Citation Nr: 22043877 Decision Date: 08/02/22 Archive Date: 08/02/22 DOCKET NO. 18-05 910 DATE: August 2, 2022 ORDER A compensable evaluation for a fracture to the proximal phalanx base of the right little finger is denied. An initial compensable evaluation for a scar associated with a right little finger fracture is denied. The appeal for an effective date prior to November 8, 2012 for a 10 percent evaluation for gastroesophageal reflux disease (GERD) is dismissed. A total disability rating based on individual unemployability (TDIU) from September 8, 2016 to August 1, 2017 is granted. Service connection for dizziness is denied. Service connection for muscle soreness is denied. Service connection for weight loss is denied. Service connection for a disability of the left hand and fingers is denied. Service connection for left elbow epicondylitis is denied. Service connection for right elbow epicondylitis is denied. New and material evidence has been received, and a claim of service connection for residuals of a lumbar strain is reopened. New and material evidence has been received, and a claim of service connection for a left knee disability is reopened. Service connection for a left knee disability is denied. New and material evidence has been received, and a claim of service connection for a right knee disability is reopened. Service connection for a right knee disability is denied. New and material evidence has been received, and a claim of service connection for left shoulder rotator cuff tendonitis is reopened. New and material evidence has been received, and a claim of service connection for right shoulder rotator cuff tendonitis is reopened. Service connection for right shoulder rotator cuff tendonitis is denied. REMANDED Entitlement to service connection for degenerative arthritis of the cervical spine. Entitlement to service connection for numbness of the left lower extremity. Entitlement to service connection for numbness of the left upper extremity. Entitlement to service connection for numbness of the right lower extremity. Entitlement to service connection for residuals of a lumbar strain. Entitlement to service connection for left shoulder rotator cuff tendonitis. Entitlement to an evaluation in excess of 10 percent for GERD. Entitlement to service connection for fatigue. Entitlement to service connection for Gulf War illness. FINDINGS OF FACT 1. The Veteran's fracture to the proximal phalanx base of the right little finger is productive of painful limitation of motion. 2. The Veteran's scar associated with his right little finger fracture is not painful, unstable, or at least 39 square centimeters. 3. The claim for an earlier effective date for the grant of service connection for GERD constitutes a freestanding claim, which is barred as a matter of law. 4. The Veteran's PTSD rendered him unemployable or unable to secure and follow a substantially gainful occupation from September 8, 2016 to August 1, 2017. 5. The Veteran's dizziness is not related to service or to exposures in Southwest Asia. 6. The Veteran's claimed muscle soreness is not a current disability. 7. The Veteran does not have a current disability characterized by weight loss. 8. The Veteran does not have a current disability of the left hand and fingers. 9. The Veteran's left elbow epicondylitis is not related to service or to exposures in Southwest Asia. 10. The Veteran's right elbow epicondylitis is not related to service or to exposures in Southwest Asia. 11. Evidence received since an October 2013 final rating decision relates to an unestablished fact, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim of service connection for residuals of a lumbar strain. 12. Evidence received since an October 2013 final rating decision relates to an unestablished fact, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim of service connection for a left knee disability. 13. The Veteran's patellofemoral syndrome of the left knee is not related to service or to exposures in Southwest Asia. 14. Evidence received since an October 2013 final rating decision relates to an unestablished fact, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim of service connection for a right knee disability. 15. The Veteran's patellofemoral syndrome of the right knee is not related to service or to exposures in Southwest Asia 16. Evidence received since an October 2013 final rating decision relates to an unestablished fact, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim of service connection for left shoulder rotator cuff tendonitis. 17. Evidence received since an October 2013 final rating decision relates to an unestablished fact, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim of service connection for right shoulder rotator cuff tendonitis. 18. The Veteran's right shoulder rotator cuff tendonitis is not related to service or to exposures in Southwest Asia. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for a fracture to the proximal phalanx base of the right little finger are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.71a, Diagnostic Code 5230 (2021). 2. The criteria for an initial compensable evaluation for a scar associated with a right little finger fracture are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.118, Diagnostic Code 7805 (2021). 3. The criteria for dismissal of the appeal for effective date earlier than November 8, 2012, for the grant of service connection for GERD are met. 38 U.S.C. § 5110 (2018); 38 C.F.R. § 3.400 (2021). 4. The criteria for a TDIU from September 8, 2016 to August 1, 2017 are met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.102, 3.340, 3.341, 3.400(o)(2), 4.15, 4.16, 4.19 (2021). 5. The criteria for service connection for dizziness are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 6. The criteria for service connection for muscle soreness are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 7. The criteria for service connection for weight loss are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 8. The criteria for service connection for a disability of the left hand and fingers are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 9. The criteria for service connection for left elbow epicondylitis are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 10. The criteria for service connection for right elbow epicondylitis are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 11. Evidence received since a final October 2013 rating decision is new and material; therefore, the Veteran's claim of entitlement to service connection for residuals of a lumbar strain is reopened. 38 U.S.C. §§ 5108, 7105(c) (2018); 38 C.F.R. §§ 3.156(a), 20.1103 (2021). 12. Evidence received since a final October 2013 rating decision is new and material; therefore, the Veteran's claim of entitlement to service connection for a left knee disability is reopened. 38 U.S.C. §§ 5108, 7105(c) (2018); 38 C.F.R. §§ 3.156(a), 20.1103 (2021). 13. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 14. Evidence received since a final October 2013 rating decision is new and material; therefore, the Veteran's claim of entitlement to service connection for a right knee disability is reopened. 38 U.S.C. §§ 5108, 7105(c) (2018); 38 C.F.R. §§ 3.156(a), 20.1103 (2021). 15. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). 16. Evidence received since a final October 2013 rating decision is new and material; therefore, the Veteran's claim of entitlement to service connection for left shoulder rotator cuff tendonitis is reopened. 38 U.S.C. §§ 5108, 7105(c) (2018); 38 C.F.R. §§ 3.156(a), 20.1103 (2021). 17. Evidence received since a final October 2013 rating decision is new and material; therefore, the Veteran's claim of entitlement to service connection for right shoulder rotator cuff tendonitis is reopened. 38 U.S.C. §§ 5108, 7105(c) (2018); 38 C.F.R. §§ 3.156(a), 20.1103 (2021). 18. The criteria for service connection for right shoulder rotator cuff tendonitis are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1989 to May 1993 and from January 1994 to September 1996, including service in Southwest Asia. This appeal is before the Board of Veterans' Appeals (Board) from December 2014, December 2017, and November 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Little Rock, Arkansas. In July 2021, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. Consideration must also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the claimant will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 1. Entitlement to a compensable evaluation for a fracture to the proximal phalanx base of the right little finger 2. Entitlement to an initial compensable evaluation for a scar associated with a right little finger fracture The Veteran claims compensable ratings for residuals of his right little finger fracture, including a scar. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021, and the rating criteria for evaluating skin disabilities under 38 C.F.R. § 4.118 were amended effective August 13, 2018. The Veteran's little finger fracture residuals are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5230. Under this code, a maximum noncompensable rating is warranted for any limitation of motion in the little finger. Alternatively, ankylosis in the little finger warrants a maximum noncompensable rating under 38 C.F.R. § 4.71a, Diagnostic Code 5227. Compensable ratings for disabilities that affect only the little finger are limited to ratings for partial or complete amputation under 38 C.F.R. § 4.71a, Diagnostic Code 5156, which warrants a 10 percent rating for amputation without metacarpal resection and a 20 percent rating for amputation with metacarpal resection. These three codes were unaffected by the February 2021 amendments. The Veteran's scar is rated under 38 C.F.R. § 4.118, Diagnostic Code 7805. This code directs that scars be rated under Diagnostic Code 7800, 7801, 7802, or 7804. Diagnostic Code 7800 applies to scars of the head, face, or neck, and is therefore inapplicable to the Veteran's finger scar. Scars associated with underlying tissue damage not of the head, face, or neck are rated under 38 C.F.R. § 4.118, Diagnostic Code 7801. Prior to the August 2018 amendments, regulations described these scars as deep and nonlinear; the code was otherwise unchanged. A 10 percent rating is warranted for scarred areas of 39 to 77 square centimeters, a 20 percent rating is warranted for scarred areas of 77 to 465 square centimeters, a 30 percent rating is warranted for scarred areas of 465 to 929 square centimeters, and a 40 percent rating is warranted for scarred areas greater than 929 square centimeters. Separate ratings may be assigned for qualifying scars in separate zones of the body. Six zones are defined as each extremity, the anterior trunk, and the posterior trunk. Scars not of the head, face, or neck, that are not associated with underlying soft tissue damage are rated under 38 C.F.R. § 4.118, Diagnostic Code 7802. Prior to the August 2018 amendments, regulations described these scars as superficial and nonlinear; the code was otherwise unchanged. A maximum 10 percent rating is warranted for scarred areas greater than 929 square centimeters. Separate ratings may be assigned for qualifying scars in separate zones of the body. Painful and unstable scars are rated under 38 C.F.R. § 4.118, Diagnostic Code 7804, which was unchanged by the August 2018 amendments. This code evaluates scars which are unstable or painful. A 10 percent rating is warranted for 1 or 2 such scars, a 20 percent rating is warranted for 3 or 4 such scars, and a 30 percent rating is warranted for 5 or more such scars. If one or more scars are both painful and unstable, 10 percent is to be added to the total rating. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. The Veteran underwent a VA examination in September 2013. He described flare-ups affecting fine motor activities. Physical examination showed evidence of limited and painful motion of the right little finger. Flexion was limited to a gap of less than one inch between fingertip and the proximal transverse crease of the palm, with evidence of pain thereat. Extension was full without pain. Repetitive testing did not lead to any additional loss of range or function. There was evidence of pain on palpation. Muscle strength was full without atrophy. There was no ankylosis. X-rays showed evidence of arthritis with a mild angular deformity. He was diagnosed with residuals of a proximal phalanx fracture of the right small finger. The examiner found no functional impact and found that no pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups. The Veteran underwent another VA examination in December 2014. He reported persistent numbness all the time on the ulnar side of his right fifth finger, affecting his grip and fine motor coordination. He described only mild functional limitations, as he still shook hands with his right hand and was able to work as an auto mechanic. He denied flare-ups. Physical examination showed evidence of limited motion of the right little finger. Flexion was limited to a gap of less than one inch between fingertip and the proximal transverse crease of the palm. There was no objective evidence of painful motion. Extension was full without pain. Repetitive testing did not lead to any additional loss of range or function. There was evidence of pain on palpation. Muscle strength was full without atrophy. There was no ankylosis. The examiner noted scarring that was neither painful nor unstable and was less than 6 square inches. He diagnosed proximal phalanx fracture of the right fifth finger, as well as ulnar neuropathy of the right fifth finger. In his March 2015 notice of disagreement, the Veteran reported severe nerve damage from two surgeries on his right pinky finger. He stated that he was told that if he could prove nerve damage, he would get an increase from 80 percent to 100 percent. The Veteran underwent another VA examination in October 2017. He reported stiffness, difficulty with range of motion, and limits on gripping with the right hand. Flare-ups were described as increased stiffness with repetitive gripping, and he described his functional loss as a lack of repetitive gripping. Extension of the little finger was limited to 15 degrees. There was no gap between the pad of the thumb and the fingers or between the fingers and the proximal transverse crease of the hand. There was objective evidence of pain with extension and mild discomfort with palpation. Repetitive testing did not lead to additional loss of function or range. The Veteran was examined immediately after repeated use over time. The examiner was unable to determine functional loss during a flare-up in terms of range of motion without examining during a flare-up. Muscle strength was full without atrophy. There was no ankylosis. The examiner noted a 3 centimeter by 0.25 centimeter scar that was neither painful nor unstable. He diagnosed residuals of a proximal fracture of the right fifth finger. The examiner noted functional loss manifested by a decrease in repetitive gripping. In his January 2018 substantive appeal, the Veteran's representative stated that VA did not properly assess military and medical records. No further specificity was offered. At his July 2021 hearing, the Veteran reported that his finger had limited range of mobility. He could not make a fist or keep change in his hand. He described that his finger would not touch his palm unless he pushed really hard. He reported stiffness and numbness. He said that his scar was painful, but the skin did not come off. The Board finds that compensable ratings are not warranted for the Veteran's little finger disability or associated scar. He is already in receipt of the maximum rating for musculoskeletal disability of the little finger based on the limited and painful motion that he reports. Moreover, he has not described any musculoskeletal symptoms beyond that contemplated by the schedular criteria. The Board notes that the VA examination reports do not estimate range of motion during flare-ups as required by Sharp v. Shulkin, 29 Vet. App. 26, 35-36 (2017). Remand for an adequate Sharp opinion is not warranted, however, as there is no range of motion that could warrant an increased rating for the Veteran's disability. Higher ratings for scarring are available for scars that are painful, unstable, or at least 39 square centimeters. There is no evidence of scarring that is unstable or at least 39 square centimeters. The only evidence of pain are the Veteran's reports at his July 2021 hearing. The Board finds the VA examiners' objective findings more probative, as their expertise is better able to distinguish between objective evidence of pain with palpation of the joint and pain of the scar tissue. Finally, the Board notes that the Veteran also reports numbness in his finger. This symptom, however, is already compensated by his 10 percent rating for cubital tunnel syndrome. For these reasons, the Board finds that compensable ratings are not warranted for the Veteran's little finger disability or associated scar. 3. Entitlement to an effective date prior to November 8, 2012 for a 10 percent evaluation for GERD The Veteran claims an earlier effective date for a 10 percent evaluation for GERD. Service connection for GERD was awarded in an October 2013 rating decision which assigned a 10 percent rating effective November 8, 2012. The Veteran neither appealed this rating decision nor submitted new and material evidence within the one-year appeal period, and the October 2013 rating decision therefore became final. In August 2017, the Veteran submitted a claim for a TDIU and for service connection for Gulf War symptoms, including indigestion. VA construed this as a claim for an increased rating for his GERD. A December 2017 rating decision denied an increased rating and proposed a reduction in rating. A subsequent November 2018 rating decision found no improvement and continued the 10 percent rating. As such, no effective date was assigned. In his July 2019 notice of disagreement, the Veteran disputed both the rating and effective date. The November 2019 statement of the case construed the appeal to be for entitlement to an earlier effective date for the initial 10 percent rating, equivalent to an earlier effective date for service connection. The method for overcoming the finality of a decision is a request for revision based on clear and unmistakable error (CUE). 38 C.F.R. § 3.105(a). Otherwise, a claimant may not properly file, and VA has no authority to adjudicate, a freestanding earlier effective date claim in an attempt to overcome the finality of an unappealed RO decision. Rudd v. Nicholson, 20 Vet. App. 296, 300 (2006). As the October 2013 rating decision is final, the Veteran's claim for an effective date earlier than November 8, 2012, for the grant of service connection for GERD is a freestanding claim. Id. As it is freestanding, the claim must be dismissed. 4. Entitlement to a TDIU The Veteran seeks a TDIU. He contends that his service-connected disabilities, when considered in combination, render him unemployable. Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation has been defined as "an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran's earned annual income." Faust v. West, 13 Vet. App. 342 (2000). When jobs are not realistically within his physical and mental capabilities, a veteran is determined unable to engage in a substantially gainful occupation. Moore v. Derwinski, 1 Vet. App. 356 (1991) (citing Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975)). In making this determination, consideration may be given to factors such as the veteran's level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A veteran is totally disabled if his service-connected disability or combination of service-connected disabilities is rated at 100 percent pursuant to the Schedule for Rating Disabilities. 38 C.F.R. § 3.340(a)(2). Even if a veteran is less than 100 percent disabled, he still is deemed totally disabled under the Schedule for Rating Disabilities if he satisfies two requirements. 38 C.F.R. § 4.16(a). First, the veteran must meet a minimum percent evaluation. If he has one service-connected disability, it must be evaluated at 60 percent or more. If he has two or more service-connected disabilities, at least one disability must be evaluated at 40 percent or more and the combined evaluation of all the disabilities must be 70 percent or more. The following will be considered as one disability with respect to the minimum percent evaluation: (1) disabilities of one or both upper extremities or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system (e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric), (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Second, the veteran must be found to be unable to secure and follow a substantially gainful occupation as a result of his service-connected disability or disabilities. Id. Where a veteran does not meet the percentage evaluation requirements under 4.16(a), he still may be deemed totally disabled on an extraschedular basis under 38 C.F.R. § 4.16(b) when the evidence nonetheless indicates that the veteran is unemployable by reason of his service-connected disabilities. Under such circumstance the matter is referred to the Director of the Compensation and Pension Service ("Director") for consideration. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Extraschedular TDIU consideration requires contemplation of the following factors: severity of the veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Although the Board does not have the authority to award an extraschedular TDIU prior to referral to the Director, the Board has jurisdiction to review and award extraschedular ratings in claims that have been denied by the Director. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015). The fact that a veteran is in receipt of a combined schedular rating of 100 percent does not preclude the availability of a TDIU. Although no additional disability compensation may be paid when a total schedular rating is already in effect, a separate award of a TDIU predicated on a single disability may form the basis for an award of SMC, and thus must be considered by the Board. Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). In determining whether a TDIU is warranted, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether the evidence is persuasively against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In September 2016, the Veteran filed a VA Form 21-8940. The AOJ denied entitlement to TDIU in a rating decision later that month. The Veteran did not file a Notice of Disagreement and so that claim for TDIU became final. On August 1, 2017, the Veteran filed a VA Form 21-8940 and a VA Form 21-526EZ, seeking TDIU based on his posttraumatic stress disorder (PTSD). The Veteran filed a Notice of Appeal in January 2018. The AOJ issued an SOC in February 2020. The Veteran perfected the claim by filing a VA Form 9 in April 2020 and so this Legacy appeal remains pending. Although the current TDIU claim was filed within one year of the September 2016 rating decision, the "continuous pursuit" provisions of the Appeals Modernization Act (AMA) do not apply to Legacy claims. In a January 2022 Board decision, the Veteran was awarded a 100 percent rating that was ultimately effective August 1, 2017. The decision was based on a finding that PTSD was productive of total occupational and social impairment. Furthermore, the decision noted that the Veteran had reported a worsening of his PTSD symptoms as early as May 2017. Affording all benefit of the doubt to the Veteran, the Board finds that the total occupational impairment found by the Board to have manifested by August 1, 2017 was also manifest between September 8, 2016 and August 1, 2017. Thus, the Board finds that it is factually ascertainable that the Veteran's service-connected PTSD increased in severity to preclude securing or following a substantially gainful occupation as of September 8, 2016, which was within the one-year look back period of the August 1, 2017 claim. A TDIU for this period is therefore granted. For the period from August 1, 2017, the Veteran is in receipt of a 100 percent rating for PTSD. He is thus only eligible for a Bradley TDIU based on a single disability. For this period, he is in receipt of two 10 percent evaluations for GERD and cubital tunnel syndrome and four noncompensable ratings for his right little finger fracture, a ventral hernia, and two scars. None of these disabilities meet the threshold for a schedular TDIU under 38 C.F.R. § 4.16(a), and there is nothing in the record to indicate that any of them alone rendered him unemployable. As such, a TDIU for the period from August 1, 2017, is denied. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the United States Court of Appeals for Veterans Claims (Court) discussed the steps to be taken in determining whether a VA examination is necessary prior to final adjudication of a claim. In disability compensation claims, VA must provide a VA medical examination 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, or establishing certain diseases manifesting during an applicable presumptive period for which the appellant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the appellant's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). The Court in McClendon observed that the third prong, which requires that the evidence of record "indicates" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Unlike service connection on a direct basis, the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 do not require competent medical nexus of a link between the qualifying chronic disability and military service. Service connection is presumed unless there is affirmative evidence to the contrary, where the criteria are met. See 38 C.F.R. § 3.317(c); Gutierrez v. Principi, 19 Vet. App. 1 (2004). The term "Persian Gulf Veteran" means a Veteran who, during the Persian Gulf War, served on active military, naval, or air service in the Southwest Asia theater of operations. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). The term "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 illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal disorders). 38 C.F.R. § 3.317(a)(2)(i). 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. See 38 C.F.R. § 3.317(a)(2). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For the purposes of 38 C.F.R. § 3.317, disabilities that have existed for six months or more or that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether the evidence is persuasively against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. VA may reopen a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). "New" evidence is evidence not previously submitted to agency decision makers and "material" evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether the evidence presented or secured since the prior final disallowance of the claim is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). VA is required to review for newness and materiality only the evidence submitted by a claimant since the last final disallowance of the claim on any basis, whether a decision on the underlying merits or a petition to reopen. Evans v. Brown, 9 Vet. App. 273, 283 (1996). In Shade v. Shinseki, 24 Vet. App. 100 (2010), the United States Court of Appeals for Veterans Claims (Court) held that § 3.159(c)(4) does not require new and material evidence as to each previously unproven element of a claim for the claim to be reopened and the duty to provide an examination triggered. In a fact pattern where a prior denial was based on lack of current disability and nexus, the Court found that newly submitted evidence of a current disability was, in concert with evidence already of record establishing an injury in service, new and material and sufficient to reopen the claim and obtain an examination. Regardless of any RO determinations that new and material evidence has been submitted to reopen service connection, the Board must still determine whether new and material evidence has been submitted in this matter. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). 5. Entitlement to service connection for dizziness 6. Entitlement to service connection for muscle soreness 7. Entitlement to service connection for weight loss The Veteran claimed service connection for Gulf War undiagnosed illnesses in August 2017. In an August 2017 statement, he clarified that his Gulf War symptoms included memory loss, dizziness, fatigue, insomnia, joint and muscle soreness, indigestion, and weight loss. The Board notes that any indigestion is already contemplated by the Veteran's service-connected GERD, and insomnia and memory loss are contemplated by his 100 percent rating for PTSD. His claims related to fatigue and Gulf War symptoms are addressed in the remand section of this decision. Service treatment records do not reflect any diagnoses of chronic conditions related to dizziness, muscle soreness, or weight loss. Such symptoms were associated with diagnoses of acute viral infections only. VA treatment records reflect that in August 1999 the Veteran reported dizzy spells associated with headaches since being exposed to fumes at work the prior day. The Veteran underwent a VA examination for dizziness in August 2017. He reported experiencing some episodes of dizziness for two years. Episodes lasted for 10 seconds and occurred three times per week when walking or waking up. He denied tinnitus, spinning sensations, or vertigo. The examiner found that there was insufficient information to assign a chronic service-connected disability for peripheral vestibular disorder or dizziness. The examiner opined that dizziness was unrelated to service because the Veteran reported that it did not arise until more than a decade after separation. The examiner further stated that it was less likely than not related to a specific exposure event during service in Southwest Asia. The Veteran underwent a VA examination for muscle soreness in October 2017. He reported muscle pain from his Southwest Asia service. The examiner explained that upon further questioning, the discomfort described was related to the joints, not the muscles. No muscle injury or disability was found. VA treatment records reflect that in September 2018 the Veteran reported a two-year history of not feeling good, losing weight, body aches, and weakness in the extremities. He denied dizziness. He was diagnosed with weight loss of unclear etiology. Several days later he elaborated to his primary care physician that he had lost 30 pounds over the prior 18 months. His physician noted weight loss of 20 pounds over two years. In February 2019 his physician stated that, on review of chart, his weight had been largely stable for two years. He had lost a significant amount of weight since 2012 but then gained it back. In his April 2020 substantive appeal, the Veteran reported that while serving in the Gulf War he was exposed to burn pits, nerve agents, feces, dead bodies, pesticides, anthrax vaccine, antimalarial pills, and nerve gas pills. He reported neurological problems, chronic fatigue, fibromyalgia, irritable bowel syndrome, and insomnia. He stated that his white blood cell count has been extremely high. At his July 2021 hearing, the Veteran attributed his dizziness and muscle pain to Gulf War exposure. He reported that he was currently 20-25 pounds below his normal weight. He stated that dizziness affected him every day. He stated that his high levels of white blood cells caused debilitating pain. The Board finds that the evidence persuasively weighs against a finding that the Veteran's dizziness, muscle soreness, or weight loss is related to service or to exposures in Southwest Asia. The August 2017 VA examiner gave an adequate opinion explaining that the Veteran's dizziness is not caused by his Gulf War exposures. The October 2017 VA examiner similarly explained that the Veteran's symptoms as reported described pain caused by joints, not muscles. In February 2019, the Veteran's VA treating physician noted that while he had lost a significant amount of weight since 2012, he had gained most of it back. There is no medical evidence contradicting these findings, and there is no evidence relating these disabilities to service beyond the Veteran's speculation that they were caused by Gulf War exposures. The Board observes that the Veteran is competent to testify as to his observations, but he is not competent to opine as to the etiology of his weight loss, as this issue is medically complex, and the Veteran is not shown to have the specialized medical training and/or expertise to address the etiology of this issue. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). For these reasons, the Board finds that the evidence persuasively weighs against a finding that the Veteran's dizziness, muscle soreness, or weight loss is related to service or to exposures in Southwest Asia. Service connection is therefore denied. 8. Entitlement to service connection for a disability of the left hand and fingers The Veteran claims service connection for a disability of the left hand and fingers. Service treatment records indicate that in November 1989 the Veteran injured his second finger. Initial treatment refers to an injury to the second finger of the right hand, but the follow-up two days later addresses the second finger of the left hand. In any event, the follow up noted that the injury was healing properly. At his July 2021 hearing, the Veteran attributed his claimed disability to Gulf War exposure. The Board finds that the evidence persuasively weighs against a finding of a current disability of the left hand and fingers. The Veteran has not described any symptoms of the left hand or fingers, and there are no treatment records or VA examinations documenting such a disability. Notably, an October 2017 VA examination conducted for purposes of rating the right hand reflects a normal examination of the left hand. As such, a VA examination is not warranted. See McClendon v. Nicholson, 20 Vet. App. 79 (2006).Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Board finds that the evidence weighs against a finding of a current disability and service connection must therefore be denied. 9. Entitlement to service connection for left elbow epicondylitis 10. Entitlement to service connection for right elbow epicondylitis The Veteran claims service connection for epicondylitis of the bilateral elbows. Service treatment records do not reflect any symptoms of or treatment for disabilities of the elbows. The Veteran underwent a VA examination in October 2017. He reported a less than 12-month history of lateral elbow pain with movement and gripping which he attributed to his service in Southwest Asia. He was diagnosed with lateral epicondylitis of the bilateral elbows. The examiner opined that the disabilities were less likely than not related to service. This opinion was based on the rationale that the disability was not evidence in service treatment records or post-service medical records. The examiner explained that no repeated peer reviewed studies showed a cause-and-effect relationship between epicondylitis and Gulf War service or exposures. At his July 2021 hearing, the Veteran attributed his elbow disabilities to Gulf War exposure. The Board finds that the evidence persuasively weighs against a finding that the Veteran's bilateral elbow epicondylitis is related to service or to Gulf War exposures. There is no indication of such disabilities in his service treatment records, and the Veteran does not claim that they arose in service. Rather, the Veteran claims that these disabilities were the result of Gulf War exposures. The October 2017 VA examiner, however, gave an adequate opinion explaining that these disabilities are diagnoses with understood etiologies. There is no evidence in the record to contradict this opinion. For these reasons, the Board finds that the evidence persuasively weighs against a finding that the Veteran's bilateral elbow epicondylitis is related to service or to Gulf War exposures. Service connection is therefore denied. 11. Whether new and material evidence has been received to reopen a claim of service connection for residuals of a lumbar strain The Veteran seeks to reopen his claim of service connection for a lumbar spine disability. Service connection for a back condition was initially denied in a January 2004 rating decision based on a finding that there was no current medical evidence of a disability related to service. Subsequently, service connection for residuals of a lumbar strain was denied in an October 2013 rating decision based on a finding that the current disability was not related to his in-service symptoms. The Veteran neither appealed the denial nor submitted evidence within the one-year appeal period, and the decision therefore became final. Evidence received since the final October 2013 rating decision includes an October 2017 VA examination report in which the Veteran attributed his low back symptoms to service in Southwest Asia. The Board finds that this evidence of a relationship to service relates to an unestablished fact necessary to substantiate the claim, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim. The Veteran's claim is therefore reopened and is addressed on the merits in the remand section of this decision. 12. Whether new and material evidence has been received to reopen a claim of service connection for a left knee disability 13. Entitlement to service connection for a left knee disability 14. Whether new and material evidence has been received to reopen a claim of service connection for a right knee disability 15. Entitlement to service connection for a right knee disability The Veteran seeks to reopen his claim of service connection for disabilities of the bilateral knees. Service connection for knee conditions was originally denied in an October 2013 rating decision based on a finding of no current disability of either knee. The Veteran neither appealed the denial nor submitted evidence within the one-year appeal period, and the decision therefore became final. Evidence received since the October 2013 final rating decision includes an October 2017 VA examination report in which the Veteran was diagnosed with bilateral patellofemoral pain syndrome. The Board finds that this evidence of a current disability relates to an unestablished fact necessary to substantiate the claims, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claims. The Veteran's claims are therefore reopened. The Board observes that the December 2017 rating decision reopened and readjudicated both knee claims. Therefore, there is no prejudice in proceeding with adjudication of the issues of service connection for right and left knee disabilities. Service treatment records do not reflect any symptoms of or treatment for disabilities of the knees. The Veteran underwent a VA examination in October 2017. He reported a history of patellar pain of several months. He attributed his pain to his service in Southwest Asia. He was diagnosed with bilateral patellofemoral pain syndrome. The examiner opined that the disabilities were less likely than not related to service. This opinion was based on the rationale that the disability was not evidence in service treatment records or post-service medical records for many years after separation. The examiner explained that no repeated peer reviewed studies showed a cause-and-effect relationship between patellofemoral syndrome and Gulf War service or exposures, while documented causes for the symptoms and condition were seen commonly from normal wear and tear. VA treatment records reflect that in December 2018 the Veteran reported knee pain to his rheumatologist. He was diagnosed with polyarthralgia. At his July 2021 hearing, the Veteran attributed his knee disabilities to Gulf War exposure. The Board finds that the evidence persuasively weighs against a finding that the Veteran's bilateral patellofemoral syndrome is related to service or to Gulf War exposures. There is no indication of such disabilities in his service treatment records, and the Veteran does not claim that they arose in service. Rather, the Veteran claims that these disabilities were the result of Gulf War exposures. The October 2017 VA examiner, however, gave an adequate opinion explaining that these disabilities are diagnoses with understood etiologies. There is no evidence in the record to contradict this opinion. For these reasons, the Board finds that the evidence persuasively weighs against a finding that the Veteran's bilateral patellofemoral syndrome is related to service or to Gulf War exposures. Service connection is therefore denied. 16. Whether new and material evidence has been received to reopen a claim of service connection for left shoulder rotator cuff tendonitis 17. Whether new and material evidence has been received to reopen a claim of service connection for right shoulder rotator cuff tendonitis 18. Entitlement to service connection for right shoulder rotator cuff tendonitis The Veteran seeks to reopen his claim of service connection for rotator cuff tendinitis of the bilateral shoulders. Service connection for rotator cuff tendonitis of the bilateral shoulders was originally denied in an October 2013 rating decision based on a finding that there was no evidence linking the Veteran's disabilities to service. The Veteran neither appealed the denial nor submitted evidence within the one-year appeal period, and the decision therefore became final. Evidence received since the final October 2013 rating decision includes an October 2017 VA examination report in which the Veteran attributed his shoulder symptoms to service in Southwest Asia. The Board finds that this evidence of a relationship to service relates to an unestablished fact necessary to substantiate the claims, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claims. The Veteran's claims are therefore reopened. The claim related to his right shoulder is addressed on the merits below; the claim related to his left shoulder is addressed in the remand section of this decision. The Board observes that the December 2017 rating decision reopened and readjudicated the right shoulder claim. Therefore, there is no prejudice in proceeding with adjudication of the issue of service connection for right rotator cuff tendonitis. Service treatment records reflect that the Veteran injured his right shoulder in a fight in November 1990. X-rays were normal. In a January 1993 report of medical history, he explicitly denied having ever experienced a painful shoulder. The Veteran underwent a VA examination in September 2013. He reported insidious onset of bilateral shoulder pain over the prior several years. He described some sports injuries that occurred in service. He was diagnosed with bilateral rotator cuff tendonitis. The examiner opined that his in-service shoulder injuries had an effect on his current shoulder condition. This opinion was based on the rationale that his in-service injuries were sprains or contusions which are self-limiting in nature and usually resolve after 6-8 weeks. The examiner explained that his current disabilities were multi-factorial in his age group and may be due to aging, genetics, sports, or activities of daily living. In an October 2013 addendum, the examiner further explained that rotator cuff tendonitis is a condition with clear and specific etiologies that is not known to be caused by exposure events in Southwest Asia. VA treatment records reflect that in December 2013 the Veteran reported pain and stiffness in both shoulders. He denied limitation of motion. He was diagnosed with osteoarthritis. The Veteran underwent another VA examination in October 2017. He described an in-service right shoulder contusion in 1990. He attributed his current episodic pain to service in Southwest Asia. He was diagnosed with bilateral rotator cuff tendonitis. The examiner opined that the disabilities were less likely than not related to service. This opinion was based on the rationale that the disability was not evidence in service treatment records aside from the isolated contusion, or post-service medical records for many years after separation. The examiner explained that no repeated peer reviewed studies showed a cause-and-effect relationship between patellofemoral syndrome and Gulf War service or exposures, while documented causes for the symptoms and condition were seen commonly from post-service occupations. VA treatment records reflect that in December 2018 the Veteran reported shoulder pain to his rheumatologist. He was diagnosed with polyarthralgia. At his July 2021 hearing, the Veteran reported that he was diagnosed with a right shoulder rotator cuff strain in service after working as a crane operator. The Board finds that the evidence persuasively weighs against a finding that the Veteran's right shoulder rotator cuff tendonitis is related to service or to Gulf War exposures. The September 2013 VA examiner gave an adequate opinion explaining that the Veteran's current disability is unrelated to the acute injury he experienced in service. The Veteran also maintains that this disability was the result of Gulf War exposures. Both the September 2013 and October 2017 VA examiners, however, gave adequate opinions explaining that these disabilities are diagnoses with understood etiologies. There is no evidence in the record to contradict these opinions. For these reasons, the Board finds that the evidence persuasively weighs against a finding that the Veteran's right shoulder rotator cuff tendonitis is related to service or to Gulf War exposures. Service connection is therefore denied. REASONS FOR REMAND 1. Entitlement to service connection for degenerative arthritis of the cervical spine. 2. Entitlement to service connection for numbness of the left lower extremity. 3. Entitlement to service connection for numbness of the left upper extremity. 4. Entitlement to service connection for numbness of the right lower extremity. 5. Entitlement to service connection for residuals of a lumbar strain. 6. Entitlement to service connection for left shoulder rotator cuff tendonitis. The Board finds that the issues of entitlement to service connection for arthritis of the cervical spine, numbness of the lower extremities, a lumbar strain, and left shoulder rotator cuff tendonitis must be remanded so that a supplemental statement of the case may be issued. The abovementioned issues were most recently adjudicated by the agency of original jurisdiction (AOJ) in a February 2020 statement of the case. They were subsequently certified to the Board in May 2020. In the interim, the Veteran submitted treatment records related to these issues in April 2020. The Veteran has the right to have this evidence considered by the AOJ prior to having the appeals adjudicated by the Board. Because this evidence was submitted prior to certification to the Board, this right is not waivable. See 38 C.F.R. §§ 19.31(b), 19.37(a). As such, remand is necessary so that a supplemental statement of the case considering all new evidence can be issued. 7. Entitlement to an evaluation in excess of 10 percent for GERD The Veteran claims an increased rating for GERD. The Board finds that remand is necessary to provide the Veteran with a current examination of his symptoms. The Veteran's GERD is rated as analogous to a hiatal hernia under 38 C.F.R. § 4.114, Diagnostic Code 7346. Under this code, a maximum 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or for other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. VA treatment records reflect that in October 2016 the Veteran reported no new symptoms with his GERD. His physician noted that the disability was stable. In January 2017 he denied gastrointestinal symptoms and reported that his GERD was controlled by medication. The Veteran underwent a VA examination in October 2017. He reported daily symptoms improved by omeprazole 5-6 times per week. He described reflux causing sleep disturbances 4 or more times per year lasting less than one day. There was no esophageal stricture, spasm, or diverticulum. He was diagnosed with GERD. The examiner found no functional impact. VA treatment records reflect that in September 2018 the Veteran reported alternating days of constipation and diarrhea with daily nausea and vomiting in the mornings. His physician restarted omeprazole. In October 2018 he reported that the omeprazole was helping a lot, though he did not take it every day. In May 2019 he presented to the emergency room reporting abdominal pain with vomiting. He was diagnosed with abdominal pain and left against medical advice after experiencing an allergic reaction before a more specific diagnosis was reached. In August 2019 he reported epigastric pain once per week, lasting several hours with gas pain. He denied diarrhea or constipation. He was diagnosed with dyspepsia in setting of substance abuse and GERD controlled by medication. At his July 2021 hearing, the Veteran stated that his GERD was getting worse. He reported use of daily medication to treat bloating with gas and pain. He described daily heartburn and vomiting once per week or so. Since the Veteran's most recent VA examination was conducted in October 2017 and the Veteran has reported a worsening of symptoms since then, the Board must remand this issue in order to afford the Veteran a contemporaneous VA examination to assess the current extent and severity of his GERD. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 8. Entitlement to service connection for fatigue is remanded. 9. Entitlement to service connection for Gulf War illness is remanded. The Veteran claims service connection for fatigue and Gulf War illness. The Board construes these claims to include chronic fatigue syndrome and fibromyalgia. The Veteran underwent a VA examination related to his Gulf War service in October 2017. The examiner found no diagnosed illnesses without etiology, undiagnosed illnesses, or diagnosed medically unexplained chronic multi-symptom illnesses. The Veteran underwent a VA examination related to fatigue in October 2017. The examiner found no diagnosis of chronic fatigue syndrome. The examiner further attributed the Veteran's reported fatigue to poor sleep consistent with his PTSD, GERD, and joint complaints. VA treatment records reflect that in April 2019, the Veteran's rheumatologist stated a belief that the reported pain could be attributed to his cervical spondylosis and stenosis, though it "might also be more complex with possible component of depression and fibromyalgia." In September 2021, the Veteran submitted a VA treatment record problem list indicating that the Veteran had been diagnosed with chronic fatigue syndrome in June 2020 and with fibromyalgia in December 2020. At his July 2021 hearing, the Veteran attributed his daily fatigue to Gulf War exposure. He reported that he had been diagnosed with fibromyalgia. The Board finds that remand is necessary to obtain treatment records associated with the Veteran's diagnoses of chronic fatigue syndrome and fibromyalgia and to provide him with VA examinations. There is currently a diagnosis of each disability listed, but there is no indication why he was given the diagnosis or on what symptoms they are based. Remand is thus necessary before the appeal can be adjudicated. The matters are REMANDED for the following action: 1. Readjudicate the appeal of the issues of entitlement to service connection for arthritis of the cervical spine, numbness of the lower extremities, a lumbar strain, and left shoulder rotator cuff tendonitis on the record, to include new evidence received since the February 2020 statement of the case. If any benefit sought remains denied, provide a supplemental statement of the case to the Veteran and his representative. 2. Schedule the Veteran for a VA examination to determine the level of severity of his GERD. The examiner should report the extent of the Veteran's disability in accordance with VA rating criteria. The claims file must be reviewed by the examiner. 3. Obtain and associate with the claims file any VA treatment records relevant to the Veteran's June 2020 diagnosis of chronic fatigue syndrome or his December 2020 diagnosis of fibromyalgia. 4. After the development in directive #3 is complete, schedule the Veteran for VA examinations regarding his Gulf War claims. The claims file must be reviewed by the examiner. Following a review of the claims file and any clinical examination results, the examiner should explain whether the Veteran has any current medically unexplained chronic multi-symptom illness, to include diagnoses of chronic fatigue syndrome or fibromyalgia. In so doing, the examiner must discuss his June 2020 and December 2020 diagnoses. All opinions are to be accompanied by a rationale consistent with the evidence of record. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. 5. After completing the above, and any other development deemed necessary, readjudicate the appeal. If any benefit sought remains denied, return the appeal to the Board. Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Gallagher, 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.