Citation Nr: 22017338 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 18-04 306 DATE: March 24, 2022 ORDER 1. Entitlement to service connection for residuals of a right leg Achilles rupture, a right leg disability, is denied. 2. Entitlement to service connection for a left leg (ankle/ Achilles) disability, to include as secondary to the right leg Achilles rupture, is denied. 3. Entitlement to service connection for bilateral pes planus is denied. 4. Entitlement to service connection for a cervical spine (neck) disability is denied. REMANDED 5. Entitlement to service connection for a lumbar spine (lower back) disability is remanded. 6. Entitlement to service connection for generalized muscle pain / spasms in the deltoids (shoulders), including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 7. Entitlement to service connection for generalized muscle pain / spasms in the hamstrings, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 8. Entitlement to service connection for vertigo, also claimed as dizziness, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 9. Entitlement to service connection for ischemia, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 10. Entitlement to service connection for hypertension, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 11. Entitlement to service connection for gastroenteritis, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 12. Entitlement to service connection for anemia, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 13. Entitlement to service connection for upper and lower body rashes, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 14. Entitlement to service connection for headaches, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. 15. Entitlement to service connection for radiculopathy left lower extremity, including as due to a qualifying chronic disability and to include as an undiagnosed illness, is remanded. FINDINGS OF FACT 1. The Veteran's right leg Achilles disability did not have its onset during active duty service and is not otherwise related to active duty service 2. The Veteran's left leg (ankle/ Achilles) disability did not have its onset during active duty service, is not otherwise related to active duty service, and was not caused or shown by a medically established baseline that it was aggravated by service-connected disability or disabilities. 3. Pes planus was noted on the July 1974 entrance examination. 4. Pes planus was not aggravated beyond its natural progression by service. 5. The evidence persuasively weighs against a finding that the current cervical spine disability had its onset during service, is otherwise related to service, or that arthritis was manifested within one year of separation from service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for residuals of a right leg Achilles rupture, a right leg disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for a left leg (ankle/ Achilles) disability, to include as secondary to service-connected disability or disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 3. The criteria for entitlement to service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 4. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1987 to June 1992. In May 2021, the Veteran provided testimony in a virtual Board hearing before the undersigned Veterans Law Judge (VLJ). During the May 2021 Board hearing, the undersigned VLJ left the record open for 60 days, until July 27, 2021, for the Veteran to submit additional evidence related to his claim, however, no new evidence was submitted by the Veteran or his representative. Additional evidence has been associated with record since the December 2017 statement of the case (SOC) that has not yet been reviewed by the agency of original jurisdiction (AOJ). This newly-associated evidence includes VA medical records dated through February 2021 and private medical records submitted by the Veteran. The substantive appeal (VA Form 9, Appeal to the Board) was filed in January 2018 which includes an automatic waiver of AOJ review of evidence added at the time of or any time after the filing of the VA Form 9 for evidence submitted by the Veteran. 38 U.S.C. § 7015. However, the automatic waiver provision does not apply to the VA medical records obtained by the Regional Office (RO) rather than submitted by the Veteran. In September 2021, the Board sent correspondence notifying the Veteran and his representative of the additional evidence and to allow the Veteran an opportunity to waive AOJ review of the additional evidence. In September 2021, the Veteran replied and selected the option to waive his right to have the case remanded for AOJ review of the additional evidence and for the Board to proceed with adjudication of his appeal. The Board will continue with adjudication of the Veteran's appeal. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may also be established under 38 C.F.R. § 3.303(b) if a chronic disease is shown in service, and subsequent manifestations of the same chronic disease at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Arthritis is a chronic condition listed under 38 C.F.R. § 3.309(a); and thus, 38 C.F.R. § 3.303(b) is applicable. Service connection may also be established based upon a legal presumption by showing that a disorder manifested itself within one year from the date of separation from service. 38 U.S.C. § 1101; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. 1. & 2. Entitlement to service connection for (1) residuals of a right leg Achilles rupture, a right leg disability and (2) a left leg (ankle/ Achilles) disability. The Veteran contends that service connection is warranted for a right leg Achilles disability and left leg (ankle/ Achilles) disability because they were incurred in service or otherwise a result of service. During the May 2021 Board hearing, the Veteran testified that when he fell down the stairs in service, he also complained about his right leg, specifically the ankle and that he ruptured his right Achilles not even a year after service. The Veteran clarified that the claimed left leg disability is mostly his left ankle, part of the left Achilles, as well as going down into the foot area. He is also claiming the left leg as secondary to the right leg Achilles disability. The Veteran and his representative confirmed during the hearing that the right leg and left leg disabilities were not being considered for undiagnosed illness. After a careful review of the evidence of record, the Board finds that the evidence persuasively weighs against a finding that service connection for either a right leg Achilles disability or a left leg (ankle/ Achilles) disability is warranted. The reasons follow. As to evidence of a current disability, the record reflects that the Veteran had a history of a right posterior tibial Achilles repair with screws in place following an Achilles tendon rupture in April 1993. A May 1998 VA medical record shows right anterior tibial tendonitis. A June 2017 VA medical record indicates that the Veteran had a callus above his right posterior heel and reported pain while ambulating. He related that it developed status-post achilles rupture and surgical repair around 1994. An October 2017 VA Gulf War General Medical examination report documents the Veteran's report of muscle spasms in his legs (Achilles tendinopathy), for which the examiner noted that the Veteran had a diagnosis. VA medical records document Achilles tendonitis from 2017 and that the Veteran had been in a boot for the left foot for 8 months. Accordingly, affording the Veteran the benefit of the doubt, the Board finds there is evidence of a current disability in the Achilles of the bilateral feet, and the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, during the May 2021 Board hearing, the Veteran reported that he injured his right leg and kept complaining about what he thought was his right ankle, when he fell down the stairs in service and hurt his back. A review of the Veteran's service treatment records reveals a September 1990 incident where the Veteran was noted to have fallen down the stairs and complained of pain in the left lumbar region with left lumbar spasm and an assessment of severe left lumbar strain. The Board finds that the Veteran is competent to report a fall while in service, which is supported by the September 1990 service treatment record, however, the September 1990 record does not document complaints involving the Veteran's lower extremities, and, in fact, documented that the Veteran denied peripheral paresthesias. Within this treatment record, the examiner wrote that the Veteran had fallen down the stairs last night and complained of "pain in [left] lumbar region." The examiner also documented that the Veteran denied constipation, dysuria, and peripheral paresthesias. The examiner physically examined the Veteran and made clinical findings regarding the Veteran's lower extremities, such as the Veteran's deep tendon reflexes were symmetrical and straight leg raising was negative. The examiner also documented that a Patrick's test was negative as well. This record shows that the examiner affirmatively examined the Veteran's lower extremities and tested his deep tendon reflexes. The Board finds that had the Veteran injured his ankles in this fall, he would have reported such fact, since he was asked about whether he had peripheral paresthesias, which would have involved symptoms in his lower extremities. Additionally, the examiner performed testing that involved his lower extremities, and someone who is experiencing pain in his ankles would have reported such fact. In other words, it does not make sense for the Veteran to report only left lumbar spine pain and not the bilateral ankle pain, if he was experiencing ankle pain. Thus, the Board finds as fact that the Veteran did not injure his ankle or ankles in September 1990, and the allegation that he injured his ankle or ankles at that time is not credible. During the May 2021 Board hearing, the Veteran also indicated that he fell off a "deuce and a half" truck in service. An October 2017 letter from the Veteran's private chiropractor, Dr. L. K., shows the examiner documented that, "history intake reveals extensive history of injuries sustained during Army deployment, including a fall from a truck causing a leg fracture...." When the undersigned asked the Veteran if he had fractured his leg, he answered, "I don't know if it was broken or fractured, but they didn't really give me any form of treatment." The Veteran explained that "at the time, we w[ere] on a movement going into combat. So that could have helped from that point up until '90, '92, 93, when I got out when the right leg was torn, the Achilles." He added, "for a long time, I was walking around on one leg, but then again, I had no medical insurance." The Board notes that the October 2017 letter from Dr. L. K. is of limited probative value as to an in-service occurrence, as it is based on the Veteran's own report of a leg fracture in service, which is not supported by the contemporaneous records. The Board has already explained why it does not find that an injury or injuries to the ankle or ankles occurred at the time of the September 1990 fall. As to the other fall where the Veteran claims he broke his leg, the Board finds that such incident did not occur for two reasons. One, the Veteran's service treatment records are silent for diagnosis, symptoms, or treatment of either the right or left leg, specifically the ankle and Achilles area. Two, in the June 1992 Report of Medical History, the Veteran reported a positive history of "cramps in your legs" but specifically denied "Broken bones," "Arthritis or rheumatism;" "Bone, joint, or other deformity;" "Lameness;" "Loss of arm, leg, finger or toe;" and "Foot trouble." Further, the Veteran checked "no" when asked if he "ever had any illness or injury other than those already noted." While it is unclear what the Veteran meant when he reported a positive history of cramps in his legs, he specifically denied a history of broken bones. He also checked a positive history of hay fever and recent gain or loss of weight. This shows that the Veteran read through the various symptoms within this form and checked yes to those he had experienced and no to those he did not experienced, which included broken bones. This is an affirmative denial of a history of broken bones and refutes the Veteran's allegation that he experienced a broken leg during service. Thus, the Veteran's allegation that he broke a leg in service is not credible. Additionally, on the June 1992 Report of Medical Examination completed at service discharge, the Veteran wrote that he was "in good health" and had "no medical disabilities at the time." The examiner documented that clinical evaluations of the lower extremities and feet were both normal. For the above reasons, the Board finds as fact that there was no disease or injury involving the Veteran's right and/or left ankle during service, and the second element is not met. The Board also finds the evidence persuasively weighs against a showing of a nexus between the Veteran's current right leg and left leg (ankle/ Achilles) disabilities and service. For example, following a Gulf War Examination in October 2017, the VA examiner found that it is less likely than not that the Veteran's Achilles tendinopathy is related to a specific exposure event/ environmental hazard experienced by the Veteran during service in Southwest Asia. She provided the rationale that a review of the evidence-based medical literature does not support a contention of Achilles tendinopathy as being caused by any specific exposure event and there is no anatomical or biological plausibility to support a nexus. She concluded that the preponderance of established scientific and medical evidence does not support such a relationship. The examiner referenced medical literature including UpToDate regarding Achilles tendinopathy, including the fact that "over 80 percent of ruptures occur during recreational sports." The examiner also indicated that she reviewed the [October 2017] letter from the Veteran's chiropractor, Dr. L. K., that the Veteran had brought with him to the examination. In regard to the right leg, medical records indicate that the Veteran had an Achilles tendon rupture, post-service, in April 1993. In the initial medical record from Nassau County Medical Center, the Veteran reported with complaints of pain in the right calf/ankle after playing football the day prior. The past medical history of "a complaint of left leg pain following a 'pop' heard when running yesterday." An x ray of the right ankle and leg was performed, which showed no evidence of fracture or dislocation. An assessment of Achilles tendon rupture and instructions for the Veteran to follow up at VA Medical Center was provided. In April 1993 VA medical records, the Veteran was noted to have felt a snap in his right heel playing football. Past medical history of a circumcision at 24 years of age in the military was noted on this record, with no notation of a previous injury or pain to the right leg or left leg. A subsequent record for the repair of the Achilles tendon provides a history of the Veteran playing basketball on April 19, 1993, and felt a snap in his right heel. Shortly after, the Veteran was unable to walk and had severe pain in the area of his right heel. Thus, while the medical record from Nassau County Hospital noted left leg pain following a "pop," it appears that this was in error and the April 1993 records are consistent in showing only a right leg/ankle "snap" or "pop," which was diagnosed as an Achilles tendon rupture. During the May 2021 Board hearing, the Veteran testified that when he hurt his back in service, he hurt his right leg at the same time and that he believed his right Achilles rupture was not just by playing football. The Veteran explained that he was just throwing the ball around with his brothers and a few friends and was always complaining about his right leg. He indicated that he did not have medical insurance at the time and was not aware of how to get to a VA hospital until the injury and until told by Nassau County Medical Center. As mentioned previously, the Board finds that the evidence does not support a finding that the Veteran hurt his right leg in service, and the Veteran did not have post-service complaints until April 1993. Importantly, in the April 1993 records, the Veteran did not mention a previous injury or pain to the right leg. Instead, when asked about his past medical history, he reported having a circumcision when he was 24 years old. This would have been a time where, had he experienced a prior injury to that area, he would have reported it. The April 1993 medical record from Nassau County Hospital specifically indicates that the Veteran heard the "pop" when running the day prior and the records include notation of him playing "football" at the time. Thus, even if the Veteran was not playing in a game of "football," the records suggest that the Veteran was at least running when playing catch when the injury occurred. In regard to the left leg, in a July 2017 VA medical record from the podiatry clinic, the Veteran related that he felt pain to the left Achilles tendon while in the gym with personal training. The Veteran was concerned due to pain to the back of the left heel at the Achilles tendon insertion and lateral tendon. Subsequent records reflect left lateral Achilles tendonitis, status-post injections and boot. In January 2018, the Veteran reported that his ankle, Achilles tendon problem, flared up and was in a boot the whole summer/2017 and could not walk except to go to his classes. In June 2018, the Veteran complained that his left foot was numb. He had been running and noted numbness to the bottom of the foot and a four out of 10 left posterior Achilles tendon pain was noted. A January 2021 VA medical record reflects that the Veteran acknowledged that previous injury to the Achilles tendon in the left lower extremity complicates pain pattern (radiating from the low back into his posterior left leg, terminating in the foot) and will make normal sciatic pain unbearable. The evidence shows that the Veteran had an injury to the left Achilles tendon with personal training in July 2017. Prior to this, a June 2012 VA medical record indicates that the Veteran started to have low back pain in November 2011 but the symptoms eventually completely resolved and returned later with the Veteran reporting that the pain from his lumbar spine went into his left leg and foot in July 2012 record. During the May 2021 Board hearing, the Veteran clarified that his claim of the left leg disability is mostly the left ankle and part of the left achilles going down to the foot area, which is consistent with the reported symptoms noted since the July 2017 medical records. The Veteran's left Achilles tendon injury and right Achilles tendon rupture were both noted to have been following physical activity during recreational sports, which is a risk factor noted by the October 2017 VA examiner. While the Veteran has proffered an October 2017 letter from his private chiropractor, Dr. L. K., opining that the Veteran's conditions are secondary to military service, the Board finds that this evidence is of no probative value, as Dr. L. K. based his opinion on an inaccurate factual premise that the Veteran's history of injuries sustained during Army deployment included a fall from a truck causing a leg fracture. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). Dr. L. K.'s statement was based upon the history provided by the Veteran and the Board reiterates that the Veteran's allegation of a leg fracture during service is not credible. The Veteran has not offered other probative and competent medical evidence to support his assertions on medical etiology. There are numerous post-service medical records reflecting complaints and treatment for the right leg and left leg (ankle/ Achilles); however, these records do not provide a positive nexus regarding the onset, etiology, or relationship of a right leg or left leg disability to military service. To the extent that the Veteran alleges that either a right leg or left leg disability is related to service, he is not competent to attribute the right leg and left leg disabilities to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is nonprobative evidence. At the present time, there is no competent evidence of a nexus between the current right leg or left leg disabilities and but instead medical records indicate that such was caused after service discharge when the Veteran was playing football and during personal training, which recreational sports and running are known risk factors for such disabilities as noted by the October 2017 VA examiner. Moreover, as the Veteran's claim for service connection for residuals of a right leg Achilles rupture ankle, a right leg disability, is denied herein, the claimed left leg (ankle/ Achilles) disability cannot be granted on a secondary basis as a right leg disability is not a service-connected disability. The Veteran was afforded a Gulf War Medical Examination in October 2017, however, was not afforded a specific VA examination or medical opinion in connection with the claims for service connection for the right leg and left leg disabilities. VA must provide a medical examination or opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As laid out above, the Board finds as fact that the record does not contain evidence establishing that an event, injury, or disease occurred in service or evidence indicating that the disabilities may be associated with the Veteran's service. For a VA examination or medical opinion to be warranted, all the criteria must be met, and at least one criterion is not met. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for residuals of a right leg Achilles rupture ankle, a right leg disability, or left leg (ankle/ Achilles) disability is warranted. Rather, the evidence persuasively weighs against a finding that such disabilities manifested in service or are etiologically related to the Veteran's active duty military service. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application, and the claims are denied. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 3. Entitlement to service connection for bilateral pes planus. The Veteran contends that service connection is warranted for bilateral pes planus, which was aggravated during service. During the May 2021 Board hearing, the undersigned VLJ informed the Veteran and his representative that because pes planus was noted on his entrance examination, the Veteran can only bring forth an aggravation claim. The Veteran and his representative confirmed during the hearing that his pes planus was not being considered for undiagnosed illness. A veteran who served after December 31, 1946, is presumed to be in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The law further provides that, if a preexisting disorder is noted upon entry into service, a veteran cannot bring a claim for service incurrence for that disorder, but a veteran may bring a claim for service-connected aggravation of that disorder. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). In this type of case, the provisions of 38 U.S.C. § 1153 and 38 C.F.R. § 3.306 apply. Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If a presumption of aggravation under section 1153 arises, due to an increase in a disability in service, the burden shifts to the government to show a lack of aggravation by establishing by clear and unmistakable evidence "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417 ; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). VA's General Counsel has held that the provisions of 38 C.F.R. § 3.306(b), providing that aggravation may not be conceded unless the pre-existing condition increased in severity during service, are not inconsistent with 38 U.S.C. § 1111. 38 C.F.R. § 3.306(b) properly implements 38 U.S.C. § 1153, which provides that a pre-existing injury or disease will be presumed to have been aggravated in service in cases where there was an increase in disability during service. The requirement of an increase in disability in 38 C.F.R. § 3.306(b) applies only to determinations concerning the presumption of aggravation under 38 U.S.C. § 1153 and does not apply to determinations concerning the presumption of sound condition under 38 U.S.C. § 1111 which requires VA to bear the burden of showing the absence of aggravation. VAOPGCPREC 3-2003; see also Wagner, 370 F.3d 1089. On the Veteran's April 1987 entrance examination report, pes planus was documented, therefore the Veteran is not presumed sound as to this disability. As stated above, the Veteran cannot bring a claim for service incurrence for such disability, but only for service aggravation. See Paulson, 7 Vet. App. at 468. The Board notes that the Veteran has conceded he had bilateral pes planus prior to service. Thus, there is no disagreement as to this finding. The Board has reviewed the evidence and finds that the pre-existing bilateral pes planus disability was not aggravated during service. The Veteran's June 1992 Report of Medical Examination for purposes of separation reflects a normal clinical evaluation of all bodily systems, to include the "feet" and "lower extremities." The Veteran indicated under notes that he was "in good health" and had "no medical disabilities at the time." In the accompanying June 1992 Report of Medical History, the Veteran reported a positive history of "cramps in your legs" but denied "arthritis or rheumatism;" "bone, joint, or other deformity;" "lameness;" "loss of arm, leg, finger or toe;" and "foot trouble." Further, the Veteran checked "no" when asked if he "ever had any illness or injury other than those already noted." The denial of a history of foot trouble is affirmative evidence that the Veteran was not experiencing foot trouble by the time of service discharge, which is evidence against a finding of aggravation during service. The Veteran signed this document, wherein he attested that the information he provided in this form was "true and complete to the best of my knowledge." The Board accords high probative value and credibility to this document, as the Veteran completed it contemporaneously with service. Moreover, during the May 2021 Board hearing, the Veteran testified that he did not remember complaints or treatment in service related to bilateral pes planus. He stated that around 1990 or 1991, he thinks he hurt his back on maybe one or two occasions prior to being in the Persian Gulf and always remembered complaining about his right leg. The Veteran testified that when he got out of service, he was always seeing a VA podiatrist for treatment including heel support for both legs. He added that he has two, different kinds of prosthetics, one for the entire ankle, and a shoe insert to take pressure off the left Achilles and the left Ankle area. This does not appear to be referring to the bilateral pes planus but rather the bilateral leg (ankle/ Achilles) disabilities that are discussed herein above, as the Veteran was talking about the shoe insert being used to assist with Achilles pain. Regardless, the Board finds that what the Veteran documented in the June 1992 Report of Medical History and the fact that clinical evaluation of his feet was normal to be more probative as to whether there was aggravation of the bilateral pes planus during service, which service ended in 1992, than statements made decades after service discharge. The Veteran also testified that a VA podiatrist explained to him that, "this is an injury that's been happening for so long that it was on my behalf that I neglected it, I probably did not realize how significant it was. And as you progress in age, it only aggravates and get it gets worse than how it originally was." It was unclear whether the Veteran was addressing the bilateral pes planus or the bilateral leg injuries, however, this does not establish that the Veteran's bilateral pes planus was aggravated during service, which period of service ended in 1992, rather, the VA podiatrist is telling the Veteran that it is worsening due to the normal progress of aging. The Veteran also stated that the VA podiatrist told him that his flat feet were not that severe, but more than likely, the Veteran had injuries that had been aggravated since then to the present. He stated that the VA podiatrist explained to him that when he ruptured the right Achilles, additional pressure and weight was put on the left side of the body and caused the left side issue from the lumbar spine all the way down to toes and ankle area. The Veteran's right Achilles was not ruptured in service, but rather post-service in April 1993, therefore, could not have aggravated the Veteran's bilateral pes planus during service. There are multiple entries in the Veteran's service treatment records of treatment he received during service, however, there are no documented complaints related to the feet. He was treated for back pain, shoulder pain, neck pain, swollen penis glands, cyst on rear end, chest pain, and other medical complaints. The lack of documentation of complaints pertaining to his feet and bilateral pes planus tends to establish that the Veteran was not experiencing an increase in his symptomatology, as he sought treatment for other medical symptoms he was experiencing during service. The Veteran has attempted to establish through his own lay assertions that his bilateral pes planus was aggravated beyond natural progression as a result of service, however, the Veteran has not offered probative evidence in support of his contentions. To the contrary, the Veteran's testimony affirms that he was not treated in service for bilateral pes planus and shows that his VA podiatrist suggests his injury is worsening due to the normal progress of aging and aggravation due to the ruptured right Achilles injury, which is not a service-connected disability as it is denied herein above. The Board accords high probative value to the service treatment records, as such were created contemporaneously with the Veteran's service, and fail to document worsening symptoms during service. The Veteran was not afforded a VA examination or medical opinion in connection with the claim for service connection for bilateral pes planus. The McLendon requirements were laid out above. The Board finds as fact that the record does not show evidence establishing that an event, injury, or disease related to the feet during service to show possible aggravation. For a VA examination to be warranted, all the criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for the claim for service connection for bilateral pes planus. In sum, pes planus was noted upon enlistment, and the most probative and competent evidence of record is against the Veteran's claim of in-service aggravation. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record. The evidence is neither evenly balanced nor approximately so with regard to whether the pre-existing bilateral pes planus was aggravated during service. As the evidence persuasively weighs against the claim of service connection for bilateral pes planus, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. See Lynch, 21 F.4th 776; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102. 4. Entitlement to service connection for a cervical spine disability. The Veteran asserts that service connection is warranted for a cervical spine (neck) disability because it was incurred in service or otherwise a result of service. During the May 2021 Board hearing, the Veteran testified that in 1989 or 1990, he went to sick call for his neck due to chronic stiff necks and muscle spasms. The Veteran's representative indicated that there was a neck complaint noted in the Veteran's service treatment records of five days on March 4, 1990. The Veteran and his representative confirmed during the hearing that the cervical spine disability is not being considered for undiagnosed illness. After a careful review of the evidence of record, the Board finds that the evidence persuasively weighs against a finding that service connection for cervical spine disability is warranted. The reasons follow. As to evidence of a current disability, the Veteran was afforded a VA examination in October 2017 for the claimed cervical spine disability and the examiner confirmed a diagnosis of cervical degenerative disc disease (DDD). Accordingly, the Board finds there is evidence of a current cervical spine disability, and the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, an April 1990 service treatment screening note of acute medical care documents the Veteran's complaint of right neck and shoulder pain of one day. Trauma in the preceding 72 hours was noted, and the Veteran requested to be seen by the physician's assistant. On the reverse page of this record is the record of acute medical care, which noted neck and shoulder pain of five days, and the Veteran's report that he was lifting weights. The examiner documented a negative history of shoulder or neck issues. The assessment provided was "trapezius muscle." As the record prior is from March 14, 1990, the Board believes that the Veteran's representative was referring to this April 1990 treatment record during the Board hearing when he mentioned a March 4, 1990 record that showed a neck complaint of five days. Thus, the second element of a service-connection claim has been met. The facts establish that the first two elements of a service-connection claim, which are evidence of a current disability and evidence of an in-service treatment for a neck injury. That fact notwithstanding, however, the Board finds that service connection for a cervical spine disability is not warranted because the evidence persuasively weighs is against a finding of a nexus between the current disability and the Veteran's military service. As mentioned above, the October 2017 VA examination report includes a September 2013 diagnosis of "cervical DDD." However, under section 14, diagnostic testing, the examiner answered "yes" when asked if imaging studies of the cervical spine had been performed and if arthritis (degenerative joint disease) was documented. This diagnosis was provided following September 2013 magnetic resonance imaging (MRI) of the cervical spine, which showed C2/3, 3/4, 4/5, 5/6, 6/7, C7-T1, T1/2- posterior disc herniation and at C6/7 there was an extruded broad based posterior disc herniation with cord compression, central stenosis, bilateral foraminal extension, and impingement of the exiting C4 nerve roots. The examiner, in her opinion in the October 2017 Gulf War Examination Report, also referred to the Veteran's disability as "cervical DDD." The Board notes that "arthritis" is defined as inflammation of a joint. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 152 (31st ed. 2007). Degenerative joint disease (DJD) is arthritis, but it is distinguished from degenerative disc disease (DDD), which is not arthritis and therefore not a chronic disease. 38 C.F.R. §§ 3.307, 3.309(a). Nonetheless, the evidence does not support a finding that the Veteran had arthritis of the cervical spine in service. The June 1992 Report of Medical Examination for purposes of separation shows a normal clinical evaluation of all bodily systems, to include the "head, face, neck and scalp" and "spine, other musculoskeletal" systems. The Veteran indicated under notes that he was "in good health" and had "no medical disabilities at the time." In the accompanying Report of Medical History, the Veteran denied that he ever had or had at the time, "swollen or painful joints;" "broken bones;" "arthritis, rheumatism, or bursitis;" "bone, joint or other deformity;" "lameness" and "neuritis." Further, the Veteran checked "no" when asked if he "ever had any illness or injury other than those already noted." The Veteran signed this document, wherein he attested that the information he provided in this form was "true and complete to the best of my knowledge." The Board accords high probative value and credibility to this document, as the Veteran completed it contemporaneously with service. Thus, by the time the Veteran was being discharged from service, his cervical spine was clinically normal. Additionally, there is no competent evidence that the Veteran has arthritis that manifested within one year from his June 1992 separation from service. Specifically, in an October 1995 VA medical record where he presented to check for "Persian Gulf Syndrome," the Veteran complained of sharp head pain and on and off neck pain that was not related to movement. The neck was noted to be supple on physical examination. In the actual Persian Gulf Registry Examination, completed in July 1997, when asked to list up to 10 major current symptoms, the only symptoms listed by the examining physician was "rash." In subsequent reviews of systems in VA medical records, the Veteran did not have any neck stiffness or pain, including in March 2006, January 2008, December 2008, and July 2010. The Veteran's neck was noted to have been tender on the left cervical lymph nodes along with his complaint of a sore throat in July 2007. In a May 2012 VA medical record, the Veteran complained of anxiety attacks with feeling dizzy, feeling like passing out, numb feeling in leg, and pain in the shoulder and neck. The Veteran reported that the anxiety attacks started when he was in jail. In a subsequent May 2012 VA medical record, the Veteran presented with a complaint of low back pain with radiation to the back of one leg. Upon physical examination, the Veteran's neck was noted to be supple and non-tender to percussion. As the Veteran testified to during the May 2021 Board hearing, that after the military, he had follow-up care for the neck "probably years later" and explained when his back flared up, the spine specialist at Bronx VA hospital noticed from MRI scan that his neck was just as bad as his back. VA medical records that show in September 2013 he went for a standing MRI for his cervical spine and in October 2013, Bronx VA notified him of significant abnormalities in the cervical spine and the lumbar spine surgery was deferred. This September 2013 MRI was referenced by the October 2017 VA examiner in her examination report when she confirmed a diagnosis of "cervical DDD." Arthritis is diagnosed primarily on clinical findings such as x-rays or specialized testing, such as an MRI, which the Veteran is not competent to conduct or interpret. See 38 C.F.R. § 4.71a , Diagnostic Code 5003 (degenerative arthritis established by x-ray findings), Diagnostic Code 5010 (traumatic arthritis established by x-ray findings), Diagnostic Code 5002 (rheumatoid arthritis must be "objectively confirmed by findings" that show limitation of motion). Cf. 38 C.F.R. § 4.66 (indicating the usual way to diagnose arthritis is by x-ray, which is also required to see arthritic changes). The Veteran's lay assertions cannot constitute competent medical evidence in support of a current diagnosis of arthritis of the cervical spine. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). While it is unclear whether the diagnosis is arthritis, the earliest diagnosis of degeneration of the cervical spine followed the September 2013 MRI, over two decades after separation from service. Thus, a presumption of service connection based on the chronicity of arthritis is not warranted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.307, 3.309(a). The Board has considered the Veteran's cervical spine disability on a direct basis and finds that the evidence persuasively weighs against a showing of a nexus between the Veteran's current cervical spine disability and service. The October 2017 VA examiner opined that the Veteran's claimed neck disability was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event or illness. However, as the rationale provided seemed to support a negative opinion, the RO requested clarification from the examiner if the opinion should have been a negative opinion in a November 2017 email. In response, the examiner provided an addendum opinion in December 2017, which confirmed that it was supposed to be a negative opinion. She found that the claimed neck disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided the same rationale as in the November 2017 opinion. She noted the Veteran's service treatment records which documented right neck pain in April 1990 with the rest of the service treatment records being silent. The examiner indicated that the June 1992 separation examination was silent for neck complaints and diagnosis. She noted that the Veteran specifically wrote "1. I'm in good health. 2. I have no medical disabilities at this time. 3. No profile." She indicated that she reviewed the claims file and his VA Medical Center outpatient treatment records dating back to 1997, which were silent for any neck conditions until he presented in 2013. The examiner stated that this was 24 years after active duty separation, with no documentation of continuity of complaints and that there is no documentation in chronicity. The Board finds of most probative value the medical opinion of the October 2017 VA examiner. The VA examination report and opinion provides competent and probative evidence that weighs against the Veteran's claim because the examiner reviewed the claims file, interviewed the Veteran, performed a physical examination, and provided a medical opinion supported by well-reasoned rationale, which was based upon the facts of the case and medical principles. The examiner's opinion is consistent with the lay and medical evidence of record. The examiner's opinion is supported by the Veteran's service treatment records, which show that while there was an in-service event, the Veteran's June 1992 Report of Medical Examination close to separation reflects a normal clinical evaluation of the "head, face, neck, and scalp" and "spine, other musculoskeletal." As explained above, with the exception of an October 1995 complaint of sharp head pain and on and off neck pain that was not related to movement when he presented to check for "Persian Gulf Syndrome," the there are no subsequent complaints related to the cervical spine until September 2013, which does not lend to a finding of a nexus between the current disability and service. The review of systems were consistently negative for any neck issues and there was no noted past medical history of such in the time between the October 1995 complaint and the September 2013 treatment. The Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disability at issue. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran has not offered probative and competent medical evidence to support his assertions on medical etiology. There are numerous post-service medical records reflecting neck pain, however, these records do not provide a positive nexus regarding the onset, etiology, or relationship of a cervical spine disability to military service. The Veteran has proffered an October 2017 letter from his private chiropractor, Dr. L. K., which indicated that the Veteran first presented to his clinic complaining of neck pain and low back pain with accompanying numbness and tingling down the left foot in December 2015. He noted that the Veteran's complaint began in 1995 after being discharged from the military service and, "history intake reveals extensive history of injuries sustained during Army deployment, including a fall from a truck causing a leg fracture...." In Social Security Administration (SSA) records completed in July 2012 for his disability claim, when asked when he first started to have pain, the Veteran answered "November 2011" and that he felt pain in the "left side of back, buttocks, and left leg and foot." When asked about his anxiety, the Veteran indicated that his condition began, "while I was in the Army it has gotten worse since 1994." The Veteran did not list a cervical spine disability or neck pain under section 3.A of the questionnaire when asked to list all the physical or mental conditions that limited his ability to work. This shows that the Veteran was not complaining of a cervical spine disability or neck pain at the time of this July 2012 application for SSA disability. Rather, the evidence is consistent that the Veteran's current neck complaints began around September 2013. Dr. L. K., opined that the Veteran's conditions are secondary to military service, however, the Board finds that this evidence is of no probative value, as Dr. L. K. based his opinion on an inaccurate factual premise that the Veteran's history of injuries sustained during Army deployment included a fall from a truck causing a leg fracture. See Reonal, 5 Vet. App. at 461. Dr. L. K.'s statement was based upon the history provided by the Veteran and the Board reiterates that the Veteran is not a qualified medical professional who can provide a diagnosis of a leg fracture. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link the current cervical spine disability to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. In sum, the Board finds that the Veteran's cervical spine disability did not manifest in service, and that it is not etiologically related to his active duty military service. As the evidence persuasively weighs against a of the evidence is against the claim of service connection for a cervical spine (neck) disability, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. See Lynch, 21 F.4th 776; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102. REASONS FOR REMAND The Board finds that remand is warranted to fully assist the Veteran with the development of his claims. VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, and there is insufficient medical evidence of record to decide the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon, 20 Vet. App. at 79. When VA undertakes to obtain an examination, it must ensure that the examination and opinion therein is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 5. Entitlement to service connection for a lumbar spine disability The Veteran was afforded a VA examination for his claimed lumbar spine disability in October 2014. The examiner provided an opinion that the claimed disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. However, the examiner provided the rationale that based on the Veteran's medical records, his subjective examination, his objective examination, and his diagnostic clinical tests, this examiner would be resorting to mere speculation when attempting to opine on whether or not this Veteran's current back condition is the result of the back pain noted on September 11, 1987, January 21, 1990, and September 15, 1990. While the examiner provided a negative opinion, in her rationale she indicated that she would be resorting to mere speculation but did not explain why this was the case. As such, the Board finds that an addendum VA medical opinion is warranted. 6. Entitlement to service connection for generalized muscle pain / spasms in the deltoids (shoulders), including as due to a qualifying chronic disability and to include as an undiagnosed illness 7. Entitlement to service connection for generalized muscle pain / spasms in the hamstrings, including as due to a qualifying chronic disability and to include as an undiagnosed illness 8. Entitlement to service connection for vertigo, also claimed as dizziness, including as due to a qualifying chronic disability and to include as an undiagnosed illness 9. Entitlement to service connection for ischemia, including as due to a qualifying chronic disability and to include as an undiagnosed illness 10. Entitlement to service connection for hypertension, including as due to a qualifying chronic disability and to include as an undiagnosed illness 11. Entitlement to service connection for gastroenteritis, including as due to a qualifying chronic disability and to include as an undiagnosed illness 12. Entitlement to service connection for anemia, including as due to a qualifying chronic disability and to include as an undiagnosed illness 13. Entitlement to service connection for upper and lower body rashes, including as due to a qualifying chronic disability and to include as an undiagnosed illness 14. Entitlement to service connection for headaches, including as due to a qualifying chronic disability and to include as an undiagnosed illness 15. Entitlement to service connection for radiculopathy left lower extremity, including as due to a qualifying chronic disability and to include as an undiagnosed illness The Board has broadened the appeal to include the theory of presumptive service connection as due to a qualifying chronic disability (see 38 U.S.C. § 1117; 38 C.F.R. § 3.317). A "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illnesses that is defined by a cluster of signs or symptoms. A "medically unexplained chronic multi-symptom 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, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. The Veteran was provided a VA Gulf War General Medical Examination in October 2017. The Board notes the Veteran's contention that his Gulf War examination was inadequate. In December 2017 email correspondence, the Veteran stated that he was previously promised by the Regional Office (RO) another examination with a different examiner due to his complaints of the examiner's unprofessionalism and bias. The Veteran testified during the May 2021 Board hearing that he did not get the proper examination for the Persian Gulf illnesses that he claimed. A review of the October 2017 Gulf War Examination reflects "no answer provided" for each bodily system listed in the medical history portion of the examination. Specifically, the medical history was noted as "normal, no symptoms, abnormal findings or complaints are reported." The examiner addressed only the Veteran's claimed bilateral leg disabilities, neck disability, and back disability in providing opinions for the respective disabilities. She found that the disabilities were less likely than not (less than 50 percent probability) related to a specific exposure event/environmental hazard experienced by the Veteran during service in Southwest Asia, however, did not address the remaining disabilities that are part of this remand listed above. As such, remand is necessary in order to provide the Veteran with a new VA examination and to obtain VA opinions regarding any nexus between the claimed disabilities and service. The matters are REMANDED for the following action: 1. Provide the Veteran's claims file to a qualified medical professional, other than the October 2014 examiner who performed the examination for the claimed lumbar spine disability, to provide an addendum opinion. If the examiner finds that an in-person physical examination is necessary, then schedule an examination. If an examination is scheduled, any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. The agency of original jurisdiction is asked to provide a copy of the below facts to the examiner. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from May 1987 to June 1992. The Veteran's military occupational specialty (MOS) was a food service specialist. The Veteran contends that his current lumbar spine disability was caused by or otherwise related to service, to include a fall down the stairs on one occasion, shown in a September 1990 service treatment record. See VBMS entry with document type, "Hearing Transcript," receipt date 05/28/2021, on pages 4-6, generally. In September 1987 and January 1990 service treatment records, the Veteran was seen for complaint of back pain with a duration of one day. See VBMS entry with document type, "STR - Medical," receipt date 12/09/2015, with "#1" in the subject field, on pages 70 (Sept. 1987) & 20 (Jan. 1990). A September 1990 service treatment record reflects that the Veteran fell down the stairs the prior night and had pain in the left lumbar region. 2+ left lumbar spasm was present but no swelling or discoloration was noted. The Veteran was unable to flex past 60 degrees due to pain. Deep tendon reflexes were symmetrical, straight leg raising was negative, and Patrick's testing was negative. An assessment of severe left lumbar strain was provided. See VBMS entry with document type, "STR - Medical," receipt date 12/09/2015, with "#1" in the subject field, on pages 26-27. A June 1992 Report of Medical Examination for purposes of separation shows normal clinical evaluations of all bodily systems, including the "spine, other musculoskeletal" and "lower extremities." The Veteran made specific notations that, "1. I'm in good health. 2. I have no medical disabilities at this time. And 3. No profile." See VBMS entry with document type, "STR - Medical," receipt date 12/09/2015, with "#1" in the subject field, on pages 14-15 (items 37 & 38). In the accompanying June 1992 Report of Medical History, the Veteran wrote, "I'm in good health" and denied that he ever had or had at the time, "swollen or painful joints;" "broken bones;" "arthritis, rheumatism, or bursitis;" "bone, joint or other deformity;" "lameness;" and "recurrent back pain." See VBMS entry with document type, "STR - Medical," receipt date 12/09/2015, with "#1" in the subject field, on pages 12-13 (item 11). A February 1994 VA medical record reflects the Veteran's complaint of low back pain for one week. The examiner documented that, "No trauma recalled." See VBMS entry with document type, "Medical Treatment Record - Government Facility," receipt date 07/23/2014, with "#2" in the subject field, on page 1. A March 1994 VA medical record shows the Veteran was noted to have complained of back pain of a one-month duration. He reported he had been doing workouts and weights. See VBMS entry with document type, "Medical Treatment Record - Government Facility," receipt date 07/23/2014, with "#3" in the subject field, on page 4. An October 1995 VA medical record shows a past medical history of "bad back, no x-rays; no often injuries; and papular nodules in the back with diagnoses of dermatitis and depression. See VBMS entry with document type, "Medical Treatment Record - Government Facility," receipt date 07/23/2014, with "#4" in the subject field, on page 6. A July 2007 VA medical record shows the Veteran complained of lower back pain. An assessment of "lower back pain probably self-limiting can take Tylenol or Motrin" was provided. See VBMS entry with document type, "CAPRI," receipt date 07/14/2014, with "#5" in the subject field, on pages 175-176. A May 2011 county correctional facility "Admission Physical Examination" shows an abnormal clinical evaluation of the back. Lower back pain muscle pull was noted. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/25/2013, with "#6" in the subject field, on pages 8-9. A November 11, 2011 medical record shows the Veteran presented with acute lower back pain/spasm. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/25/2013, with "#7" in the subject field, on page 17. On November 15, 2011, the Veteran complained of low back pain from working out and running in the yard. On December 1, 2011, the Veteran complained of back pain and stated that it was "not intense but still there" See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/25/2013, with "#8" in the subject field, on pages 4-5. A December 2011 radiological report of the lumbar spine AP/lateral revealed no evidence of fracture seen, no spondylolisthesis, no paraspinal abnormalities, mild degenerative changes seen, and visualized bowel gas pattern was unremarkable. The impression provided was no acute abnormality. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/25/2013, with "#6" in the subject field, on page 5. A December 30, 2011 medical record documents a past medical history of lower back pain and that the Veteran was seen for complaint of back spasm previously. Lower back pain/spasm was noted that appeared to be worse at night. The Veteran was given Robaxin 500MG at bedtime. Lumbago was listed under chronic problems. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/25/2013, with "#9" in the subject field, on page 17. In May 2012 VA medical records, the Veteran complained of low back pain with radiation to the back of one leg since the preceding Saturday, with no trauma and no falls. He had one leg numbness while walking from the "sali." See VBMS entry with document type, "CAPRI," receipt date 07/14/2014, with "#10" in the subject field, on pages 701-704. May 2012 reports of CT and x-ray of the lumbar spine show an impression of degenerative disc disease was provided following CT scan. See VBMS entry with document type, "CAPRI," receipt date 07/14/2014, with "#10" in the subject field, on pages 691-692. A June 2012 VA medical record shows the Veteran reported that he started having lower back pain in November 2011 but his symptoms eventually resolved, and the pain returned in January and continued until March. The most recent episode of lower back pain and lower extremity symptoms began 2.5 weeks prior of unknown etiology. See VBMS entry with document type, "CAPRI," receipt date 07/14/2014, with "#10" in the subject field, on pages 675. In an October 2014 back (thoracolumbar spine) conditions Disability Benefits Questionnaire (DBQ), the examiner diagnosed the Veteran with degenerative disc disease of the lumbar spine and L5, S1 radiculopathy. See VBMS entry with document type, "C&P Exam," receipt date 10/21/2014, on page 1, generally. At the October 2014 examination, the Veteran reported the history as a 1990 injury to the back on a fall while in service. Id. The October 2014 examiner opined that the claimed lumbar spine disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. However, she provided the rationale that she would be resorting to mere speculation when attempting to opine on whether or not the Veteran's current condition was the result of the back pain noted on 09/11/1987, 01/21/1990, and 09/15/1990. Id. at page 12. In a November 2017 letter, the Veterans private chiropractor, Dr. L. K. indicated that the Veteran first presented to his clinic in December 2015 complaining of neck pain and low back pain with accompanying numbness and tingling down the left foot. He stated that the Veteran's complaints begin in 1995 after being discharged from military history. Dr. L. K. stated, "history intake reveals extensive history of injuries sustained during Army deployment, including a fall from a truck causing a leg fracture, and exposure to nerve gas agents. The fall from a truck or leg fracture is not documented in service. He opined that the Veteran's conditions are permanent chronic conditions secondary to military service. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 11/02/2017. The examiner is informed that the Board finds that the alleged fall from the truck causing a leg fracture did not happen. Thus, the examiner should not accept that fact documented by Dr. L. K. to be true. A December 2020 VA medical record shows the Veteran's brain and spine MRI results were reviewed and he was informed that there were no lesions or inflammation. The only abnormality noted were mild arthritis changes in the lower and upper spine with some pinged nerve roots and slipped discs in the neck. See VBMS entry with document type, "CAPRI," receipt date 02/11/2021, on page 1. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: a) Please list the Veteran's diagnosed lumbar spine disabilities. b) For the lumbar spine disabilities diagnosed, was it incurred during the Veteran's service from May 1987 to June 1992, to include the in-service complaints of back pain, as described during his May 2021 Board hearing testimony? Please state upon what facts, medical principles, and/or medical literature you base the opinion. The examiner should consider and address the facts listed above, to include but not limited to the May 2021 hearing testimony and September 1987, January 1990, and September 1990 documented complaints in service treatment records. Specifically, the Veteran's fall down stairs in September 1990. (Locations in VBMS file laid out above.) c) If arthritis of the lumbar spine was found, the examiner is asked to address whether that arthritis manifested within one year of service discharge in June 1992 (thus, in approximately June 1993). Please state upon what facts, medical principles, and/or medical literature you base the opinion. Please explain your answers by citing to supporting clinical data and/or medical literature, as deemed appropriate. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. Schedule a VA Gulf War examination to assist in determining the nature and etiology of the claimed disabilities on appeal with a qualified medical professional. The Veteran's claims file should be made available to the examiner who must review the claims file. All appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail, to include current symptomatology. The examiner should note all reported symptoms, and specifically state whether any of the Veteran's complaints are attributable to a known diagnosis. If there are known diagnoses to which the Veteran's complaints are attributable, based upon a review of the record (including service treatment records, post-service treatment records, lay statements, history of the Veteran, and clinical findings), the examiner should offer the following opinions with supporting rationale with respect to each disorder: a) Please list the any confirmed diagnoses for the claimed: 1. generalized muscle pain in the deltoids (shoulders), 2. generalized muscle pain in the hamstrings, 3. vertigo (dizziness), 4. ischemia, 5. hypertension, 6. gastroenteritis, 7. anemia, 8. upper and lower body rashes, 9. headaches, and 10. radiculopathy left lower extremity. b) For each diagnosis identified: 1. generalized muscle pain in the deltoids (shoulders), 2. generalized muscle pain in the hamstrings, 3. vertigo (dizziness), 4. ischemia, 5. hypertension, 6. gastroenteritis, 7. anemia, 8. upper and lower body rashes, 9. headaches, and 10. radiculopathy left lower extremity, did such disability have its onset during the Veteran's active duty from May 1987 to June 1992? Please state upon what facts, medical principles, and/or medical literature you base the opinion. c) If no diagnosis is identified, does the Veteran have a disability due to symptoms of or similar to (1) generalized muscle pain in the deltoids (shoulders), (2) generalized muscle pain in the hamstrings, (3) vertigo (dizziness), (4) ischemia, (5) hypertension, (6) gastroenteritis, (7) anemia, (8) upper and lower body rashes, (9) headaches, and (10) radiculopathy left lower extremity? If so, did such disability have its onset in during the Veteran's active duty from May 1987 to June 1992? Please state upon what facts, medical principles, and/or medical literature the opinion is based. d) Notwithstanding any diagnosis or functional impairment identified, is the disorder(s) a "medically unexplained chronic multi-symptom illness?" A "medically unexplained chronic multi-symptom 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, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. Please state upon what facts, medical principles, and/or medical literature the opinion is based. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After all available evidence has been associated with the record, review the evidence, and determine if further development is warranted. The AOJ should take any additional development as deemed necessary. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, 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.