MRI study, as to the Veteran's lumbosacral spine, relates an impression of anterolisthesis at L5-S1, with bilateral pars defects, as well as bulging of the disc at T11-T12, with a left paracentral annular tear. Another June 2011 entry notes that the Veteran's initial injury was in May 2011 and that an x-ray was ordered, at that time. The examiner reported that the Veteran's pain had been resolved, but that mild pain persisted. It was noted that the results of an MRI study had been ordered. A subsequent June 2011 entry notes that the Veteran came into sick call for a medication refill, as well as an extension of his light duty. The examiner reported that the Veteran had no new, or worsening pain, and that he had been tolerating the Flexeril well. A diagnosis was not provided at that time. A June 2011 revised duty status report, on that same day, indicates that the Veteran would stay on light duty for ten days. The diagnosis was back pain. A July 2011 treatment entry notes that the Veteran was seen for low back pain. The Veteran reported that he was skateboarding in May 2011 and hit a parked car. He stated that he had been going downhill, with lots of speed, that he lost control, and that he hit his left side on the car. The Veteran indicated that he was unable to stand for a few minutes, but that he eventually got up and moved. He maintained that his symptoms had progressively increased since that time. The Veteran complained of current low back pain, which could be stabbing and throbbing, as well as a general stabbing pain in the right-sided mid back. The assessment was segmental dysfunction of the sacroiliac region; lower back pain; mid back pain; and muscle weakness. On a medical history form at the time of a December 2011 separation examination, the Veteran checked that he did not have recurrent back pain or any back problem. The reviewing examiner referred to several medical issues, but the reviewing examiner did not specifically refer to thoracolumbar spine problems. On a December 2011 report of medical assessment form, the Veteran indicated that since his last physical examination, he had been treated by a health care provider for a back injury. He also stated that he had suffered from a back injury while on active duty, for which he did not seek medical care. The Veteran further reported that his back and disc problems limited his ability to work in his primary military specialty or required geographic or assignment limitations. The Veteran maintained that he intended to seek VA disability for his back. The reviewing examiner referred to a December 2011 medical history form, but such form did not address any thoracolumbar spine problems. The Veteran was not referred for further evaluation. A December 2011 chronological record of medical care report indicates that the Veteran's medical records were reviewed since his last physical examination, and that changes in his medical health were noted on the December 2011 medical history report. The examiner did not specifically indicate if that the Veteran was or was not qualified for separation, but the examiner signed the report. A listing of treatment at Department of Defense (DOD) military treatment facilities indicates that the Veteran was diagnosed with thoracolumbar spine disabilities on multiple occasions. A July 2011 entry lists diagnoses of nonallopathic lesions of the sacral region, not elsewhere classified; lumbago; pain in the thoracic spine; and muscle weakness, generalized. An August 2011 entry lists diagnoses, including somatic dysfunction of the sacral region; lumbago; and pain in the thoracic spine. Another August 2011 entry, on that same day, lists diagnoses, including nonallopathic lesions of the sacral region, not elsewhere classified; lumbago; pain in the thoracic spine; and muscle weakness, generalized. A December 2011 entry lists diagnoses of degeneration of the thoracic or thoracolumbar intervertebral disc, and lumbosacral spondylosis, without myelopathy. A post-service April 2016 VA examination report shows that the Veteran was seen for complaints of thoracolumbar problems. A December 2014 VA Form 21-526EZ, Application for Compensation and related Compensation Benefits, indicates that the Veteran filed a claim for service connection for slipped discs in the back. A November 2015 VA Gulf War general medical examination report includes a notation that the Veteran's claims file was review. The examiner did not refer to the Veteran's claimed thoracolumbar spine disability, or to any back complaints. An April 2016 VA Gulf War general medical examination report includes a notation that the Veteran's claims file was reviewed. As to the Veteran's medical history, the examiner stated that thoracolumbar spine conditions had been reported. The examiner indicated that there were not any diagnosed illnesses for which no etiology was established. The examiner reported that there were no additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. The examiner maintained that there also was no functional impact of additional signs or symptoms that may represent and undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness. The examiner indicated that the Veteran related that he developed lower back pain while he was in the military, which was possibly secondary to overuse. It was noted that the Veteran stated that he had been seen by a private chiropractor for the seven to eight years for back pain, but that he had not been seen by a VA specialist or had VA x-rays for his back condition. The examiner reported that the Veteran maintained that had not been provided with a VA examination for his thoracolumbar spine condition. The examiner also stated that the RO needed to review the Veteran's military records and to decide if he needed an examination for his back. The Board observes that the Veteran's service treatment records show that he was treated for thoracolumbar spine problems on numerous occasions during service, with diagnoses including soft tissue bruising, with x-ray results of L5-S1 spondylosis, bilaterally, with Grade I spondylolisthesis; segmental dysfunction of the sacroiliac region; lower back pain; mid back pain; muscle weakness, generalized; nonallopathic lesions of the sacral region, not elsewhere classified; lumbago; pain in the thoracic spine; and degeneration of the thoracic or thoracolumbar intervertebral discs, as well as lumbosacral spondylosis, without myelopathy. Additionally, the Board observes that the Veteran has reported that he suffered from thoracolumbar spine problems during and since service. The Board further notes that a December 2014 VA Form 21-526EZ, Application for Compensation and related Compensation Benefits, indicates that the Veteran filed a claim for service connection for slipped discs in the back, approximately three years after his separation from service. The Board observes that an April 2016 VA Gulf War general medical examination report notes that there were not any diagnosed illnesses for which no etiology was established. The examiner also reported that there were no additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. The examiner further maintained that there also was no functional impact of additional signs or symptoms that may represent and undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness. The Board observes, however, that the examiner did indicate that the Veteran related that he developed lower back pain while he was in the military, which was possibly secondary to overuse, and that he had been seen by a private chiropractor for the seven to eight years for back pain. The Board notes that the examiner did not specifically provide a diagnosis, as to the Veteran's claimed thoracolumbar spine disability, or address the etiology of Veteran's such condition, at that time. Therefore, The Board finds that the April 2016 VA Gulf War general medical examination report is not very probative value in this matter. The Board observes that the Veteran was diagnosed with numerous thoracolumbar spine disabilities during service as indicated by the numerous thoracolumbar diagnoses discussed above. The Board also observes that an April 2016 VA Gulf War general medical examination report notes that the Veteran reported that he had been treated by a private chiropractor for the seven to eight years, which would be from approximately 2007 or 2009, for back pain. Therefore, the evidence clearly indicates that the Veteran is currently diagnosed with a thoracolumbar spine disability. The Board also finds the Veteran's reports of thoracolumbar spine problems during and since his period of service to be credible. See Jandreau v. Nicholson, 492 F.3d 1372 (2007) (holding that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Resolving any doubt in the Veteran's favor, the Board finds that the evidence is at least in in approximate balance as to whether the Veteran's thoracolumbar disability commenced during his period of service and has continued to be present since service. The benefit of the doubt doctrine applies. 38 U.S.C. § 5107(b), Lynch v. McDonough, __ F.4th __, No. 2020-2067, 2021 U.S. App. LEXIS 37312 (Fed. Cir. Dec. 17, 2021). Therefore, service connection for a thoracolumbar spine disability is warranted. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and for bilateral plantar fasciitis. As discussed above, the Board has granted service-connection for a thoracolumbar spine disability. This case was remanded in July 2019, partly to schedule the Veteran for a VA examination to determine the etiology of any disability associated with his claimed residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and bilateral plantar fasciitis. The examiner was to identify any diagnosed disability associated with residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and bilateral plantar fasciitis. If there was a diagnosis, as to any of those disabilities, the examiner was to provide an opinion as to whether it was at least as likely as not (50 percent or greater probability) that any such disability had its onset in service, or within one year of service separation, or was causally related to service. The July 2019 Board remand specifically directed that the Veteran, as well as his representative, must be notified in writing, at his correct and current address of record, that he was being scheduled for an examination, and of the potential consequences that may result from his failure to attend a VA examination, pursuant to 38 C.F.R. § 3.655(b). Pursuant to the July 2019 Board remand, the RO sent a notice to the Veteran that indicated that if a claimant, without good cause, failed to report for an examination or reexamination, the claim shall be rated based on the evidence of record, or even denied. It was noted that examples of good cause included, but were not limited to, illness or hospitalization, death of a family member, etc. The Board observes that the July 2019 notice to the Veteran was sent to an address for the Veteran in Durham, Connecticut. The Board notes, however, that a subsequence December 2020 supplemental statement of the case lists an address for the Veteran in Tamarac, Florida. In November 2019, the RO requested that the Veteran be scheduled for VA examinations, as to his claimed residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and bilateral plantar fasciitis. A December 2019 Exam Scheduling Request Clarification Response notes that the request for the examinations was cancelled because the Veteran was in the hospital. In April 2020, the RO again requested that the Veteran be scheduled for VA examinations, as to his claimed residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and bilateral plantar fasciitis. The Board notes that the address listed for the Veteran on the Exam Scheduling Request was in Durham, Connecticut. Subsequent December 2020 Exam Scheduling Request Contention Cancellation reports, regarding examinations for the Veteran's claimed disabilities, indicate that the examinations were canceled because the Veteran refused the examinations. The Board notes that the Exam Scheduling Request Contention Cancellation reports do not indicate the reason that the Veteran refused the examinations. The Board also observes that those reports do not specifically indicate the address that was used to notify the Veteran of the examinations. The Board further notes that the Veteran is service-connected for (PTSD), with an unspecified depressive disorder and an alcohol use disorder, with a 100 percent disability rating. The Board emphasizes that it is important that the Veteran report for his scheduled VA examination(s). His failure to attend any scheduled VA examination without showing good cause may adversely affect his claim. 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of a claimant and death of an immediate family member. 38 C.F.R. § 3.655 (a). In light of the above, and the lack of adequate VA examinations of record, the Board finds that another attempt should be made to schedule a VA examination, or examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to the Veteran's claims for service connection for residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and for bilateral plantar fasciitis. See also Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and for bilateral plantar fasciitis, since December 2020. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptomatology regarding his claimed residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and bilateral plantar fasciitis. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination(s) (or telehealth interview, review of the record, etc., if an in-person examination is not feasible), a physical examination is not necessary unless the examiner deems it necessary, to determine the nature, onset, and likely etiology of his claimed residuals of frostbite of the right lower extremity; residuals of frostbite of the left lower extremity; right trench foot; left trench foot; and bilateral plantar fasciitis. The entire claims file must be reviewed by the examiner(s). Then, based on the results of the examination, the examiner(s) is (are) asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after examining the Veteran and reviewing the claims file, it is determined that the Veteran's disability pattern is either (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by any service-connected disability(ies)? (f) If not caused by another medical condition, has any disorder been aggravated by any service-connected disability(ies)? In responding to the above inquiries, please acknowledge and discuss the Veteran's treatment for immersion foot on one occasion during service, and any reports by the Veteran of symptoms he thought were due his claimed disabilities during and since service. N. RIPPEL Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. D. Regan, 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.