Citation Nr: A25035241 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240316-426298 DATE: April 16, 2025 ORDER Entitlement to service connection for other specified trauma and stressor related disorder with major depressive disorder (MDD), recurrent, moderate (claimed as depression) is denied. Entitlement to service connection for fatigue is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for left lower extremity shin splints is denied. Entitlement to service connection for right lower extremity shin splints is denied. REMANDED Entitlement to service connection for migraines is remanded. FINDINGS OF FACT 1. The persuasive weight of the evidence is against finding that the Veteran's other specified trauma and stressor related disorder with MDD encompasses psychiatric disability symptomatology that is separate and distinct from his service-connected insomnia disorder. 2. The persuasive weight of the evidence of record is against finding that the Veteran's fatigue is a separate and distinct disability related to service as opposed to a manifestation of his already service-connected insomnia disorder. 3. The evidence of record is against finding that the Veteran's GERD had its onset during service, or is otherwise related to an in-service injury, event, or disease. 4. The persuasive weight of evidence is against a finding that the Veteran has a diagnosis of left lower extremity shin splint disability that had its onset in service, or that is otherwise related to service. 5. The persuasive weight of evidence is against a finding that the Veteran has a diagnosis of right lower extremity shin splint disability that had its onset in service, or that is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for other specified trauma and stressor related disorder with MDD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for fatigue have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for entitlement to service connection for GERD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for entitlement to service connection for left lower extremity shin splints have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 5. The criteria for entitlement to service connection for right lower extremity shin splints have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Army and Army National Guard starting in October 2014, with confirmed periods of active duty from June 2015 to November 2015, October 2016 to March 2017, and January 2019 to January 2020, and multiple periods of active-duty training, with service in Southwest Asia. This matter comes to the Board of Veterans' Appeals (Board) on appeal from October 2023 and January 2024 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia and respectively, denied service connection for left and right lower extremity shin splints; and fatigue, GERD, other specified trauma and stressor related disorder, and migraines. In the March 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the January 2024 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the claim of service connection for migraines, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii). SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Further, special service connection rules exist for Gulf War Veterans. 38 U.S.C. §§ 1117; 38 C.F.R. § 3.317. Relevantly, here, the Southwest Asia theater of operations includes service, among other places, in Kuwait. 38 C.F.R. § 3.317(e)(2). For purposes of 38 C.F.R. § 3.317, other than conditions that have been presumptively linked to service in Southwest Asia, there are two types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a diagnosed medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding gastrointestinal diseases). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. §§ 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317 (a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). On the other hand, the term "MUCMI" refers to 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 MUCMIs of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered "medically unexplained." Id. On August 10, 2022, the President signed the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 (PACT Act), which therein expanded VA's duty to consider and provide examinations to ascertain connections between disabilities and claimants' participation in known or conceded toxic exposure risk activities (TERAs) unless an exception applies. See 38 U.S.C. § 1168. In this case, given the circumstances of the Veteran's service, the Board has considered his in-service environmental exposures in Kuwait as well as Garrison-type exposures to diesel fuels, gas, fumes, dust, and oils in light of his duties as a Wheeled Vehicle Mechanic. The Veteran was afforded appropriate TERA examinations for his claimed disabilities except where exceptions applied as explained below. In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal). To the extent the evidence is found in "approximate balance," the Board will afford the benefit of the doubt in favor of the Veteran. Lynch v. McDonough, 21 F. 4th 776 (Fed, Cir. 2021) (holding that exact equipoise is not required for the benefit of the doubt to be applied, but rather the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal"). 1. Entitlement to service connection for other specified trauma and stressor related disorder with major depressive disorder, recurrent, moderate (claimed as depression) is denied. The Veteran contends that he lost many close friendships during service and that service also made him consume alcohol which contributed to his depression. He also stated that he was on deployment when the situation in Iran was heating up and his unit was told to be ready and on standby which has caused chronic anxiety. For reasons outlined below, the Board finds the Veteran's claim must be denied. The Board finds that while the Veteran has been diagnosed with additional psychiatric disabilities, the manifestations he complains of have already been attributed to another separately service-connected disability. As an initial matter, the Board takes judicial notice of the fact that while this appeal was pending, the Veteran was granted for another mental health disorder, insomnia disorder, granted in an August 2024 rating decision and assigned a 70 percent rating. The rating decision indicated that the disability rating included compensation for, among other things, depressed mood, anxiety, disturbances in motivation and mood, mild memory loss, and chronic sleep impairment. The grant of one service-connected psychiatric disability does not necessarily moot out the pending claim of another because it is possible that there are potential manifestations not otherwise compensated by the already service-connected disability. See Amberman v. Shinseki, 570 F.3d 1277, 1381 (Fed. Cir. 2009) (noting that "the amount of impairment is measured by the social and occupational difficulties caused by the veteran's disorder"). Psychiatric disabilities, however, are all rated under the same General Rating Formula for Mental Disorders and assigned one disability rating for the combined symptomatology. See 38 C.F.R. § 4.125. Thus, a pending claim for a separate psychiatric disability is necessarily moot if there are no uncompensated manifestations by the already service-connected disability. See, e.g., Bean v. McDonough, 66 F.4th 979 (Fed. Cir. 2023). Simply stated, VA regulations prohibit rating (i.e., compensating) multiple disabilities based on the same signs and symptoms. Further, for an acquired psychiatric disability, service connection requires that a disability is diagnosed conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 or DSM-V). See 38 C.F.R. § 4.125; see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). Turning to the evidence of record, the Veteran's DD-214 reflects that his military occupational specialty was as a Wheeled Vehicle Mechanic. Several service treatment records from November 2018, December 2020, and November 2021 reflect that the Veteran denied any mental health issues. His November 2019 post-deployment health assessment indicates that the Veteran did not feel that he was in great danger of being killed, did not encounter dead bodies or see people killed or wounded, and did not engage in direct combat where he discharged a weapon during his deployment. The Veteran's November 2019 medical examination report upon separation was normal. In September 2023, the Veteran reported during VA mental health treatment that he has been struggling with symptoms of anxiety and depression for a few years. He stated that he feels overwhelming sadness and has lost interest in activities he once enjoyed. The psychiatrist noted diagnoses of unspecified trauma and stress or related disorder, unspecified depression, and unspecified anxiety. The Veteran reported being involved in levels 1, 2, and 3 combatives in addition to military combat and stated that he almost had his arm broken during striking exercises and watched another soldier's leg get broken by an instructor. October 2023 VA mental health records indicate that the Veteran reported struggling with symptoms of anxiety, depression, insomnia, irritability, constant worrying and racing thoughts since his deployments in service. In a December 2023 disability benefits questionnaire (DBQ), the psychologist noted that the Veteran did not have a diagnosis of posttraumatic stress disorder (PTSD) under DSM-5 criteria, but had diagnoses of other trauma and stressor related disorder, and MDD under DSM-5 criteria as the Veteran reported anxiety, chronic sleep disturbance, problems with short term memory, and daily depressed mood resulting in reduced motivation affecting relationships. The psychologist indicated that it was not possible to differentiate which symptoms were attributable to each diagnosis. She noted the Veteran's reported in-service stressors of hand to hand combat during service wherein his arm was almost broken during a reverse arm bar and witnessing an instructor break a student's leg. The Veteran's symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The psychologist indicated that the Veteran was not exposed to a traumatic event where he witnessed, experienced, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and his response did not involve intense fear, helplessness or horror. Analysis The evidence of record indicates that the Veteran has a diagnosis of mental disabilities in accordance with 38 C.F.R. § 4.125 (a), which provides that all psychiatric diagnoses must conform to the DSM-5 as the December 2023 psychologist noted diagnoses of other trauma and stressor related disorder and MDD under DSM-5 criteria. However, the December 2023 DBQ reflects that the manifestations of the diagnosed psychiatric disabilities are already compensated by the service-connected insomnia disorder as each diagnosed psychiatric disability was manifested by symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships Under the circumstances presented here, the Veteran's claim seeking service connection for other trauma and stressor related disorder and MDD is necessarily moot because the evidence shows all his manifestations are already compensated by the disability ratings assigned. See 38 C.F.R. § 4.125; see also Bean v. McDonough, 66 F.4th 979 (Fed. Cir. 2023). Accordingly, for reasons outlined above, the persuasive weight of the evidence is against the claim of entitlement to service connection for other trauma and stressor related disorder and MDD. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for other trauma and stressor related disorder and MDD is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for fatigue is denied. The Veteran contends that he has suffered from fatigue due to being woken up many times in the middle of the night during service and spending long days and nights working in service. He stated this has led him to being a light sleeper and accustomed to little sleep. After reviewing all available evidence, to include medical opinions and the Veteran's competent reports regarding symptomatology, the Board finds that service connection is not warranted for fatigue. Turning to the available evidence of record, the Veteran reported in a November 2019 post-deployment health assessment that he was bothered by feeling tired or having low energy. September 2023 post-service treatment records indicate that the Veteran reported awakening unrefreshed and fatigued, stating that he is very fatigued and tired every day. A December 2023 Gulf War DBQ reflects that the examiner noted chronic fatigue syndrome, but also that there are no diagnosed illnesses for which no etiology has been established. In a December 2023 DBQ, the examining nurse practitioner (NP) opined that the Veteran's fatigue was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by TERA stating that there were subjective reports of fatigue only. She noted that the file is silent for evidence of a formal workup for, diagnosis, or treatment of chronic fatigue syndrome (CFS). Therefore, she was unable to confirm a diagnosis. The NP indicated that the Veteran did not have CFS, while the Veteran reported onset of fatigue in 2019. He reported that his symptoms started after deployment and that he felt tired and weak. The Veteran stated that even if he slept well, he would wake up tired, his body felt generally weak, and that he did not feel like doing anything. He also reported brain fog and difficulty standing, and indicated that the symptoms have worsened over time. The NP noted that the Veteran did not have an acute onset of CFS and also did not have debilitating fatigue which reduced daily activity level to less than 50 percent of pre-illness level. She also indicated that other clinical conditions that may produce similar symptoms have been excluded to the extent possible. She did note that the Veteran's fatigue symptoms impact his ability to work as he reported 1 to 2 weeks of work time as a firefighter lost in the past 12 months. In a separate December 2023 DBQ, the NP opined that the Veteran's fatigue was less likely than not incurred in or caused by an in-service injury, event, or illness, stating that the four standard Gulf War disability patterns: an undiagnosed illness; MUCMI of unknown etiology; a diagnosable chronic multi-symptom illness with a partially explained etiology; or, a disease with a clear and specific etiology and diagnosis were not applicable. She also noted that there is no evidence of persistent/recurrent symptoms or concern of a diagnosis for the claimed condition of fatigue. Analysis It is noteworthy that during the development of this issue, service connection was granted for insomnia disorder. As such, to the extent the Veteran's complaints of fatigue are manifestations of the already service-connected insomnia disorder, any further award here would be impermissible pyramiding. 38 C.F.R. § 4.14. In this regard, the Board notes that the Veteran's complaints of fatigue are well documented in his post-deployment assessment and his post-service treatment history. However, seemingly consistently throughout the record, the Veteran has indicated that these symptoms were due to his insomnia disorder which resulted in chronic sleep impairment and an inability to get a good night's sleep causing him to feel fatigued. It is further noteworthy that while the December 2023 NP noted CFS, she also indicated that she was unable to confirm a diagnosis of CFS following an examination of the Veteran and a review of the Veteran's medical history, concluding that the Veteran's CFS was less likely than not due to service to include any indicated TERA. Thus, the Board finds that the NP's finding of a lack of a diagnosis of CFS outweighs the notation of CFS by the same NP in the separate DBQ, as she provided a thorough rationale and explanation to support her finding of no diagnosis of CFS, whereas there was no explanation as to why she noted CFS on the Gulf War DBQ. Her opinion regarding a lack of a nexus of fatigue to service to include TERA is also afforded significant probative value as she based her opinion on an accurate characterization of the evidence of record following an examination of the Veteran with consideration of his lay statements and medical records. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The NP also indicated that the Veteran's fatigue was less likely than not incurred in or caused by service, and that there are no diagnosed illnesses for which no etiology is established. Therefore, the provisions under 38 U.S.C. § 1117, do not apply. In conclusion, the Veteran has not been diagnosed with CFS, his complaints of fatigue symptomatology are not at least as likely as not related to service to include as due to TERA, the provisions of 38 U.S.C. § 1117 are inapplicable, and it is reasonable to conclude that the Veteran's fatigue symptomatology are attributable to his already service connected insomnia disorder which causes chronic sleep impairment resulting in an inability to feel rested. There is no competent and credible evidence of record that the Veteran has pertinent symptomology not attributable to an already-service connected disability or that such symptomology is related to in-service exposures. Accordingly, the Board finds that the persuasive evidence of record is against service connection for the reported fatigue symptomatology, and, in any case, the manifestations complained thereof appeared to already be compensated under the Veteran's rating for insomnia disorder. Thus, the claim seeking service-connection specifically for fatigue fails for lack of a separate disability and, in any case, is moot as the manifestation is already compensated. As such, the appeal is denied. 3. Entitlement to service connection for gastroesophageal reflux disease is denied. The Veteran contends that his GERD had its onset during deployment in Kuwait in 2019. He stated that the food and drinks he consumed while serving in Kuwait gave him stomach complications. It is not reasonably in dispute that the Veteran has a diagnosis of GERD and that he served in Southwest Asia (with presumed toxic exposure risk activity (TERA)). Relevant to this Veteran's claim, signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, gastrointestinal signs or symptoms. See 38 C.F.R. § 3.317 (b). GERD specifically, however, is neither a MUCMI nor an undiagnosed illness and, therefore, does not fall within the presumptions of 38 C.F.R. § 3.317 (a)(2). Atencio v. O'Rourke, 30 Vet. App. 74, 84 (2018). As previously noted, the Veteran has been diagnosed with GERD which constitutes a known diagnosis and, therefore, does not fall within the presumptions of 38 C.F.R. § 3.317 (a)(2). When presumptive service connection is not applicable, direct service connection may be considered. Combee v. Brown, 34 F.3d 1039, 1043-44 (1994). Turning to the relevant evidence of record, the Veteran's service treatment records do not reflect treatment for or complaints of GERD, or symptoms associated with GERD. June 2023 VA treatment records indicate that the Veteran reported intermittent GERD, and August 2023 VA treatment records reflect that the Veteran takes medication to treat his GERD. A July 2023 TERA memorandum indicates that the Veteran was exposed to vehicle gas/diesel fuels, fumes, and oils as a wheeled vehicle mechanic and participated in a TERA during service. An August 2023 Gulf War Disability Benefits Questionnaire (DBQ) reflects, among other things, esophagal disorders, and knee and lower leg issues. The examiner noted that there were no diagnosed illnesses for which no etiology was established. An August 2023 DBQ reflects a diagnosis of GERD with the examiner noting onset in 2023. The examiner indicated that the Veteran's GERD symptoms have improved since beginning treatment with Famotidine in June 2023. The Veteran indicated that he suffered from substernal pain and reflux, but his GERD did not impact his ability to work. In a December 2023 DBQ, the examining nurse practitioner (NP) opined that the Veteran's GERD was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by TERA after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The NP stated that there is no medical or scientific evidence available that provides any indication of a relationship between the development of GERD and the TERA, concluding that the Veteran's GERD is related to risk factors unrelated to service. The NP stated that the Veteran's GERD is a disease with a clear and specific etiology and diagnosis, and also noted the risk factors for GERD which included anxiety/depression, older age, excessive body mass index, and smoking. A December 2023 Gulf War Medical DBQ reflects a diagnosis of GERD, but the examiner indicated that there were no diagnosed illnesses for which no etiology was established. The NP noted that the Veteran's GERD was functional rather than structural. A separate December 2023 DBQ reflects a 2023 diagnosis of GERD with the Veteran reporting onset in 2018 with burning in his stomach and chest. He stated that he now has regurgitation of acid into his throat and burning of his esophagus with occasional difficulty breathing. The Veteran treated his GERD with Pepcid daily, and the NP noted symptoms of pyrosis, reflux, regurgitation, substernal pain, sleep disturbance, nausea, and vomiting. The Veteran's GERD impacted his ability to work with the Veteran explaining that it effects his breathing and that when he is performing physical activities, the acid makes him feel like he is going to vomit. He stated that GERD also interferes with his ability to drink water and stay hydrated. Analysis For the reasons explained below, the Board finds that service connection for GERD is not warranted. With regard to the DBQs of record, the Board finds the information therein sufficient to adjudicate the claim and to render the DBQs adequate. Based on the entirety of the evidentiary record, the Board finds the persuasive weight of the evidence is against a finding of entitlement to service connection for GERD. There is no persuasive indication that the condition began in service, as while the Veteran reported onset in service, there is no evidence of treatment for GERD in the medical records until 2023, years after service. The Veteran's service treatment records contain references to complaints for other matters, such as a recurrent noise in his ears and it is reasonable to conclude that if the Veteran were treated for GERD, specifically with medication, such would have been indicated in service treatment records. Buczynski v. Shinseki, 24 Vet. App. 221, 226-27 (2011) (where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). The Board finds as a fact in this case that the medical evidence of record is persuasively against a finding that the Veteran suffered from GERD in service that continues to the present. Nor has the condition been persuasively linked to any incident in service, to include his known participation in a TERA. Indeed, there is persuasive evidence to the contrary provided by the December 2023 NP who considered the Veteran's medical history to include reports of onset in service, medication needed to treat the symptoms, as well as reported symptoms. Nonetheless, the NP opined that the Veteran's GERD was less likely than not due to service to include TERA, reporting that it was more likely due to risk factors unrelated to service and detailing potential risk factors for developing GERD. The NP provided a thorough rationale to support their opinion based on an accurate characterization of the evidence of record, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The December 2023 DBQ is thus considered adequate for adjudication of the Veteran's service connection claim and is afforded significant probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There are no contrary medical opinions in the evidence of record as to the etiology of the Veteran's GERD. The Board acknowledges the Veteran's contention that his GERD is due to service. While the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and are within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis or render a medical opinion on this matter. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the issue in this case is outside the realm of common knowledge of a lay person because it involves a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). Thus, the Veteran's statements in this regard are not competent and are afforded no probative weight. Thus, with respect to a nexus between the Veteran's current GERD and in-service occurrence, the Board assigns more probative weight to the December 2023 NP's opinion which found that there was no nexus between service and the current diagnosis of GERD after an examination, thorough review of the Veteran's file and extensive medical history, and consideration of symptoms and reported treatment. As such, the Board finds no causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For the above reasons, the evidence is neither evenly balanced nor approximately so regarding whether service connection for GERD is warranted. Rather, the evidence persuasively weighs against service connection for GERD. The benefit of the doubt doctrine, see 38?U.S.C. §?5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th 776, 781-82 (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). 4. Entitlement to service connection for right and left lower extremity shin splints is denied. The Veteran contends that he suffers from shin splints which were caused by running on the road for miles at a time during service, consistent with the circumstances of his service. A November 2019 post-deployment assessment indicates that the Veteran reported pain in his arms, legs, or joints. An August 2023 Gulf War Disability Benefits Questionnaire (DBQ) reflects, among other things, esophagal disorders, and knee and lower leg issues. The examiner noted that there were no diagnosed illnesses for which no etiology was established. An August 2023 DBQ indicates that the Veteran does not have a current diagnosis associated with knee pain. The Veteran did not report flare-ups of the knee or lower leg or any functional loss or impairment. Bilateral knee range of motion was normal with no evidence of pain, crepitus or localized tenderness or pain on palpation. There was no additional pain or loss of range of motion with repetitive use testing, and no diagnosis of shin splints or any other tibial or fibular impairment of either the right or left leg. The Veteran did not report use of any assistive device as a normal mode of locomotion and the examiner noted that the Veteran's claimed leg disability did not impact his ability to work. October 2023 VA treatment records reflect that the Veteran requested vitamin D supplements to help with shin pain which he stated he had been experiencing "for a while now." December 2023 service treatment records indicate that the Veteran complained of shin splints which occurred after running. No visual deformities were present, only pain to the shins for which he was given heat packs and ibuprofen. Analysis Based on the evidence currently of record, the Board finds the evidence persuasively weighs against a finding of a current bilateral shin splint disability subject to service connection at any time during, or proximate to, the claims period. The Board has considered the issue broadly pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009), to include any shin disability. However, the Veteran does not have a current shin disability. The Veteran does not have a diagnosis of shin splints, as the August 2023 examiner noted, and post-service treatment records reflect no complaints, treatments, or diagnoses of a shin splint disability. The Board notes that the Veteran complained of leg pain in service, and shin pain in post-service treatment records. In that regard, the Board acknowledges, that "pain" can be a disability for purposes of service connection if it reaches the level of a functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Nonetheless, subjective pain is not enough to establish the presence of a disability, there must be competent evidence specific to the claimant tending to show that the impairment has risen to a level of a functional impairment. Wait v. Wilkie, 33 Vet. App. 8 (2020); but see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the current disability requirement is satisfied if the disability existed at any time during the pendency of the appeal even if resolved currently). Here, the Board considered whether the Veteran's description of bilateral shin pain at any point during the pendency of this appeal rose to the level of a functional impairment such that it could be considered a disability for service connection purposes. The persuasive weight of the evidence indicates to the contrary. Indeed, there is evidence to the contrary, as the August 2023 DBQ reflects normal range of motion, and no functional loss or impairment in addition to a finding no diagnosis of shin splints or any other tibial or fibular impairment of either leg. Additionally, the examiner indicated that the leg disability did not impact the Veteran's ability to work. While the Veteran has competently reported shin pain during service and post-discharge, the evidence does not rise to the level of a VA disability as the evidence does not show a shin disability causing functional impairment of earning capacity. Accordingly, there is no disability for VA purposes. The Board finds the August 2023 examiner's findings to be persuasive and premised on a thorough review of the relevant records, a physical examination, and consideration of the Veteran's lay statements. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Further, shin splints are not a presumptive condition associated with Gulf War service. The Veteran has not contended, and the evidence does not support, that shin splints are an undiagnosed condition or a MUCMI. Service connection under 38 U.S.C. 1117 is thus not for application. To the extent that the Veteran asserts that he has a current diagnosis of shin splints, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical knowledge and the ability to interpret complicated diagnostic medical testing. The Veteran's statements in this regard are therefore not competent. Jandreau v. Nicholson, 492 F.3d 1377 n. 4 (Fed. Cir. 2007). The evidence as a whole persuasively weighs against a finding that the Veteran has a bilateral lower extremity shin splint disability that can be attributed to service. As the evidence weighs persuasively against the issue on appeal, the Board finds the appeal must be denied. Lynch v. McDonough, 21 F.4th 776, 781-82 (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). REASONS FOR REMAND 1. Entitlement to service connection for migraines is remanded. The Board finds a remand is necessary as to the service connection claim for migraines to correct a pre-decisional duty-to-assist error. Namely, to clarify the discrepancy as to whether the Veteran has a current diagnosis of migraines that is related to his reports of an in-service injury or a service-connected disability. The Veteran contends that a lack of sleep, stressful situations, and bright sunlight illuminating on the sand during service contributed to his migraines. Service treatment records do not confirm any in-service complaints, treatment, or diagnoses of headaches or related symptoms. Indeed, to the contrary, periodic health assessments throughout service in December 2016, February 2018, November 2018 and the November 2019 separation examination (as well as a post-service October 2021 health assessment) all indicate the Veteran denied such complaints. After service, there is conflicting evidence pertaining to the Veteran's reports of headaches as well as whether he was diagnosed with migraines specifically. That is, while some treatment records dated in 2023 indicate the Veteran's complaints of headaches as well as an August 2023 VA examiner noting specifically a diagnosis of migraines, other records and examinations concluded to the contrary. In particular, a December 2023 VA examiner seems to have made contrary findings. The first report indicates the Veteran does not have, and never had a diagnosed headache disability despite the lay contentions of onset in 2018. The examiner therein noted the Veteran's contentions: that he was hit on the head during service and that he experiences sensitivity to light and sound, and that he gets a migraine 1 to 2 times a month. He indicated that his symptoms have gotten worse over time and that he takes Ibuprofen to treat his migraines. The examiner noted that the Veteran's headaches impact his ability to work as when he has one during work, he has to lay down or ask to perform alternative duties. On the other hand, the December 2023 VA examiner, within the Gulf War portion of the examination, noted a pertinent history of, among other things, migraine headaches. The examiner opined in a separate December 2023 DBQ that the Veteran's headaches were less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by service as the four standard Gulf War disability patterns are not applicable and there is no evidence of persistent/recurrent symptoms or concern of a diagnosis for the claimed migraines. She added that the Veteran's migraines were less likely than not caused by the indicated TERA noting subjective reports of migraines only, and reporting that the claims file is silent for evidence of formal workup for, diagnosis, or treatment of a chronic migraine condition. She was thus unable to confirm a diagnosis. The medical evidence and opinions rendered are internally inconsistent and, as such, the AOJ should have sought further clarification to confirm the Veteran's diagnosis (now or at any time during the pendency of the appeal) and likely etiology thereof in light of the entirety of the evidentiary picture. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinion based on inaccurate factual premise may properly be rejected as non-probative). Further, in light of the Veteran's general contentions that his headaches are due to in-service environmental factors, but alternatively attributable to lack of sleep, the Board finds the record reasonably raised the contention that his headaches are secondary to his service-connected insomnia disorder. As this theory was inferable in the record at the time of the AOJ decision, the Board finds it was a pre-decisional duty-to-assist error not to develop this alternative theory, to include obtaining a secondary service-connection opinion. While the Board is remanding this matter at this time to obtain an additional VA medical opinion, the Board is mindful of the holding in Smith v. Wilkie, 32 Vet. App. 332 (2020) and the impact of implicit credibility determinations within remand orders. The Board does not at this time make any determinations regarding the credibility of any evidence currently of record, to include those described in this remand. The matter is thus REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of the Veteran's claimed headaches. The examiner is directed to consider the entirety of the relevant evidence of record, consider the Veteran's lay statements describing in-service environmental factors and lack of sleep / stress, and then render an opinion as to the following: (a.) Resolve whether the Veteran has a headache disability, to include migraines, or had such a disability (even if it since resolved) at any time during the period on appeal. The examiner is directed to consider the Veteran's complaints of headaches and the various notations of "migraines" found in the 2023 treatment records and examinations. (b.) For any and all found headache disability, to include migraines specifically, the examiner must opine whether said condition is "at least as likely as not" i. Related to an in-service injury, event, or disease, to include the Veteran's description of suffering a head injury during service, lack of sleep, stress, and exposure to bright sunlight during service; ii. Or, alternatively, caused or aggravated by his service-connected insomnia disorder. NOTE: It is "but for" causation or aggravation that is required, not proximate cause. Specifically, would the Veteran have developed the migraine headaches, or would his migraine headaches have been less severe but for the service-connected insomnia disorder either because there is an etiological link or because the service-connected insomnia disorder resulted in the inability to treat the migraine headaches? The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If such reports are discounted by the examiner, the examiner must explain why. The clinician must provide a complete rationale for any opinion expressed, based on the clinician's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on the next page) ? 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Maddox, Rolen 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.