LUMBOSACRAL STRAIN

THOMAS L. ENGLISH · 2026 · Case ID: 26004894

MIXED

Summary

The veteran, who served on active duty from October 2003 to July 2007, appeals the denial of service connection for lumbosacral strain, left ankle disorder, and fibromyalgia, and the remand of acquired psychiatric disorder, TBI, fatigue disorder, and headache disorder. The Board granted service connection for tinnitus. For lumbosacral strain, the Board found a current disability and an in-service event (lay statements about falling and altercations), but denied service connection due to negative nexus opinions from VA examiners, citing lack of chronicity and post-service etiology. The Board afforded low probative value to some opinions for failing to consider lay statements, but ultimately found the evidence against the claim. For tinnitus, the Board found a current disability and sufficient in-service noise exposure (lay statements about shipboard noise and weapons qualifications), and granted service connection, affording the veteran the benefit of the doubt due to conflicting evidence and positive lay statements. For the left ankle disorder and fibromyalgia, service connection was denied due to a lack of current diagnosis, with the Board finding the evidence against the claims. The case was remanded for further development on the psychiatric disorder, TBI, fatigue disorder, and headache disorder due to inadequate or conflicting medical opinions and procedural errors by the RO.

Rationale

Current diagnosis confirmed by VA examinations.; STRs silent for low back complaints; denied recurrence.; Negative nexus opinions from VA examiners citing lack of chronicity and post-service etiology.; Board afforded low probative value to some opinions for failing to consider lay statements.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-58 724

Full Decision Text

Citation Nr: 26004894
Decision Date: 04/23/26 Archive Date: 04/23/26

DOCKET NO. 17-58 724
DATE: April 23, 2026

ORDER

Entitlement to service connection for lumbosacral strain is denied.

Entitlement to service connection for tinnitus is granted.

Entitlement to service connection for a left ankle disorder is denied.

Entitlement to service connection for fibromyalgia is denied.

REMANDED

Entitlement to service connection for an acquired psychiatric disorder is remanded.

Entitlement to service connection for traumatic brain injury (TBI) is remanded.

Entitlement to service connection for a fatigue disorder (claimed as chronic fatigue syndrome (CFS)) is remanded.

Entitlement to service connection for a headache disorder is remanded.

FINDINGS OF FACT

1. The competent and credible evidence of record persuasively establishes a finding that the lumbosacral strain is not related to active-duty service.

2. The competent and credible evidence of record persuasively establishes a finding that the tinnitus is related to active-duty service.

3. The competent and credible evidence of record persuasively establishes a finding that there is no current left ankle disorder.

4. The competent and credible evidence of record persuasively establishes a finding that there is no current fibromyalgia diagnosis.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for lumbosacral strain have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for entitlement to service connection for a left ankle disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for entitlement to service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from October 2003 to July 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal from August 2014 and July 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO).

These issues were previously before the Board in August 2022, and September 2023, remanded each time for further development. That development was completed, and the case has since been returned to the Board for appellate review.

While on remand, October and November 2024 rating decisions granted service connection for degenerative disease of the cervical spine, right ankle lateral collateral ligament sprain status post right ORIF [open reduction and internal fixation] for right lateral malleolus fracture, and bilateral plantar fasciitis. This represents a full grant of the benefits sought, and these issues are no longer in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997).

SERVICE CONNECTION

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

In addition, service connection for certain chronic diseases may be established on a presumptive basis by showing that the condition manifested
the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

In addition, service connection for certain chronic diseases may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a).

Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

1. Entitlement to service connection for lumbosacral strain

The Veteran alleges that the lumbosacral strain began during service and has existed since that time.

First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran underwent VA examinations in July 2015 and April 2024 where the examiners confirmed diagnoses of lumbosacral strain. Accordingly, the first element of service connection is met.

Second, the Board finds that there was an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran's service treatment records (STRs) are silent for any complaints of or treatment for low back pain. He specifically denied any recurrent back pain on a report of medical history upon separation from service. At the July 2015 VA examination, the Veteran reported that he remembered falling a lot on the ships. At the April 2014 VA examination, he indicated that he was assaulted and hit in the back several times with a steel boot, and that the pain has continued to the present. The Board acknowledges that the Veteran's military personnel records noted that he was involved in physical altercations during service. The Board finds the Veteran's statements competent as they are capable of lay observation. 38?U.S.C. §?1154(a); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (noting that a lay witness is competent to report to factual matters of which he or she has first-hand knowledge). Further, these statements have been corroborated by the military personnel records. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the probative value of a witness statement may be affected by inconsistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Accordingly, the second element of service connection is met.

Third, the Board finds that the evidence of record does not support a finding that the lumbosacral strain is related to active service.

The July 2015 VA examiner provided a negative nexus opinion. They noted that the Veteran had reported upper back pain in conjunction with stomach cramps in April 2007 but made no further reports of back pain. The examiner pointed to February 2014 VA treatment records which noted low back symptoms for one year duration. They concluded that as there was no continuum of care for the transient back pain in 2007 until 2013, then it was less likely than not that the lumbosacral strain was related
1996). Accordingly, the second element of service connection is met.

Third, the Board finds that the evidence of record does not support a finding that the lumbosacral strain is related to active service.

The April 2014 VA examiner provided a negative nexus opinion as there was no chronicity of care during or after service, then a post-service event was the more likely etiology.

In an August 2025 addendum opinion, a VA examiner provided another negative nexus opinion. They noted that the STRs were silent for any low back complaints, and that he did not report any low back pain until 2014. The examiner acknowledged the Veteran's lay statements but determined that they were not sufficient to render an in-service diagnosis. Accordingly, they concluded that it was less likely than not that the claimed condition was related to service.

The Board affords the August 2025 medical opinion significant probative value as it was conducted by a medical professional with consideration of the Veteran's lay statements, and specific facts in this case, and is supported by well-reasoned rationale. Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

Low probative value is afforded to the April 2014 and August 2025 opinions as they neglected to consider the Veteran's lay statements. A medical opinion based solely on the absence of documentation in the service treatment records or that fails to take into account lay statements is inadequate. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006) (VA examiner's opinion inadequate that relied on the absence of contemporaneous medical evidence); see also Acevedo v. Shinseki, 25?Vet. App.?286, 294 (2010); Dalton v. Nicholson, 21?Vet. App.?23, 39 (2007).

The Board acknowledges the Veteran's lay statements; however, he is not competent to opine on the adequacy of the examinations chosen to diagnose the etiology of their respiratory disability as the record does not show they possess the requisite medical training, expertise, or credentials. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

The Board has also considered whether presumptive service connection can be established where there is evidence of continuity of symptomology of a chronic condition since service. See 38 C.F.R. § 3.309. However, the record of evidence does not show a current diagnosis until many years following separation from service.

Accordingly, as the probative evidence of record is against the Veteran's claim, the Board finds that the criteria for the claim of entitlement to service connection for lumbosacral strain have not been met, and the appeal is denied.

2. Entitlement to service connection for tinnitus

The Veteran alleges that tinnitus began during service and has existed since that time.

First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran underwent VA examinations in August 2015 and February 2025 where the examiners confirmed a diagnosis of tinnitus. Accordingly, the first element of service connection is met.

Second, the Board finds that there was an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran's STRs are silent for any complaints of or treatment for tinnitus. At the August 2015 VA examination, the Veteran indicated that he could not remember a precipitating event. In a May 2020 statement, he asserted that he was exposed to loud noises while on a ship with a helicopter landing pad, and due to his weapons qualifications. At the February 2025 VA examination, he shared that he believed that the tinnitus was related to military noise such as firearms. The Board finds the Veteran's statements competent as they are capable of lay observation. 38?U.S.C. §?1154(a); Washington, 19 Vet. App. at 368 (noting that a lay witness is competent to report to factual matters of which he or she has first-hand knowledge); Caluza, 7 Vet. App. at 511 (noting that the probative value of a witness statement may be affected by inconsistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Accordingly, the second element of service connection is met.

Third, the Board finds that the evidence of record does support a finding that the tinnitus is related to active service.

The August 2015 VA examiner provided a negative nexus opinion. They explained that because the Veteran's hearing was normal, and there was no evidence of tinnitus during service, then the tinnitus was not related to service.

The February 2025 VA examiner provided a negative nexus opinion. They acknowledged the Veteran's statement that the condition began during service, but pointed to the 2009 hearing examination during which he denied any tinnitus. The examiner conceded that the Veteran had military noise exposure, there was no evidence of auditory damage on active duty to relate to the current tinnitus.

In a second opinion, the examiner addressed the Veteran's toxic exposure risk activities (TERA), specifically asbestos. They indicated that a search for current studies did not find any evidence connecting asbestos to tinnitus. Therefore, the examiner concluded that the tinnitus is not related to any TERA.

The Board affords both the August 2015 and February 2025 medical opinions significant probative value as they were conducted by medical professionals with consideration of the Veteran's lay statements, and specific facts in this case, and are supported by well-reasoned rationale. Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion. Prejean, 13 Vet. App. at 448-9. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez e, 22 Vet. App. at 301.

The Board also affords the Veteran's own statements significant probative weight. The Board finds that the Veteran is competent to report the symptoms of his tinnitus, and that these lay statements that the ringing in the Veteran's ears are related to service, are credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994).

The Board finds the Veteran has established continuity of symptomatology of tinnitus. Tinnitus is a chronic disease for purposes of 38 C.F.R. § 3.309(a). See Fountain v. McDonald, 27 Vet. App. 258 (2015). Resolving all reasonable doubt in his favor, the Board finds the probative, competent evidence demonstrates that the Veteran's current tinnitus at least as likely as not had its onset during active duty.

As the probative evidence of record is both for and against the Veteran's claim, the Board will afford him the benefit of the doubt and find that the criteria for the claim of entitlement to service connection for tinnitus have been met, and the appeal is granted.

3. Entitlement to service connection for a left ankle disorder

The Veteran alleges that he has a left ankle disorder began during service and has existed since that time.

Unfortunately, service connection is not possible at this time, as the Board finds that there is not a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).

3. Entitlement to service connection for a left ankle disorder

The Veteran alleges that he has a left ankle disorder began during service and has existed since that time.

Unfortunately, service connection is not possible at this time, as the Board finds that there is not a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).

August 2014 VA treatment records noted acute ankle pain, unspecific to either the left or the right ankle. As indicated above, the Veteran is now service-connected for the right ankle. He underwent a VA examination in April 2024 where the examiner was unable to confirm a current diagnosis. The Board acknowledges that where pain alone results in functional impairment of earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). On examination, the left ankle had full range of motion, and the Veteran denied any pain. The examiner indicated that there was no functional loss of the left ankle.

Accordingly, the criteria for the claim of entitlement to service connection for a left ankle disorder have not been met, and the appeal is denied.

4. Entitlement to service connection for fibromyalgia

The Veteran alleges that he has fibromyalgia began during service and has existed since that time.

Unfortunately, service connection is not possible at this time, as the Board finds that there is not a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).

In July 2015, a VA examiner indicated a diagnosis of fibromyalgia on the disability benefits questionnaire (DBQ); however, in a corresponding opinion, they noted that the Veteran has not been diagnosed with fibromyalgia. They noted that he had been evaluated by neurology and rheumatology services in 2014, which suggested that his pain complaints could be a somatization disorder. The examiner pointed to February 2015 VA treatment records which indicated that his symptoms were primarily due to TBI, PTSD, and insomnia rather than fibromyalgia. In May 2015, a rheumatologist noted that his symptoms were likely due to chronic tendonitis and muscular pain secondary to TBI as the pain was primarily located in the axial area with no other tender points on the extremities.

April 2021 VA treatment records noted other pain disorder related to psychological circumstances.

In a September 2024 VA addendum opinion, a VA examiner indicated that his psychiatric symptoms were most likely exacerbated by his chronic pain related to fibromyalgia, per medical literature. They explained that chronic pain can negatively impact people with psychiatric disorders. The examiner determined that comorbid psychiatric disorders and chronic pain can often contribute to worse outcomes for the individual, and therefore it is at least as likely as not that the schizoaffective disorder was aggravated by chronic pain associated with his fibromyalgia.

The Veteran underwent another VA examination in May 2025 where the VA examiner found no fibromyalgia diagnosis.

In a June 2025 addendum opinion, a VA examiner acknowledged several opinions about the etiology of the Veteran's diffuse pain but indicated that there is no substantiation that the pain is caused or related to any mental disorder that is diagnosed. They noted that the Veteran is not diagnosed with a somatic symptom disorder, despite speculation by providers in neurology and rheumatology. Rather, the examiner indicated that a 2015 rheumatology note that the pain is due to tendonitis, and muscular injury is the most plausible explanation for the pain as it is primarily located in the axial areas, and not in the extremities. They noted that fibromyalgia was diagnosed in 2024, and that this was also a more likely etiology for the pain.

In August 2025, the RO requested another addendum opinion due to the conflicting evidence regarding whether the Veteran has a current fibromyalgia diagnosis. A VA examiner indicated that the 2024 note of a history of fibromyalgia was based on subjective information provided by the Veteran, and not diagnostic. The examiner stressed that the Veteran is diagnosed with the service-connected cervical spine and right ankle which could account for some or all of the Veteran's symptoms, and that they were unable to render a
explanation for the pain as it is primarily located in the axial areas, and not in the extremities. They noted that fibromyalgia was diagnosed in 2024, and that this was also a more likely etiology for the pain.

Accordingly, the criteria for the claim of entitlement to service connection for fibromyalgia have not been met, and the appeal is denied.

In reaching this decision the Board considered the doctrine of reasonable doubt. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence persuasively favors the claim or is in approximate balance, with the Veteran prevailing in either event, or whether the evidence persuasively weighs against the claim, in which case the claim is denied. In other words, 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 to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (2021). Here, however, as the evidence is persuasively against the claim and the positive and negative evidence is not in approximate balance, the doctrine is not for application. Id.

REASONS FOR REMAND

1. Entitlement to service connection for an acquired psychiatric disorder is remanded.

The Veteran originally styled his claim as one for service connection for posttraumatic stress disorder (PTSD), and depression. The Veteran underwent a VA examination in April 2024 where the examiner confirmed a diagnosis of schizoaffective disorder. Across several opinions from September 2024, a VA examiner, in short, indicated that there was no PTSD diagnosis, and that the schizoaffective disorder pre-existed service.

A Veteran generally is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). This presumption of soundness can be overcome with clear and unmistakable evidence both that a disability preexisted service and was not aggravated by service. Id. To determine that a preexisting condition was aggravated by service, VA must not rest on the notion that the record contains insufficient evidence of aggravation, rather VA must rely on affirmative evidence to prove there was no aggravation. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). The examiner did not adhere to this standard. Accordingly, remand is required.

2. Entitlement to service connection for TBI is remanded.

The Veteran underwent a VA examination in April 2024 where the examiner found that there was no current TBI diagnosis. In a corresponding opinion, they explained that although numerous clinicians have mentioned TBI, it appears that they based their diagnosis on subjective information by the Veteran, and that for examination purposes, there was insufficient corroborative evidence to suggest a diagnosis.

However, the Board notes that a VA examiner in May 2014 confirmed a diagnosis of TBI. The requirement for service connection that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain v. Nicholson,?21?Vet. App.?319?(2007). Although the April 2024 examiner dismissed the TBI diagnosis in the VA treatment records, they did not address the May 2014 VA examination. Accordingly, remand is required.

3. Entitlement to service connection for a fatigue disorder is remanded.

The September 2023 Board decision remanded this issue to obtain a VA medical opinion addressing whether the Veteran's reported fatigue symptoms are related to the TBI. The RO did not obtain such an opinion. The Board is obligated by law to ensure
is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain v. Nicholson,?21?Vet. App.?319?(2007). Although the April 2024 examiner dismissed the TBI diagnosis in the VA treatment records, they did not address the May 2014 VA examination. Accordingly, remand is required.

3. Entitlement to service connection for a fatigue disorder is remanded.

The September 2023 Board decision remanded this issue to obtain a VA medical opinion addressing whether the Veteran's reported fatigue symptoms are related to the TBI. The RO did not obtain such an opinion. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Accordingly, there was not substantial compliance with the September 2023 Board remand instructions, and remand is required.

4. Entitlement to service connection for a headache disorder is remanded.

The Veteran underwent a VA examination in October 2024 where a VA examiner, a nurse practitioner, confirmed a diagnosis of migraine headaches. In a corresponding opinion, they suggested that the headaches are related to an in-service TBI, and that this was out of their scope of practice, so they declined to provide an opinion.

In December 2024, a VA examiner provided a negative nexus opinion, based in part on the April 2024 VA examination which found no TBI diagnosis. Accordingly, remand is required because entitlement to service connection for headaches is inextricably intertwined with the pending TBI claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other).

By this remand the Board makes no determination, expressed or implied, concerning the credibility of any statements on file.

The matters are REMANDED for the following action:

1. Obtain an addendum opinion regarding the etiology of the psychiatric disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided.

NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints.

NOTE (2): If any medical history is rejected, a complete explanation is required.

(a) The examiner must provide an opinion regarding whether it is clear and unmistakable (undebatable) that the disorder pre-existed the Veteran's active service.

(b) If the answer to (a) is in the positive, provide an opinion regarding whether it is also clear and unmistakable (undebatable) that any current disorder was not aggravated by active service.

The examiner is reminded that they may not rest on the notion that the record contains insufficient evidence of aggravation, rather must rely on affirmative evidence to prove there was no aggravation.

(c) If the examiner finds that the disorder did NOT clearly and unmistakably preexist service, or was clearly and unmistakably NOT aggravated by service, the examiner must provide an opinion regarding whether the likelihood is at least approximately balanced or nearly equal, if not higher, that the disorder had onset in, or is otherwise related to, active service.

(d) The examiner should consider the following: 1) military personnel records regarding the Veteran's disciplinary action for an aggravated assault in July 2004, assault and provoking gestures in September 2004, unauthorized absence and dereliction of duty in June 2005, and an unauthorized absence in April 2007, resulting in his recommended general discharge in June 2007; 2) the June 2013, July 2020, and August 2020 statements regarding military sexual trauma, and in-service hazing; 3) the May 2007 STRs; and 4) the May 2014, and April 2024 VA examinations.

2. Obtain an addendum opinion regarding the etiology of the TBI from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided.

NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints.

NOTE (2): If any medical history is rejected, a complete explanation is required.

NOTE (3): The
2020 statements regarding military sexual trauma, and in-service hazing; 3) the May 2007 STRs; and 4) the May 2014, and April 2024 VA examinations.

NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints.

NOTE (2): If any medical history is rejected, a complete explanation is required.

NOTE (3): The examiner is reminded that the requirement for service connection that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves.

(a) First, confirm whether there is a TBI diagnosis. Please consider both the May 2014 and April 2024 VA examinations.

(b) The examiner must provide an opinion regarding whether the likelihood is at least approximately balanced or nearly equal, if not higher, that the TBI had onset in, or is otherwise related to, active service.

3. Provide the Veteran with an appropriate examination to determine the etiology of the fatigue disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided.

NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints.

NOTE (2): If any medical history is rejected, a complete explanation is required.

(a) The examiner must provide an opinion regarding whether it is approximately at least as likely as not (an approximate balance of positive and negative evidence) that the fatigue disorder had onset in, or is otherwise related to, active service.

(b) If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine as to whether the likelihood is at least approximately balanced or nearly equal, if not higher, that there are symptoms due to any undiagnosed illness, or a medically unexplained chronic multi-symptoms illness resulting from service in Southwest Asia. If so, the examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria.

(c) The examiner must also provide an opinion whether it is approximately at least as likely as not (an approximate balance of positive and negative evidence) that the CFS is caused by the TBI.

(d) The examiner must also provide an opinion whether it is approximately at least as likely as not (an approximate balance of positive and negative evidence) that the CFS is aggravated by the TBI.

4. If and only if a VA examiner determines that there is a TBI diagnosis, obtain an addendum opinion regarding the etiology of the headache disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided.

NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints.

NOTE (2): If any medical history is rejected, a complete explanation is required.

(a) The examiner must provide an opinion regarding whether the likelihood is at least approximately balanced or nearly equal, if not higher, that the headaches had onset in, or is otherwise related to, active service.

(b) The examiner must also provide an opinion whether the likelihood is at least approximately balanced or nearly equal, if not higher, that the headaches are caused by the TBI.

(c) The examiner must also provide an opinion whether the likelihood is at least approximately balanced or nearly equal, if not higher, that the headaches are aggravated by the TBI.

Thomas L. English

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Rogos, J.

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.

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