Citation Nr: 22011214 Decision Date: 02/25/22 Archive Date: 02/25/22 DOCKET NO. 19-31 250 DATE: February 25, 2022 ORDER Service connection for chilblains of the hands and feet due to fibromyalgia is granted. Service connection for Raynaud's phenomenon of the hands and fingers due to fibromyalgia is granted. REMANDED The claim for service connection for a low back disability other than fibromyalgia pain is remanded. The claim for service connection for a left ankle disability other than fibromyalgia pain is remanded. The claim for service connection for a right ankle disability other than fibromyalgia pain is remanded. FINDINGS OF FACT 1. The probative evidence of record shows that the Veteran's chilblains of the hands and feet are related to his service-connected fibromyalgia. 2. The probative evidence of record shows that the Veteran's Raynaud's phenomenon of the hands and fingers are related to his service-connected fibromyalgia. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for chilblains of the hands and feet have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2020). 2. The criteria for establishing entitlement to service connection for Raynaud's phenomenon of the hands and fingers have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1999 to September 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2020, the Board, in relevant part, denied the Veteran's claims for service connection for degenerative arthritis of the lumbar spine; chilblains of the feet and right hand; bilateral finger disabilities, including Raynaud's syndrome; and bilateral foot and ankle disabilities, and the Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court). In November 2020, the Court granted a Joint Motion for Remand (Joint Motion), vacating those portions of the Board's April 2020 decision and remanding them to the Board for readjudication. The Board notes that the Veteran has also appealed the issue of entitlement to a higher rating for headaches. However, that claim is being processed under the modernized review system, also known as the Appeals Modernization Act (AMA). Therefore, it will be addressed in a separate decision. Service Connection Service connection may be established 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. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may also be established for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). A disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Additionally, under legislation specific to Persian Gulf veterans, service connection may be established on a presumptive basis for 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 no later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). 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 any 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 chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants presumptive service-connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). Such chronic disability must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 C.F.R. § 3.317(a)(1). Objective indications of a 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). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). Manifestations of an undiagnosed illness may include, among other things, joint and muscle pain. 38 C.F.R. § 3.317(b). Compensation shall not be paid, however, if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf war; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or events that occurred between the appellant's most recent departure from active duty in the Southwest theater of operations during the Persian Gulf war and the onset of the illness; or if there is affirmative evidence that the illness is the result of the appellant's own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(c). The record shows that the Veteran served aboard the USS Abraham Lincoln between 2001 and 2003, which was in the Southwest Asia theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317(e) (defining the Southwest Asia theater of operations); see also 38 U.S.C. § 101(33) (defining the Persian Gulf War as beginning on August 2, 1990, and ending on a date thereafter to be prescribed by Presidential proclamation or law). Therefore, he qualifies for consideration for presumptive service connection for disabilities resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness. 1. Entitlement to service connection for chilblains of the hands and feet 2. Entitlement to service connection for Raynaud's phenomenon of the hands and fingers In a January 2022 rating decision, service connection was granted for fibromyalgia. Upon review of the record, the Board finds that the probative evidence of record shows that the Veteran's chilblains of the feet and right hand and Raynaud's phenomenon of the hands and fingers are related to his service-connected fibromyalgia. VA treatment records show that in December 2011, the Veteran reported lesions on his hands, which swell during the winter and are relieved in the summer, as well as a burning sensation in his fingertips. The assessment was chilblains, rule out systemic lupus or underlying connective tissue disease. In February 2013, the Veteran sought treatment for multiple medical problems, including chilblains, lower back pain, headache, and lightheadedness. It was noted that the Veteran had a history of chilblains with discolored hands, swollen distal fingers, and occasional blisters during the winter, which resolved during warmer months. The treatment provider discussed a referral to a rheumatologist. An April 2018 VA dermatology treatment record noted a history of Raynaud's symptoms during cold weather, which began around age 20 and were mild at the time. The Veteran reported worsening symptoms in recent years with increased pain, color changes, tingling in the hands, and blisters/ulcers on the right hand. Scleroderma was considered, but the Veteran denied other symptoms of scleroderma. It was noted that an autoimmune workup in 2011 was negative, and the Veteran was referred to rheumatology and vascular surgery for further workup. A June 2018 VA rheumatology treatment record notes that the Veteran had a history of Raynaud's, skin lesions on the right hand, and color changes in the hands and toes during the winter for many years. He also described an itchy, burning sensation and dizziness. The assessment was Raynaud's, not typical ischemic lesions, and no evidence of connective disease at that time. In June 2019, the Veteran reported migraine-like headaches, depression, fatigue, and painful, stiff joints throughout the body. The Veteran was referred back to rheumatology. A July 2019 VA rheumatology treatment record shows that the Veteran reported that his Raynaud's symptoms were stable on current pain medications, but he reported chronic widespread pain and stiffness in the joints and muscles, which had been present for about 15 years. He also reported occasional numbness and tingling in the fingers, chronic fatigue, headaches, dizziness, depression, anxiety, mental fog, and poor short-term memory. The assessment was possible fibromyalgia. In January 2021, it was noted that the Veteran had chronic polyarthralgia in the neck, lower back, hands, wrists, elbows, shoulders, knees, and ankles, status post negative rheumatology labs. The assessment included possible fibromyalgia and Raynaud's. In May 2021, the Veteran reported chronic back pain for about 20 years. He denied any specific injury apart from a car accident. The assessment was possible fibromyalgia. Subsequent treatment records note that the Veteran has fibromyalgia, and in October 2021, he started a trial of pregabalin to treat fibromyalgia. In December 2021, the Veteran underwent VA hand /finger and foot examinations. The examiner indicated that the Veteran's symptoms were consistent with chilblains of the hands and feet, which was a diagnosable, but medically unexplained chronic multi-symptom illness of unknown etiology. Later that month, the Veteran underwent a VA fibromyalgia examination. A physical examination revealed trigger points for pain bilaterally in the lower cervical region, occiput, trapezius muscle, lateral epicondyle, and knees. The examiner indicated that the Veteran had fibromyalgia, and the findings, signs, or symptoms included widespread musculoskeletal pain, stiffness, fatigue, sleep disturbance, headaches, depression, anxiety, Raynaud's-like symptoms, and chilblains. In a January 2022 rating decision, service connection was granted for fibromyalgia, and a 40 percent rating was assigned for constant symptoms of widespread musculoskeletal pain, tender points, stiffness, Raynaud's-like symptoms, sleep disturbance, and fatigue. Based on the foregoing, the Board finds that that the probative evidence of record shows that the Veteran's chilblains of the hands and feet and Raynaud's phenomenon of the hands and fingers are related to his service-connected fibromyalgia. Although the 40 percent rating assigned for fibromyalgia already contemplates Raynaud's-like symptoms, the prohibition against pyramiding does not preclude an award of service connection for disabilities with overlapping symptoms. See Fenderson v. Vest, 12 Vet. App. 119, 125 (1999) (explaining that VA first determines whether the Veteran is entitled to service connection and then selects the appropriate diagnostic code to rate the service-connected disabilities); see also Esteban v. Brown, 6 Vet. App. 259, 260-61 (1994) (separate ratings are permissible where none of the symptomatology for one condition is duplicative of or overlapping with the symptomatology of another condition). As the Veteran's treatment records note diagnoses of Raynaud's phenomenon and chilblains, which are related to the Veteran's service-connected fibromyalgia, service connection is granted. See 38 C.F.R. § 3.310. REASONS FOR REMAND 1. The claim for service connection for a low back disability other than fibromyalgia pain is remanded. Service treatment records show that the Veteran was involved in a motor vehicle accident in July 2000, after which he reported mild/resolving back pain. In July 2002, he reported stabbing back pain below the shoulder blade that started when he boarded the ship. He also reported a history of two motor vehicle accidents without injuries to the back or extremities, just a muscle strain. The assessment was musculoskeletal strain. In August 2002, the Veteran reported mid/low back pain over the past few years with no known specific etiology. The assessment was chronic thoracic/lumbar strain. VA treatment records show that in January 2013, the Veteran reported intermittent back pain and stiffness for a long time, and x-rays of the lumbar spine revealed degenerative changes. A May 2017 MRI of the lumbar spine likewise revealed mild degenerative changes without significant spinal canal or neural foraminal narrowing. In the March 2021 remand, the Board directed the agency of original jurisdiction (AOJ) to provide the Veteran with a VA examination to determine whether the Veteran's back pain was attributable to a diagnosed disability, an undiagnosed illness, or a medically unexplained chronic multi-symptom illness. The examiner was instructed to provide an opinion as to the etiology of any diagnosed low back disability, including whether such was related to the July 2000 motor vehicle accident, the 2002 reports of back pain, and/or the general rigors of service, including heavy lifting. The Veteran underwent a VA back examination in December 2021. The examiner indicated that the Veteran had degenerative arthritis of the spine, which is a disease with a clear and specific etiology and diagnosis. Although the record shows that the Veteran has back pain as a symptom of his service-connected fibromyalgia, the record also shows a diagnosis of degenerative arthritis of the spine. As previously noted, the prohibition against pyramiding does not preclude an award of service connection for disabilities with overlapping symptoms. See Fenderson, 12 Vet. App. at 125; see also Esteban, 6 Vet. App. at 260-61. Accordingly, another medical opinion should be obtained addressing whether a current low back disability other than fibromyalgia pain, including degenerative arthritis of the lumbar spine, was incurred in or caused by service. See 38 C.F.R. § 3.159(c)(4); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). 2. The claim for service connection for a left ankle disability other than fibromyalgia pain is remanded. 3. The claim for service connection for a right ankle disability other than fibromyalgia pain is remanded. An August 2011 VA treatment record shows that the Veteran reported injuring his right ankle in March playing soccer, and it was not getting better. He stated that it was still painful and swollen. An MRI revealed a chronic partial tear/sprain of the anterior talofibular and calcaneofibular ligaments, and he underwent physical therapy for a recurrent ankle sprain for several months. In July 2016, the Veteran reported recurrence of right ankle pain over the past few weeks. An MRI showed preserved joint spaces and unremarkable soft tissues. In July 2018, the Veteran reported right anterior ankle pain and swelling for the past month and denied any new trauma. In June 2019, the Veteran reported painful, stiff joints throughout the body. A July 2019 VA rheumatology treatment record shows that the Veteran reported chronic widespread pain and stiffness in the joints and muscles for about 15 years, and the assessment was possible fibromyalgia. In May 2021, the Veteran reported chronic polyarthralgia in multiple areas, including the ankles. The assessment was possible fibromyalgia. In the March 2021 remand, the Board directed the AOJ to provide the Veteran with a VA ankle examination to determine whether the Veteran's bilateral ankle pain was attributable to a diagnosed disability, an undiagnosed illness, or a medically unexplained chronic multi-symptom illness. The examiner was instructed to provide an opinion as to the etiology of any diagnosed ankle disability, including whether such was caused by the general rigors of service, including prolonged standing on steel and cement floors and/or an alleged trip and fall during service. The Veteran underwent a VA ankle examination in December 2021. The examiner indicated that the Veteran had a chronic/recurrent right lateral collateral ligament sprain and a left ankle strain, which were diseases with a clear and specific etiology and diagnosis. Although the record shows that the Veteran has bilateral ankle pain as a symptom of his service-connected fibromyalgia, the record also shows a diagnosis of chronic/recurrent right ankle sprain, and the VA examiner indicated that the Veteran's left ankle symptoms were consistent with a strain. As previously noted, the prohibition against pyramiding does not preclude an award of service connection for disabilities with overlapping symptoms. See Fenderson, 12 Vet. App. at 125; see also Esteban, 6 Vet. App. at 260-61. Accordingly, another medical opinion should be obtained addressing whether a current left and/or right ankle disability other than fibromyalgia pain was incurred in or caused by service. See 38 C.F.R. § 3.159(c)(4); see also Stegall, 11 Vet. App. at 271. The matters are REMANDED for the following action: 1. Obtain a medical opinion with respect to the Veteran's claim for service connection for a low back disability other than fibromyalgia pain. Do not schedule the Veteran for another examination unless it is deemed necessary to respond to the question presented. After a review of the claims file, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that a current low back disability other than fibromyalgia pain (including degenerative arthritis of the lumbar spine) was incurred in or caused by service, to include as due to a July 2000 motor vehicle accident, July and August 2002 reports of back pain, and/or the general rigors of service, including heavy lifting. A complete rationale for all opinions must be provided. 2. Obtain a medical opinion with respect to the Veteran's claim for service connection for left and right ankle disabilities other than fibromyalgia pain. Do not schedule the Veteran for another examination unless it is deemed necessary to respond to the question presented. After a review of the claims file, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that a current left and/or right ankle disability other than fibromyalgia pain (including a chronic/recurrent right ankle sprain and a left ankle strain) was incurred in or caused by service, to include as due to the general rigors of service, including prolonged standing on steel and cement floors and/or an alleged trip and fall during service. A complete rationale for all opinions must be provided. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Banister, 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.