PES PLANUS

Summary

The Veteran, who served in the Army from October 1986 to October 1990, with subsequent service in the Army Reserve and Naval Reserve, appeals the denial of service connection for Chronic Fatigue Syndrome (CFS) and the grant of service connection for a bilateral foot disability. The Veteran claimed his bilateral foot disability, noted as mild pes planus upon entry, was aggravated by service due to rigorous marches and heavy equipment, and alternatively claimed it was caused or aggravated by existing service-connected musculoskeletal disabilities. Service treatment records showed mild pes planus at enlistment, treatment for foot pain and rash during service, and moderate pes planus upon separation. VA examinations in February 2023 and October 2024 found the pre-existing pes planus was aggravated beyond its natural progression by service. The Board found service connection for the bilateral foot disability warranted on an aggravation basis. For CFS, the Veteran claimed it was due to exposure to environmental hazards in the Persian Gulf, including exhaust, fumes, asbestos, and burn pits, and potentially related to tuberculosis or major depressive disorder. He submitted articles supporting CFS diagnosis and etiology. However, service treatment records were silent for CFS, though he reported symptoms like shortness of breath and malaise. Post-service VA examinations found no diagnosis of CFS or undiagnosed illness, attributing his symptoms to diagnosed conditions like OSA, rhinitis, and major depressive disorder. VA examiners opined it was less likely than not that CFS was caused by service exposures. The Board found the Veteran did not meet the criteria for CFS and that his symptoms were attributable to known diagnoses, denying the CFS claim.

Rationale

Pre-service mild pes planus noted on enlistment.; Aggravated beyond natural progression by in-service duties.; Increase in severity during service and post-service.; No clear and unmistakable evidence to rebut aggravation presumption.

Full Decision Text

Citation Nr: A26032025
Decision Date: 04/06/26	Archive Date: 04/07/26

DOCKET NO. 250103-504754
DATE: April 6, 2026

ORDER

Entitlement to service connection for a bilateral foot disability, to include pes planus and plantar fasciitis is granted.

Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to exposure to environmental hazards in the Persian Gulf, is denied.

FINDINGS OF FACT

1. After resolving reasonable doubt, the Veteran's bilateral pes planus was noted at entry to service and was aggravated beyond its natural progression during his active service.

2. The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War.

3. The Veteran's fatigue symptoms have been attributed to known diagnosed conditions, including his service-connected major depressive disorder, obstructive sleep apnea (OSA), and rhinitis.

4. The Veteran does not have CFS, an undiagnosed illness, or a medically unexplained chronic multi-system illness (MUCMI).

CONCLUSIONS OF LAW

1. The criteria for service connection for a bilateral foot disability have been met.  38 U.S.C. §§ 1110, 1131, 1153, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306.

2. The criteria for service connection for CFS have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 1117, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.102, 3.303, 3.304, 3.307, 3.317.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from October 1986 to October 1990, with additional service in the Army Reserve and Naval Reserve.  

These matters are before the Board of Veterans' Appeals (Board) on appeal from an October 2024 rating decision adjudicated under the Appeals Modernization Act (AMA) by a Department of Veterans Affairs (VA) Regional Office (RO).  The Veteran was notified of the October 2024 rating decision in a November 2024 letter.  See November 2024 Notification Letter (e.g., VA Form 20-8993, VA Form 21-0290, PCGL).

Within the framework of the AMA, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) and elected Direct Review by a Veterans Law Judge in January 2025.  See January 2025 VA Form 10182 Notice of Disagreement.  The Board notes that under the direct review option, no additional evidence received after the appealed rating decision is to be considered; rather, review is limited to the evidence of record at the time of that decision.  38 C.F.R. §§ 19.2(d), 20.301.

The Board notes that additional evidence, to include updated VA treatment records, a February 2026 examination for housebound status or permanent need for regular aid and attendance completed by the Veteran, and a March 2026 VA aid and attendance or housebound examination, was added to the claims file during a period of time when new evidence was not allowed.  Therefore, the Board may not consider this evidence.  38 C.F.R. §§ 3.2500, 20.302(a).  However, the Veteran may file a Supplemental Claim and submit or identify this evidence.  If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered.  38 C.F.R. § 3.2501.  Specific instructions for filing a Supplemental Claim are included with this decision.

Lastly, the Board acknowledges that the Veteran filed a timely appeal to a May 2025 Veterans Health Administration (VHA) decision for eligibility to benefits under VA's Program of Comprehensive Assistance for Family Caregivers (PCAFC).  See August 2025 VA Form 10182 Notice of Disagreement; October 2025 PCAFC - Veteran.  That issue will be addressed in a separate decision under a different docket number.

Service Connection

Service connection may be granted for 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.  Establishing service connection generally requires evidence of (1) a current
 acknowledges that the Veteran filed a timely appeal to a May 2025 Veterans Health Administration (VHA) decision for eligibility to benefits under VA's Program of Comprehensive Assistance for Family Caregivers (PCAFC).  See August 2025 VA Form 10182 Notice of Disagreement; October 2025 PCAFC - Veteran.  That issue will be addressed in a separate decision under a different docket number.

Service Connection

Service connection may be granted for 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.  Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); 38 C.F.R. § 3.303.

Service connection may be awarded on a presumptive basis to a Persian Gulf veteran who (1) exhibits objective indications; (2) of a chronic disability such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026; and (4) such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.  38 C.F.R. § 3.317(a)(1).

In addition to certain chronic disabilities from undiagnosed illness, service connection may also be given for a medically unexplained chronic multi-symptom illness (such as CFS, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs and symptoms, as well as for any diagnosed illness that the VA Secretary determines by regulation warrants a presumption of service connection.  38 C.F.R. § 3.317(a)(2)(i)(B).

The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War.  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(d).

A review of the service personnel records (SPRs) shows that the Veteran's Military Operational Specialty (MOS) was machinist's mate and that he served in the Persian Gulf in support of Operation Desert Storm and Operation Desert Shield from August 1990 to October 1990.  See May 2021 Military Personnel Record; July 2022 Military Personnel Record; see also July 2024 Other.  Therefore, the Veteran is a qualifying Persian Gulf Veteran and exposure to environmental hazards and burn pits has been conceded.

1. Entitlement to service connection for a bilateral foot disability, to include pes planus and plantar fasciitis, to include as secondary to service-connected disabilities, is granted.

The Veteran states that his bilateral foot disability existed prior to service and was aggravated beyond its natural progression while he was serving on active duty.  In this regard, he explained that his bilateral foot disability became symptomatic due to wear and tear from performing long marches while carrying heavy equipment in service and reported that he has been experiencing bilateral foot pain since he was discharged from active duty.  Alternatively, he stated that his diagnosed bilateral foot disability may have been caused or aggravated by his service-connected musculoskeletal disabilities.  See, e.g., September 2021 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief); September 2023 Correspondence; March 2024 Correspondence; July 2024 Correspondence.  

A review of the service treatment records (STRs) shows an October 1986 enlistment report of medical examination, which notes the Veteran's feet to be abnormal, and the examiner explained that the Veteran had mild pes planus.  In December 1986, the Veteran reported that he had been experiencing right foot pain for five days and explained that his symptoms manifested due to overuse.  On physical examination, the examiner noted tenderness to palpation on the plantar side of the first and second toes.  The assessment was stress pain of the right foot secondary to overuse, and the examiner prescribed arch
; Attorney Brief); September 2023 Correspondence; March 2024 Correspondence; July 2024 Correspondence.  

A review of the service treatment records (STRs) shows an October 1986 enlistment report of medical examination, which notes the Veteran's feet to be abnormal, and the examiner explained that the Veteran had mild pes planus.  In December 1986, the Veteran reported that he had been experiencing right foot pain for five days and explained that his symptoms manifested due to overuse.  On physical examination, the examiner noted tenderness to palpation on the plantar side of the first and second toes.  The assessment was stress pain of the right foot secondary to overuse, and the examiner prescribed arch supports.  A subsequent February 1987 chronological record of medical care shows that the Veteran received a set of small bar plugs, a type of shoe insert.  

In April 1987, the Veteran sought treatment for a chronic rash, manifested by discoloration and itching, on both of his feet and indicated that his symptoms had been present for several months.  On physical examination, the examiner noted dry, chaffing, and peeling skin on the bottom of the Veteran's feet.  The assessment included dyshidrotic eczema.  However, the Veteran's feet were subsequently found to be normal on his September 1990 separation report of medical examination, and the Veteran denied foot trouble on the corresponding report of medical history.  See July 2021 STR - Medical; February 2022 STR - Medical; March 2024 STR - Medical - Photocopy.

A review of the post-service treatment records shows an October 1991 enlistment report of medical examination to the Army Reserve, which notes the Veteran's feet to be abnormal.  In this regard, the examiner explained that he had moderate asymptomatic pes planus.  See October 2021 Military Personnel Record.

The Veteran was afforded a VA examination for foot conditions in February 2023.  The examiner diagnosed bilateral pes planus and bilateral plantar fasciitis.  During the examination, the Veteran reported that he was diagnosed with mild bilateral pes planus in 1986 and explained that he developed pain in his feet over time.  He also indicated that he was diagnosed with moderate to severe pes planus shortly after he was discharged from active duty in October 1991.  

After performing and examination and reviewing the evidence of record, the examiner opined that the Veteran's bilateral foot disability, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness.  In support of his opinion, the examiner noted that the Veteran's pre-existing bilateral foot disability was exacerbated by the rigorous marches and long hikes he was required to perform while wearing hard boots and carrying a heavy sack during service.  In this regard, he explained that such exercises caused the arches in the Veteran's feet to flatten and that pulling of the fascia could lead to chronic pain.  As such, the examiner found that the Veteran's pre-existing bilateral foot disability was aggravated beyond its natural progression by an in-service injury.  See February 2023 C&P examination.

The Veteran last underwent a VA examination for foot conditions in October 2024.  The examiner noted that the Veteran had been diagnosed with bilateral pes planus and bilateral plantar fasciitis.  During the examination, the Veteran reported that he was diagnosed with pes planus on his October 1986 enlistment report of medical examination and explained that his symptoms worsened during service.  He also indicated that his diagnosed plantar fasciitis was caused by his bilateral pes planus and denied any major foot trauma or surgery.

After performing an examination and reviewing the evidence of record, the examiner opined that the Veteran's bilateral foot disability, which clearly existed prior to service, was aggravated beyond its natural progression while he was serving on active duty.  In support of his opinion, the examiner noted that the October 1986 enlistment report of medical examination showed evidence of bilateral pes planus but emphasized that the STRs showed that the Veteran was treated for right foot pain with tenderness to palpation on the plantar surface, which was assessed as right foot plantar pain due to overuse/stress and was treated with arch supports in December 1986.  In this regard, he explained that the December 1986 record signified the relationship between the Veteran's plantar foot pain and his pre-existing bilateral pes planus and showed that was present while he was still serving on active duty.  Thus, the examiner found that the Veteran's pre-existing pes planus was clearly aggravated by his in-service duties/actions.   

After a review of the evidence of record, the Board finds that service connection is warranted for the Veteran's diagnosed bilateral foot disability.  

In general, a veteran is considered
 right foot pain with tenderness to palpation on the plantar surface, which was assessed as right foot plantar pain due to overuse/stress and was treated with arch supports in December 1986.  In this regard, he explained that the December 1986 record signified the relationship between the Veteran's plantar foot pain and his pre-existing bilateral pes planus and showed that was present while he was still serving on active duty.  Thus, the examiner found that the Veteran's pre-existing pes planus was clearly aggravated by his in-service duties/actions.   

After a review of the evidence of record, the Board finds that service connection is warranted for the Veteran's diagnosed bilateral foot disability.  

In general, a veteran is considered to have been in sound condition when examined and accepted for service, except as to defects, infirmities, or disorders noted on his or her entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service.  See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b).  Evidence of a veteran being asymptomatic upon entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation; instead, the evidence must establish that the preexisting condition worsened.  See Green v. Derwinski, 1 Vet. App. 320, 322-23 (1991).  A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease.  38 U.S.C. § 1153; 38 C.F.R. § 3.306(a).  Clear and unmistakable evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service.  38 C.F.R. § 3.306(b).

In this regard, mild pes planus was noted on entrance.  Therefore, the Veteran was not sound on entrance.  However, his pre-existing mild pes planus was aggravated by his military service, as there was an increase in severity during service, as evidence by his complaints during service.  Notably, following his separation from service, in October 1991, he was noted to have moderate pes planus, indicating an increase in disability.  

There is not clear and unmistakable evidence to rebut the presumption of aggravation.  In this regard, the Board observes that there was a private medical opinion from Dr. M. B. Shoag dated in January 2022 and numerous VA examinations and opinions.  However, only the aforementioned February 2023 and October 2024 VA opinions are adequate upon which to base a determination.  These opinions reflect aggravation during service, and while they do not address whether the presumption was clearly and unmistakably rebutted, the Board will not remand to potentially develop negative evidence.  The Board concludes that the evidence is sufficient to grant service connection for pes planus and plantar fasciitis on an aggravation basis.

2. Entitlement to service connection for CFS, to include on a secondary basis and as due to exposure to environmental hazards in the Persian Gulf, is denied.

The Veteran states that his claimed CFS was caused by exposure to exhaust, engine fumes, heated air, and asbestos in his military occupational specialty (MOS) as a machinist's mate.  He also noted that he tested positive for tuberculosis in service and stated that his claimed CFS may have developed as a residual thereof.  He further indicated that it may have been caused or aggravated by his service-connected major depressive disorder.

Alternatively, the Veteran reported that his claimed CFS may have been caused by exposure to environmental hazards, to include toxic fumes from open air burn pits, while he was serving in the Persian Gulf and/or that his CFS symptoms may be a MUCMI or an undiagnosed illness.  In this regard, he reported that he sought treatment for shortness of breath multiple times while he was serving on active duty and argued that such symptoms may have been indicative of a MUCMI.  He further explained that he had been experiencing fatigue symptoms, to include constantly feeling tired and nodding off when he sat in one place for too long, since service and contended that the doctors who evaluated him during and after service may have lacked the requisite expertise to diagnose CFS.  See, e.g., September 2021 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief); November 2023 Correspondence; July 2024 Correspondence; August 2024 Correspondence. 

In support of his claim, the Veteran submitted an
 that he sought treatment for shortness of breath multiple times while he was serving on active duty and argued that such symptoms may have been indicative of a MUCMI.  He further explained that he had been experiencing fatigue symptoms, to include constantly feeling tired and nodding off when he sat in one place for too long, since service and contended that the doctors who evaluated him during and after service may have lacked the requisite expertise to diagnose CFS.  See, e.g., September 2021 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief); November 2023 Correspondence; July 2024 Correspondence; August 2024 Correspondence. 

In support of his claim, the Veteran submitted an article titled Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Essentials of Diagnosis and Management, which states that many clinicians lack the knowledge to appropriately diagnose and manage CFS and that up to 91 percent of individuals with CFS in the United States may remain undiagnosed.  He also submitted an article titled Dyspnea in Chronic Fatigue Syndrome: Comparison of Two Prospective Cross Sectional Studies, which found that subjects who participated in the studies had significantly greater complaints of dyspnea, systemic pain, other symptoms, and disability when compared to healthy controls.  See July 2024 Correspondence.  

In addition, the Veteran submitted a study titled How Mycobacterium Tuberculosis Infection Could Lead to the Increasing Risks of Chronic Fatigue Syndrome and the Potential Immunological Effects: A Population-Based Retrospective Cohort Study, which found that mycobacterium tuberculosis infections were associated with an elevated risk of subsequent CFS, particularly in men aged 65 years or older.  See July 2024 Correspondence.  He also submitted a letter to the editor published in American Family Physician, a peer-reviewed and evidence-based clinical journal, titled Chronic Fatigue Syndrome and Depression, which argues that depression could be the key etiologic factor in CFS.  See August 2024 Correspondence.  In addition, the Veteran submitted a VA slide deck titled Conducting Gulf War Medical Opinions, a copy of another Board decision in which a veteran's claim for entitlement to service connection for CFS was remanded to obtain outstanding records and a VA medical opinion, and a document explaining what constitutes an undiagnosed illness and the causes thereof.  See August 2024 Correspondence; August 2024 Remand BVA or CAVC; October 2024 Correspondence.

A July 2024 toxic exposure risk activity memorandum shows that the Veteran was exposed to asbestos in service.  See July 2024 Other.  Moreover, as discussed above, the Veteran is a qualifying Persian Gulf Veteran and exposure to environmental hazards and burn pits has been conceded.

A review of the STRs shows an October 1986 enlistment report of medical examination, which notes the Veteran's head, sinuses, lungs, and neurologic system to be normal.  A February 1987 chronological record of medical care shows that the Veteran reported that he had been experiencing dyspnea while working in the engine room for approximately one week, though he was not experiencing such symptoms when he sought treatment.  The assessment was shortness of breath with an unknown etiology, and the examiner asked the Veteran to return when his symptoms were present.  Seven days later, the Veteran sought treatment for shortness of breath after working, and the examiner diagnosed him with probable mild heatstroke.  However, a subsequent treatment record dated three days later shows that the Veteran came up from the engine room to report dyspnea, and the examiner found that the etiology of his symptoms was unknown at that time.

In February 1988, the Veteran reported that he had been experiencing headaches, nausea, vomiting, diarrhea, and general malaise for two days, and the examiner diagnosed him with a viral syndrome.  Thereafter, a March 1988 tuberculosis contact/reactor follow-up shows that the Veteran tested positive for tuberculosis.  At that time, he denied any contact with an individual with tuberculosis but acknowledged that he had traveled to Thailand, the Philippine Islands, Okinawa, Korea, and Australia since his last tuberculosis test.  A chest x-ray obtained at that time revealed no active disease, and an isoniazid monitoring history record shows that the Veteran was treated for tuberculosis from March 1988 to October 1988.  Thereafter, a June 1989 physical examination for tuberculosis program shows that the Veteran had taken a full year of isoniazid treatment. 

A subsequent April 1990 medical questionnaire for respirator users shows that the Veteran reported that he did not have, and had never experienced, shortness of breath or lung disease.  The Veteran's head, sinuses, lungs, and neurologic system were noted to be normal on his
, the Philippine Islands, Okinawa, Korea, and Australia since his last tuberculosis test.  A chest x-ray obtained at that time revealed no active disease, and an isoniazid monitoring history record shows that the Veteran was treated for tuberculosis from March 1988 to October 1988.  Thereafter, a June 1989 physical examination for tuberculosis program shows that the Veteran had taken a full year of isoniazid treatment. 

A subsequent April 1990 medical questionnaire for respirator users shows that the Veteran reported that he did not have, and had never experienced, shortness of breath or lung disease.  The Veteran's head, sinuses, lungs, and neurologic system were noted to be normal on his September 1990 report of medical examination, and the Veteran denied frequent trouble sleeping, shortness of breath, and swollen or painful joints on the corresponding report of medical history.  See July 2021 STR - Medical; February 2022 STR - Medical.  Thus, although the Board acknowledges that the Veteran was treated for symptoms that can be associated with CFS in service, to include sore throat, general malaise, and shortness of breath, his STRs are silent for any findings or diagnoses of CFS.  See, e.g., August 2024 Rating Decision - Narrative. 

A review of the post-service treatment records shows that the Veteran underwent a VA Gulf War general medical examination in December 2021.  The examiner noted that the Veteran had been diagnosed with irritable bowel syndrome and microscopic hematuria, but found that the Veteran did not have any other diagnosed illnesses for which no etiology was established or any additional signs or symptoms that may represent an undiagnosed illness or a MUCMI.  Following the examination, the examiner found no findings, signs, or symptoms to support a diagnosis of CFS.  

The Veteran was also afforded a VA examination for CFS in December 2021.  During the examination, the Veteran reported that his symptoms, to include falling asleep during the day without noticing, headaches, joint pain, and muscle pain, manifested in October 1990 but denied any symptoms at the time of the examination.  However, the examiner found that the Veteran did not have CFS and explained that there were no findings, signs, or symptoms to support a diagnosis.  After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's claimed CFS was caused by a specific in-service exposure event while he was serving in the Persian Gulf.  In support of his opinion, the examiner explained that there was no pathology to render a diagnosis.  See December 2021 C&P examination.

During his December 2021 and July 2022 VA examinations for mental disorders, the examiners found that the Veteran's service-connected major depressive disorder was manifested by chronic sleep impairment and sleep disturbances.  See December 2021 C&P examination; July 2022 C&P examination; see also July 2022 VA examination.  In addition, a December 2021 VA examination for sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx shows that the Veteran's service-connected rhinitis was manifested by running nose, mucus, itchy throat, watery eyes, tiredness, aching, and stuffiness.  See December 2021 C&P examination.

The Veteran next underwent a VA Gulf War general medical examination in February 2022.  The examiner noted that the Veteran had been diagnosed with polycythemia vera, but found that he did not have any other diagnosed illnesses for which no etiology was established or additional signs or symptoms that may represent an undiagnosed illness or a MUCMI.  See March 2022 C&P examination.  

In addition, July 2022 and February 2023 VA examinations for sleep apnea shows that the Veteran's service-connected OSA was manifested by persistent daytime hypersomnolence.  See July 2022 C&P examination; February 2023 C&P examination.

The Veteran was also afforded a VA examination for CFS in June 2024.  During the examination, the Veteran reported that his symptoms, to include feeling tired, joint and muscle pain, headaches, inability to recall recent events, and lack of concentration began gradually in or around 1990.  In this regard, he noted that he was not able to play soccer, walk for more than two blocks, or drive but indicated that he was still able to walk, eat, and bathe alone.  However, the examiner found that the Veteran did not have CFS.  In this regard, the examiner noted findings, signs, and symptoms attributable to CFS, to include nonexudative pharyngitis, generalized muscle aches or weakness,
 afforded a VA examination for CFS in June 2024.  During the examination, the Veteran reported that his symptoms, to include feeling tired, joint and muscle pain, headaches, inability to recall recent events, and lack of concentration began gradually in or around 1990.  In this regard, he noted that he was not able to play soccer, walk for more than two blocks, or drive but indicated that he was still able to walk, eat, and bathe alone.  However, the examiner found that the Veteran did not have CFS.  In this regard, the examiner noted findings, signs, and symptoms attributable to CFS, to include nonexudative pharyngitis, generalized muscle aches or weakness, headaches, and sleep disturbance.  However, she emphasized that the Veteran only met four of the required six minimum symptoms to warrant a diagnosis of CFS and emphasized that he had not experienced debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months.  In addition, the examiner noted that the Veteran had been diagnosed with major depressive disorder, which could cause the Veteran's reported symptoms.

After performing an examination, reviewing the evidence of record, and considering the total potential exposure through all of the Veteran's applicable military deployments and the synergistic, combined effect of all of his toxic exposure risk activities, the examiner opined that it was less likely than not that the Veteran's claimed CFS was caused by his indicated toxic exposure risk activities.  In support of her opinion, the examiner explained that there was no pathology to warrant a diagnosis or condition that could be related to the Veteran's in-service toxic exposure risk activities.  See June 2024 C&P examination.  

The Veteran also underwent a VA Gulf War general medical examination in August 2024.  The examiner found that the Veteran did not have any diagnosed illness for which no etiology was established and indicated that he did not have any signs or symptoms that might represent an undiagnosed illness or a MUCMI.  See August 2024 C&P examination.  

VA obtained an addendum medical opinion in October 2024.  After reviewing the evidence of record, the examiner found that the Veteran's claimed CFS was not an undiagnosed illness, a MUCMI, a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology.  Rather, the examiner explained that there was no pathology to warrant a diagnosis or condition that could be related to the Veteran's claimed CFS.  In support of her opinion, the examiner noted that the Veteran had not been diagnosed with CFS by a specialist and emphasized that his subjective reports of fatigue were likely a symptom of his diagnosed rhinitis, OSA, and major depressive disorder, which could all result in fatigue, daytime sleepiness, and an overall feeling of tiredness or lack of energy.  See October 2024 C&P examination.  

Following a review of the evidence of record, the Board finds that service connection for CFS is not warranted.

Initially, the Board notes that the Veteran has not been diagnosed with, or treated for, CFS.  Rather, the probative evidence of record shows that the Veteran's reports of fatigue and related symptoms have been attributed to known diagnosed conditions, including his service-connected major depressive disorder, OSA, and rhinitis.  See December 2021 C&P examination; July 2022 C&P examination; February 2023 C&P examination; June 2024 C&P examination; October 2024 C&P examination.  

In this regard, the Board finds the June 2024 and October 2024 VA examiner's opinions to be the most probative evidence of record as such considered all pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided complete rationales, relying on and citing to the records reviewed.  Moreover, the opinions include clear conclusions with supporting data, as well as reasoned medical explanations connecting the two.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl, 21 Vet. App. at 124.

In reaching the above conclusions, the Board acknowledges and has considered the articles and studies submitted by the Veteran, to include the articles stating that many clinicians lack the knowledge to appropriately diagnose or manage CFS.  However, as stated above, the Board finds that the probative evidence of record shows that the Veteran does not meet the criteria for a CFS diagnosis and that the symptoms he attributes to his claimed disability have been related to other, known clinical diagnoses.  In this regard, there is no indication, beyond the
 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl, 21 Vet. App. at 124.

In reaching the above conclusions, the Board acknowledges and has considered the articles and studies submitted by the Veteran, to include the articles stating that many clinicians lack the knowledge to appropriately diagnose or manage CFS.  However, as stated above, the Board finds that the probative evidence of record shows that the Veteran does not meet the criteria for a CFS diagnosis and that the symptoms he attributes to his claimed disability have been related to other, known clinical diagnoses.  In this regard, there is no indication, beyond the Veteran's statements, that he may have CFS.  Therefore, as the medical evidence of record does not show that the Veteran has had a separate diagnosis for CFS during the appeal period, and in consideration that his symptoms have been attributed to known diagnoses, including multiple conditions for which he is already service connected, the Board finds that the Veteran does not have an undiagnosed disability or a MUCMI pursuant to 38 C.F.R. § 3.317.

In reaching this conclusion, the Board has considered the Veteran's assertions that his symptoms were caused by CFS or an undiagnosed or multi-symptom illness related to his service in the Persian Gulf.  See, e.g., September 2021 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief); November 2023 Correspondence; July 2024 Correspondence; August 2024 Correspondence.  In this regard, the Veteran is considered competent to report the observable manifestations of his claimed disability.  See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994).  However, while a Veteran can competently report the onset and continuity of subjective symptoms, he is not competent to render a diagnosis or to determine the medical etiology of his reported symptoms.  See Jandreau v. Nicholson, 492 F.3d 1372, 1376, 1377 (Fed. Cir. 2007).

Thus, the Board finds that any lay assertions by the Veteran in the present case are outweighed by the medical evidence of record, to include the June 2024 and October 2024 VA medical opinions.  As stated above, the VA examiners have the training, knowledge, and expertise on which they relied to form their opinions and provided persuasive rationales.  Importantly, there is no competent medical evidence to the contrary.

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Lastly, the Board acknowledges that the medical opinions of record have not addressed whether the Veteran's claimed CFS was caused by his in-service tuberculosis.  However, the Board finds no such examination was required because the evidence does not indicate that the Veteran has a been diagnosed with CFS.  38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).  As such, the Board finds that a VA medical opinion addressing the abovementioned theory of entitlement is not necessary to decide the Veteran's claim.

Based on the foregoing, the Board finds that the Veteran does not have a diagnosis of CFS or of an undiagnosed illness, and as such, that the first Shedden requirement has not been met.  Thus, as the evidence is persuasively against the claim for entitlement to service connection for CFS, the benefit-of-the-doubt doctrine cannot be applied.  The claim is denied.  38 U.S.C. § 5107(b); Lynch, 999 F.3d at 1394.

 

 

S. HENEKS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	K. Justis, 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.