Citation Nr: 22015688 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 16-50 607 DATE: March 18, 2022 ORDER Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Service connection for a left ankle disability is denied. Service connection for a right ankle disability is denied. Service connection for a left elbow disability is denied. Service connection for a right elbow disability is denied. Service connection for a left hand disability is denied. Service connection for a left hip disability is denied. Service connection for bilateral plantar fasciitis is denied. Service connection for a skin disability is denied. REMANDED Service connection for chronic fatigue syndrome is remanded. Service connection for a respiratory disability is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) as a result of service-connected disabilities for the period prior to June 27, 2020 is remanded. FINDINGS OF FACT 1. A right knee disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a right knee disability manifested during service or is otherwise due to active service. 2. A left knee disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a left knee disability manifested during service or is otherwise due to active service. 3. A left ankle disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a left ankle disability manifested during service or is otherwise due to active service. 4. A right ankle disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a right ankle disability manifested during service or is otherwise due to active service. 5. A left elbow disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a left elbow disability manifested during service or is otherwise due to active service. 6. A right elbow disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a right elbow disability manifested during service or is otherwise due to active service. 7. A left hand disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a left hand disability manifested during service or is otherwise due to active service. 8. A left hip disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a left hip disability manifested during service or is otherwise due to active service. 9. Bilateral plantar fasciitis has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that bilateral plantar fasciitis manifested during service or is otherwise due to active service. 10. A skin disability has been attributed to a known clinical diagnosis, and the weight of the evidence is against a finding that a skin disability manifested during service or is otherwise due to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 2. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 3. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 4. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 5. The criteria for service connection for a left elbow disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 6. The criteria for service connection for a right elbow disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 7. The criteria for service connection for a left hand disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 8. The criteria for service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 9. The criteria for service connection for bilateral plantar fasciitis have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 10. The criteria for service connection for a skin disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1977 to July 1992. The Veteran died in September 2021; the Veteran's surviving spouse has been substituted as the appellant for purposes of completion of this appeal. In an April 2016 rating decision, service connection was denied for the following, in pertinent part: bilateral plantar fasciitis; chronic fatigue syndrome; left and right ankle strain; left and right elbow strain; left hand strain; left hip instability; left and right knee strain; respiratory disorder; and a skin condition. The Veteran perfected an appeal with regard to the denial of these issues. Statements of the case issued in September 2016 and November 2016 included the above issues, plus a denial of entitlement to a TDIU. In October 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; the transcript is of record. In January 2020 and September 2021, these matters were remanded for further development. In a January 2022 rating decision, service connection for a right hand strain was granted; this constitutes a full grant of the benefit sought on appeal. 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). The Veteran claims entitlement to service connection for disabilities of the knees, ankles, elbows, left hand, left hip, skin and plantar fasciitis, all as due to service and/or an undiagnosed illness due to environmental exposures while serving in the Persian Gulf. He asserts that his claimed disabilities are part of a constellation of symptoms, specifically muscle pain, joint pain, or neurological signs or symptoms, as due to an illness as described under 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(a)(2); see also 75 Fed. Reg. 61995-97 (2010); see also 76 Fed. Reg. 41696-98 (July 15, 2011). Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. The period within which such disabilities must become manifest to a compensable degree in order for entitlement to compensation to be established is December 31, 2026. 38 C.F.R. § 3.317(a)(1)(i). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a),(b). The term "objective indications of a qualifying chronic disability" include both "signs," in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. See 38 C.F.R. § 3.317(a)(3). As an initial matter, the Board notes that the Veteran's service personnel records reflect that he served in the Persian Gulf from September 1990 to March 1991. Based on this evidence and for purposes of analysis under 38 C.F.R. § 3.317, it is established that the Veteran had active military service in the Southwest Asia theater of operations during the Persian Gulf War. Left and right knees A September 1986 service treatment record reflects complaints of left knee pain, which included intermittent pain for the past three years. 04/20/1993 STR-Medical-Photocopy at 16. July 1989 and June 1992 Reports of Medical Examination reflect that his 'lower extremities' were clinically evaluated as normal. 04/20/1993 STR-Medical at 4, 48. A June 1992 Report of Medical History reflects that the Veteran checked the 'No' box for '"trick" or locked knee.' Id. at 3. A July 2013 VA treatment record reflects complaints of bilateral knee pain; he was prescribed Tramadol for pain in his knees and shoulders. 12/16/2015 CAPRI. A March 2016 VA examination reflects the Veteran's report of bilateral knee pain after spending years walking on steel decks of ships. He reported that he was seen during active duty for bilateral knee pain, and he was told he had problems with knee ligaments. At present, he reported constant bilateral knee pain, left greater than right. He has to cross his legs and pop his knees every now and then to relieve pain. The examiner diagnosed bilateral knee strain. An x-ray examination was normal. The examiner commented that the bilateral knee examination was normal and there was no pathology or diagnosis and no condition upon which to render an opinion. 03/28/2016 C&P Exam at 23-32, 50. A July 2016 VA treatment record reflects an assessment of knee arthritis. 03/08/2021 at 21-22. A June 2019 VA treatment record reflects that the Veteran reported right knee pain for more than 30 years with an acute pain flare-up 24 hours ago when his "knee gave way" and the Veteran almost fell. 03/04/2020 CAPRI at 24-25. A July 2019 VA treatment record reflects complaints of knee pain. Id. at 21. At a June 2020 examination, the Veteran denied any knee issues. See C& P Examination, 2/6/2021. The examiner noted that he was seen for bilateral knee pain in 2016 but his knee x-ray was negative. The examiner found that he did not have a current diagnosis pertaining to the knees. The examiner stated that all available medical records are silent for complaint/diagnosis/treatment for his knees. There is no continuation of the problem or treatment. There was no objective evidence of pain on examination. An October 2021 C&P examiner reviewed the claims folder and opined that the right knee strain is less likely than not (less than 50 percent probability) due to the Veteran's service as there is no record of complaint or treatment of such condition during the Veteran's active duty period. The examiner opined that the left knee strain is less likely than not (less than 50 percent probability) due to the Veteran's service. The examiner noted that the Veteran was seen in September 1986 for sprain with twisting motion, however, several days later there was no swelling or bruising noted. The examiner stated that there were no further notes of complaint or treatment during active duty period to suggest chronicity or nexus. The Veteran's reported knee problems have been attributed to specific clinical diagnoses left knee strain and right knee strain. As detailed above, while there is a report of left knee pain in September 1986, service treatment records are negative for any complaints pertaining to the right knee. With regard to the left knee, there is no continuity of symptomatology after the September 1986 report. As detailed, he denied any knee problems on separation in June 1992 and his lower extremities were clinically evaluated as normal in July 1989 and June 1992. With regard to any relationship to service, the Board accepts the opinion of the October 2021 examiner as highly probative medical evidence on the subject, as such was based on examination of the Veteran and review of medical records on file, to include the service treatment records, and contains a detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). As the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claims. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges that the Veteran is competent to describe knee problems and acknowledges his lay statements and testimony at the Board hearing. While he is competent to report having experienced knee problems, he is not competent to provide diagnoses in this case nor determine the etiology of the diagnosed disabilities. Based on the Veteran's lay assertions, opinions were sought, which were negative. While the Veteran believes he has disabilities of the knees due to service the preponderance of the evidence weighs against finding that his left and right knee strains are due to service. The Veteran is not competent to provide a nexus opinion regarding these issues. The issues are medically complex and requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377; see Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the most probative, competent evidence is against a link between disabilities of the left and right knee and service. Because the preponderance of the evidence is against the issues, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). Left and right ankles A January 1990 service treatment record reflects complaints of left ankle pain due to twisting it the evening before. The assessment was ankle sprain. An x-ray examination was negative for a fracture. 04/20/1993 STR-Medical-Photocopy at 45-47. A June 1992 Report of Medical Examination reflect that his 'lower extremities' were clinically evaluated as normal. 04/20/1993 STR-Medical at 4. A March 2016 VA examination reflects the Veteran's report of generalized joint pain due to Gulf War exposure, including bilateral ankle strain. The Veteran could not recall any specific service-related or non-service related injury to his ankles. He noted that they pop and crack from time to time and when they pop they are painful. He has not been treated for any ankle condition. He takes Goody Powder as needed for generalized arthralgias. The examiner diagnosed bilateral ankle strain but commented that a bilateral ankle was normal and there was no pathology or diagnosis. 03/28/2016 VA examination at 11-18, 40. At a June 2020 examination (entered into Caseflow in February 2021), the Veteran claimed he had pain in both of his ankles but "they are fine now." He never visited a doctor for this complaint during or after service. The examiner noted that he was never seen for ankle pain. Per the Veteran, his ankle pops when he walks. The examiner noted that all available medical records are silent for complaint/diagnosis/treatment of ankle pain. There is no continuation of the problem or treatment for ankle pain. There was no objective evidence of pain on examination. The October 2021 examiner reviewed the claims folder and opined that the left ankle condition is less likely than not (less than 50 percent probability) due to the Veteran's service. He was seen in January 1990 following slipping on stairs with mild swelling on the left ankle. No serious injury was noted to indicate chronicity. The claimed right ankle condition is less likely than not (less than 50 percent probability) due to the Veteran's service as there is no record of complaint or treatment of such condition during the Veteran's active duty period. While an opinion based solely on the absence of in-service findings might in some cases be deficient, here there is no other evidence of continuity of symptomatology, so the limitation in the examiner's rationale is harmless error. The Veteran's reported ankle problems have been attributed to specific clinical diagnoses left ankle strain and right ankle strain. As detailed, while there is a report of the Veteran twisting his ankle in January 1990, service treatment records are negative for any complaints pertaining to the right ankle. With regard to the left knee, there is no continuity of symptomatology after the January 1990 report. As detailed, his lower extremities were clinically evaluated as normal in June 1992. With regard to any relationship to service, the Board accepts the opinion of the October 2021 examiner as highly probative medical evidence on the subject, as such was based on examination of the Veteran and review of medical records on file, to include the service treatment records, and contains a detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). As the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claims. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges that the Veteran is competent to describe ankle problems and acknowledges his lay statements and testimony at the Board hearing. While he is competent to report having experienced ankle problems, he is not competent to provide diagnoses in this case nor determine the etiology of the diagnosed disabilities. Based on the Veteran's lay assertions, opinions were sought which were negative. While the Veteran believes he has disabilities of the ankles due to service the preponderance of the evidence weighs against finding that his left and right ankle strains are due to service. The Veteran is not competent to provide a nexus opinion regarding these issues. The issues are medically complex and requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377; see Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the most probative, competent evidence is against a link between disabilities of the left and right ankle and service. Because the preponderance of the evidence is against the issues, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). Left and right elbows A September 1987 service treatment record reflects complaints of bilateral pain to the elbows. He had been going up and down vertical ladders more frequently. The assessment was bilateral muscular strain. 04/20/1993 STR-Medical-Photocopy at 11. In October 1990, the Veteran slipped into the water and sustained abrasions to his hands and soreness of his elbows. The diagnosis was elbow strain, mild. 04/20/1993 STR-Medical-Photocopy at 18. On a June 1992 Report of Medical History, the Veteran checked the 'No' box for 'pain or "trick" shoulder or elbow.' Reports of Medical Examinations conducted in July 1989 and June 1992 reflect that his 'upper extremities' were clinically evaluated as normal. Id. at 3-6, 48. A March 2016 VA examination reflects the Veteran's report of generalized joint pain due to Gulf War exposure, including bilateral elbow strain. He did not recall any specific service-related or non-service related injury to his elbows. He reported an intermittent dull ache in both elbows. He attributed his symptoms to years of turning wrenches and using hand tools. He has not been treated for any elbow condition. He takes Goody Powder as needed for generalized arthralgias. The examiner diagnosed bilateral elbow strain but the examiner commented that examination of the elbows was normal and there was no pathology or diagnosis. 03/28/2016 CAPRI at 18-25, 41. The Veteran told the June 2020 examiner that he had pain in both of his elbows a couple of years ago, but they are fine now. He never visited a doctor for this complaint. The June 2020 examiner indicated that the Veteran was never seen for elbow pain while in service. He denied any elbow pain at the time of the examination. The October 2021 C&P examiner reviewed the claims folder and opined that the right and left elbow disabilities are less likely than not (less than 50 percent probability) due to the Veteran's service. The Veteran was seen twice for elbow issues. Once was in September 1987 after working on heavy equipment. There were no findings on exam other than subjective pain and he was diagnosed with a strain. Three years later, the Veteran slipped onto his arms and was diagnosed with elbow strain without significant findings. The examiner found no evidence of significant injury to suggest a chronic issue. The Veteran's reported elbow problems have been attributed to specific clinical diagnoses left elbow strain and right elbow strain. As detailed, service treatment records contain reports of two separate incidents pertaining to the elbows. However, there is no continuity of symptomatology after the October 1990 report. As detailed, his lower extremities were clinically evaluated as normal in June 1992 and he denied any problems with his elbows. With regard to any relationship to service, the Board accepts the opinion of the October 2021 examiner as highly probative medical evidence on the subject, as such was based on examination of the Veteran and review of medical records on file, to include the service treatment records, and contains a detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). As the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claims. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges that the Veteran is competent to describe elbow problems and acknowledges his lay statements and testimony at the Board hearing. While he is competent to report having experienced elbow problems, he is not competent to provide diagnoses in this case nor determine the etiology of the diagnosed disabilities. Based on the Veteran's lay assertions, opinions were sought which were negative. While the Veteran believes he has disabilities of the elbows due to service the preponderance of the evidence weighs against finding that his left and right elbow strains are due to service. The Veteran is not competent to provide a nexus opinion regarding these issues. The issues are medically complex and requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377; see Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the most probative, competent evidence is against a link between disabilities of the left and right elbow and service. Because the preponderance of the evidence is against the issues, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). Left hand As detailed, service connection has been granted for a right hand disability. Service treatment records reflect that in October 1990 the Veteran slipped and sustained hand abrasions. 04/20/1993 STR-Medical-Photocopy at 18. He sustained other injuries to the right hand, which resulted in service connection being granted. A June 1992 Report of Medical Examination conducted in June 1992 reflects that his 'upper extremities' were clinically evaluated as normal. Id. at 4. A March 2016 VA examination reflects that the Veteran presented with a claim of generalized joint pain due to Gulf War exposure, including bilateral hand strain. He did not recall any service-related incident in which he injured his hands. He stated that he developed a progressive stiffness and popping in both hands and fingers over the years. He reported using hand tools on his job, and report decreased grip strength occasionally. The Veteran recalled that his right hand got crushed between two pieces of steel in a work-related accident. He noted pain across the back of his right hand intermittently. The examiner diagnosed bilateral hand strain, but the examiner commented that examination of the hands was normal. X-ray examinations of the hands were normal. 03/28/2016 C&P Exam at 1-10, 40. A June 2020 C&P examination does not include any relevant medical history; there are no lay assertions of record. The examiner stated that service treatment records are silent for complaint/diagnosis/treatment of a hand condition and there was no objective evidence of bilateral hand pain on examination. The examiner indicated that there were no claimed symptoms. The October 2021 C&P examiner reviewed the claims folder and opined that the claimed left hand condition is less likely than not (less than 50 percent probability) due to the Veteran's service. The examiner noted that the Veteran has a record of falling on both arms (with left hand sprain) in October 1990 but without further note of issue or complaint during active duty. The Veteran's reported left hand problems have been attributed to a specific clinical diagnosis left hand strain. As detailed, while there is a report of the Veteran sustaining injury to his hands in October 1990, service treatment records are negative for any subsequent complaints pertaining to the left hand. As detailed, his upper extremities were clinically evaluated as normal in June 1992. With regard to any relationship to service, the Board accepts the opinion of the October 2021 examiner as highly probative medical evidence on the subject, as such was based on examination of the Veteran and review of medical records on file, to include the service treatment records, and contains a detailed rationale for the medical conclusion. See Boggs v. West, 11 Vet. App. 334 (1998). As the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges that the Veteran is competent to describe left hand problems and acknowledges his lay statements and testimony at the Board hearing. While he is competent to report having experienced left hand problems, he is not competent to provide a diagnosis in this case nor determine the etiology of the diagnosed disability. Based on the Veteran's lay assertions, an opinion was sought which was negative. While the Veteran believes he has a disability of the left hand due to service the preponderance of the evidence weighs against finding that his left hand strain is due to service. The Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex and requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377; see Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the most probative, competent evidence is against a link between a disability of the left hand and service. Because the preponderance of the evidence is against the issue, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). Left hip Service treatment records do not reflect any complaints of or treatment for a left hip disability. A June 1992 Report of Medical Examination conducted in June 1992 reflects that his 'lower extremities' were clinically evaluated as normal. 04/20/1993 STR-Medical-Photocopy at 4. A March 2016 VA examination reflects the Veteran's report of instability of the left hip due to Gulf War exposure. He did not recall any left hip injury or problem during military service. After separation from the military, he noted that his left hip "goes out" every now and then. He describes it as the left hip "pops out," causing him to catch himself while he is walking. He has no associated left hip pain. He has not sought treatment for or been diagnosed with any left hip condition. The examiner diagnosed left hip instability, but the examiner commented that a left hip examination was normal and there was no left hip pathology or diagnosis upon which to render an etiological opinion. 03/28/2016 C&P Exam at 16, 50. A June 2020 examination (entered into Caseflow in February 2021) reflects that the Veteran denied any hip pain and the examiner noted that the medical record does not support any diagnosis of hip pain or problem. The examiner stated that all available medical records are silent for complaint/diagnosis/treatment for this condition. There is no continuation of the problem or treatment. There is no objective evidence of pain on examination. The October 2021 C&P examiner reviewed the claims folder and noted that the Veteran stated that his left hip began to bother him as a result of his time in the Persian Gulf War due to wearing of boots, heavy equipment, and body armor. The examiner opined that his left hip condition is less likely than not (less than 50 percent probability) due to the Veteran's service as there is no record of complaint or treatment of such condition during the Veteran's active duty period. While an opinion based solely on the absence of in-service findings might in some cases be deficient, here there is no other evidence of continuity of symptomatology, so the limitation in the examiner's rationale is harmless error. The Veteran's reported left hip problems has been attributed to specific clinical diagnoses left hip strain. Service treatment records are negative for any complaints pertaining to the left hip. As detailed, his lower extremities were clinically evaluated as normal in June 1992. With regard to any relationship to service, the Board accepts the opinion of the October 2021 examiner as highly probative medical evidence on the subject, as such was based on examination of the Veteran and review of medical records on file, to include the service treatment records, and contains a detailed rationale for the medical conclusion. See Boggs v. West, 11 Vet. App. 334 (1998). As the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges that the Veteran is competent to describe left hip problems and acknowledges his lay statements and testimony at the Board hearing. While he is competent to report having experienced left hip problems, he is not competent to provide a diagnosis in this case nor determine the etiology of the diagnosed disability. Based on the Veteran's lay assertions, an opinion was sought which was negative. While the Veteran believes he has a disability of the left hip due to service the preponderance of the evidence weighs against finding that his left hip strain is due to service. The Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex and requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377; see Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the most probative, competent evidence is against a link between a disability of the left hip and service. Because the preponderance of the evidence is against the issue, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). Bilateral plantar fasciitis Service connection is in effect for right foot injury with loss of third right toe, rated noncompensably disabling, effective July 3, 1992. Service treatment records do not reflect any complaints of or treatment for bilateral plantar fasciitis. A June 1992 Report of Medical Examination reflects that his 'feet' were clinically evaluated as normal. 04/20/1993 STR-Medical-Photocopy at 4. A November 2011 VA examination references plantar fasciitis but indicates that such condition is not due to the Veteran's service-connected status post injury of the right foot with amputation of the third distal toe. 11/03/2011 VA Examination at 5. A March 2016 VA examination reflects a diagnosis of plantar fasciitis but the examiner commented that there was no objective evidence of bilateral plantar fasciitis. 03/28/2016 C&P Exam at 11, 50. A June 2020 examination reflects that the Veteran was treated for plantar fasciitis, but he denied any new symptoms/signs or pain and he reported that it was resolved. The examiner found no objective evidence of bilateral plantar fasciitis. The October 2021 examiner noted review of the claims folder and noted that prior compensation and pension exams indicated that the Veteran had plantar fasciitis diagnosed around the time of right toe amputation but was not chronically bothering him. The examiner opined that his claimed bilateral plantar fasciitis is less likely than not (less than 50 percent probability) due to the Veteran's service as there is no record of complaint or treatment of such condition during the Veteran's active duty period. While an opinion based solely on the absence of in-service findings might in some cases be deficient, here there is no other evidence of continuity of symptomatology, so the limitation in the examiner's rationale is harmless error. The Veteran's reported bilateral plantar fasciitis has been attributed to a specific clinical diagnosis. Service treatment records are negative for any complaints pertaining to plantar fasciitis. As detailed, his feet were clinically evaluated as normal in June 1992. With regard to any relationship to service, the Board accepts the opinion of the October 2021 examiner as highly probative medical evidence on the subject, as such was based on examination of the Veteran and review of medical records on file, to include the service treatment records, and contains a detailed rationale for the medical conclusion. See Boggs v. West, 11 Vet. App. 334 (1998). As the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges that the Veteran is competent to describe plantar fasciitis problems and acknowledges his lay statements and testimony at the Board hearing. While he is competent to report having experienced plantar fasciitis problems, he is not competent to provide a diagnosis in this case nor determine the etiology of the diagnosed disability. Based on the Veteran's lay assertions, an opinion was sought which was negative. While the Veteran believes he has a disability of plantar fasciitis due to service the preponderance of the evidence weighs against finding that his plantar fasciitis is due to service. The Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex and requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377; see Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the most probative, competent evidence is against a link between a disability of bilateral plantar fasciitis and service. Because the preponderance of the evidence is against the issue, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). Skin disability A May 1983 service treatment record reflects a rash on his hands and an assessment of scabies. 04/20/1993 STR-Medical-Photocopy at 34. A June 1983 service treatment record reflects a papular rash on both hands. Id. at 33. A July 1987 service treatment record reflects a rash and bumps on his chin and under his chin for two days. The assessment was rule out contact dermatitis and rule out folliculitis of beard. Id. at 12. In February 1990, he sought treatment for cellulitis of the right forearm. 04/20/1993 STR-Medical-Photocopy at 40. A June 1992 Report of Medical History reflects that the Veteran checked the 'No' box with regard to 'skin diseases.' A June 1992 Report of Medical Examination reflects that his 'skin, lymphatics' were clinically evaluated as normal. Id. at 3-6. A March 2016 VA examination reflects diagnoses of hypersensitivity reaction, skin, and folliculitis, but the examiner stated that the skin shows no pathology and there was no diagnosis and no condition upon which to render an opinion. 03/28/2016 C&P Exam at 15, 27. A May 2019 private treatment record reflects that he had lumps on his scalp and the diagnoses were psoriasis and impetigo. 11/13/2019 Medical Treatment Record-Non-Government Facility at 33, 40. In June 2020, the Veteran underwent an examination wherein the examiner found no skin condition on examination. The examiner responded 'none' with regard to whether he had a prior skin condition that had resolved. The examiner stated that all available medical records are silent for complaint/diagnosis/treatment of skin condition. There is no continuation of the problem or treatment. There was no objective evidence of rash or skin condition on examination. There was no condition upon which to render an opinion. The October 2021 C&P examiner reviewed the claims folder and opined that the claimed skin condition is less likely than not (less than 50 percent probability) due to the Veteran's service. The examiner acknowledged that he was seen for several acute skin issues during active duty period. He was seen for scabies, cellulitis and hand abrasions. The examiner found that each condition was acute in nature and resolved without chronic issue. The claimed folliculitis is less likely than not (less than 50 percent probability) due to the Veteran's service as there is no record of complaint or treatment of such condition during the Veteran's active duty period. Furthermore, folliculitis is an acute event which may tend to recur intermittently but does not typically remain chronic. The Veteran's reported skin problems have been attributed to a specific clinical diagnosis. While service treatment records reflect complaints pertaining to the skin, the October 2021 determined that such problems were acute in nature and that his current problems are not due to service. With regard to any relationship to service, the Board accepts the opinion of the October 2021 examiner as highly probative medical evidence on the subject, as such was based on examination of the Veteran and review of medical records on file, to include the service treatment records, and contains a detailed rationale for the medical conclusion. See Boggs v. West, 11 Vet. App. 334 (1998). As the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges that the Veteran is competent to describe his skin problems and acknowledges his lay statements and testimony at the Board hearing. While he is competent to report having experienced skin problems, he is not competent to provide a diagnosis in this case nor determine the etiology of the diagnosed disability. Based on the Veteran's lay assertions, an opinion was sought which was negative. While the Veteran believes he has a skin disability due to service the preponderance of the evidence weighs against finding that he has a skin disability due to service. The Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex and requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377; see Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the most probative, competent evidence is against a link between a disability of a skin disability and service. Because the preponderance of the evidence is against the issue, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). REASONS FOR REMAND Chronic fatigue syndrome The Veteran underwent a March 2016 VA examination wherein he claimed chronic fatigue syndrome due to Gulf War exposures. He reported persistent fatigue and complained of non-restorative sleep. The examiner found that the Veteran does not meet the criteria for a diagnosis of chronic fatigue syndrome, and that he has numerous other nonservice-connected etiologies for his complaint of fatigue. 03/28/2016 CAPRI at 23-25, 27. An August 2016 private treatment record reflects a diagnosis of chronic fatigue syndrome. 04/09/2019 Medical Treatment Record-Non-Government Facility at 13. A July 2017 'Chronic Fatigue Syndrome Disability Benefits Questionnaire' reflects a diagnosis of chronic fatigue syndrome in October 2015; an etiological opinion was not proffered. A June 2020 examiner found that the Veteran does not have chronic fatigue syndrome. The examiner stated that all available medical records are silent for complaint/diagnosis/treatment of chronic fatigue syndrome. There is no objective evidence of chronic fatigue syndrome on examination today. The examiner continued to state that there was no diagnosis and no condition upon which to render an opinion. The examiner, however, did not appear to give any consideration to the diagnoses of record. A further opinion must be sought. An October 2021 C&P examiner reviewed the claims folder and stated that the Veteran does not have record of diagnosis or complaint during active duty period with lack of criteria to also diagnosis the condition of chronic fatigue syndrome. The examiner stated that the Veteran does not have the criteria to meet the diagnosis of chronic fatigue syndrome. While the examiner concluded that the Veteran does not have a diagnosis of chronic fatigue syndrome, the examiner did not address the following inquiry: If the fatigue complaints are not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of fatigue, or a medically unexplained chronic multisymptom illness? Thus, remand is necessary for an addendum opinion. Respiratory disability An August 2015 private evaluation reflects an assessment of dyspnea in part possibly from chronic obstructive pulmonary disease, and right-sided pleural effusion. 04/09/2019 Medical Treatment Record-Non-Government Facility at 4. Correspondence dated in October 2015 from a private medical practice states that the Veteran has respiratory problems due to Desert Storm Syndrome. 01/17/2019 Medical Treatment Record-Non-Government Facility at 1. The Veteran underwent a March 2016 VA examination wherein he complained of a respiratory condition due to Gulf War exposures. The examiner found no objective evidence of any pulmonary pathology, thus no diagnosis was rendered. Examination of the lungs was normal. 03/28/2016 CAPRI at 18-20, 27. A January 2019 private treatment record reflects a chronic problem of shortness of breath, and the assessment was rule out cardiac cause. 11/13/2019 Medical Treatment Record-Non-Government Facility at 9, 12. The June 2020 examiner stated that the Veteran was never seen for any respiratory condition while in service, never diagnosed with any lung problems, and there was no continuation of any problem related to the lungs seen in the record. The examiner, however, did not appear to give any consideration to the diagnoses of record. A further opinion must be sought. An October 2021 C&P examiner found no respiratory (pulmonary/lung etiology) complaint during service and concluded that the Veteran does not have record of diagnosis or complaint during active duty period with lack of criteria to also diagnosis the condition. While the examiner concluded that the Veteran does not have a diagnosis of a respiratory disability, the examiner did not address the following inquiry: If the respiratory complaints are not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of the respiratory system (upper or lower), or a medically unexplained chronic multisymptom illness? Thus, remand is necessary for an addendum opinion. Entitlement to a TDIU The Veteran's claim for a TDIU is inextricably intertwined with the service connection issues in appellate status. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Thus, the Board will defer consideration of this issue in light of the above issues being remanded. The matters are REMANDED for the following actions: 1. Request that the October 2021 C&P examiner (or another qualified examiner if the October 2021 examiner is unavailable) review the claims folder and respond to the following: If the fatigue complaints are not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of fatigue, or a medically unexplained chronic multisymptom illness? Provide a comprehensive rationale for every opinion. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. An examination should be scheduled if deemed necessary by the examiner. 2. Request that the October 2021 C&P examiner (or another qualified examiner if the October 2021 examiner is unavailable) review the claims folder and respond to the following: If the respiratory complaints are not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of the respiratory system (upper or lower), or a medically unexplained chronic multisymptom illness? Provide a comprehensive rationale for every opinion. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. (Continued on the next page) An examination should be scheduled if deemed necessary by the examiner. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.W. Kreindler, 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.