RESIDUALS OF TRAUMATIC BRAIN INJURY (TBI)

E. I. VELEZ · 2026 · Case ID: A26034215

MIXED

Summary

The Veteran, who served on active duty from January 1999 to April 2020, appeals the October 2020 rating decision. The Board granted service connection for Traumatic Brain Injury (TBI), finding the evidence in relative equipoise and resolving doubt in the Veteran's favor, despite conflicting VA opinions. Service connection for a back disability was also granted, based on in-service complaints and a favorable interpretation of pain with functional impairment, even without a specific diagnosis. However, claims for chest pain/costochondritis, left foot disability, and right foot disability were denied due to a lack of current disability or functional impairment, as the evidence preponderated against these claims. A 10 percent rating was granted for a right shoulder scar, finding it painful but not unstable, resolving doubt in the Veteran's favor. The claim for a compensable rating for tinea pedis was denied, as the evidence did not meet the criteria for a 10 percent rating under the General Rating Formula for the Skin, with the Board finding the evidence persuasively against the claim. Several issues were remanded for additional development, including constipation due to an inadequate VA opinion, and right hand/finger pain due to an inadequate examination and failure to address secondary service connection to a service-connected shoulder disability. Additionally, GERD and migraines were remanded to reassess severity without considering medication effects.

Rationale

Evidence in relative equipoise; Benefit of the doubt resolved in Veteran's favor; Favorable finding by AOJ regarding in-service treatment for head injury

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210503-156759

Full Decision Text

Citation Nr: A26034215
Decision Date: 04/14/26 Archive Date: 04/14/26

DOCKET NO. 210503-156759
DATE: April 14, 2026

ORDER

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

Entitlement to service connection for a back disability, however diagnosed, is granted.

Entitlement to service connection for chest pain/costochondritis is denied.

Entitlement to service connection for left foot disability is denied.

Entitlement to service connection for right foot disability is denied.

Entitlement to a 10 percent rating, but no higher, for surgical scar, right shoulder is granted, subject to the laws and regulations governing the payment of monetary benefits.

Entitlement to a compensable rating for tinea pedis is denied.

REMANDED

Entitlement to service connection for constipation is remanded.

Entitlement to service connection for right thumb pain is remanded.

Entitlement to service connection for right index finger pain is remanded.

Entitlement to service connection for right long finger pain is remanded.

Entitlement to service connection for right ring finger pain is remanded.

Entitlement to service connection for right little finger is remanded.

Entitlement to a compensable rating for gastroesophageal reflux disease (GERD) is remanded.

Entitlement to a compensable rating for migraines is remanded.

FINDINGS OF FACT

1. Resolving reasonable doubt in his favor, the Veteran has a TBI that was incurred during his active duty service.

2. The Veteran's back disability began during active duty service.

3. The evidence of record does not indicate the Veteran has a diagnosis of chest pain or costochondritis, or symptoms relating to such that causes impairment in earning capacity, at any point during the appeal period.

4. The evidence of record does not indicate the Veteran has a diagnosis of a left foot disability, or symptoms relating to such that causes impairment in earning capacity.

5. The evidence of record does not indicate the Veteran has a diagnosis of a right foot disability, or symptoms relating to such that causes impairment in earning capacity.

6. Resolving reasonable doubt in his favor, the evidence shows that the Veteran has a painful right shoulder scar.

7. The Veteran's tinea pedis of both feet has not been shown to have affected at least five percent of the entire body or exposed areas, nor has treatment of the condition required intermittent systemic therapy such as with corticosteroids or other immunosuppressive drugs.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a TBI have been met. 38 U.S.C. §§ 1110, 5107 (2024); 38 C.F.R. §§ 3.102, 3.303 (2025).

2. The criteria for entitlement to service connection for a back disability have been met. 38 U.S.C. §§ 1110, 5107 (2024); 38 C.F.R. §§ 3.102, 3.303 (2025).

3. The criteria for service connection for chest pain/costochondritis have not been met. 38 U.S.C. §§ 1110, 5107 (2024); 38 C.F.R. §§ 3.102, 3.303 (2025).

4. The criteria for service connection for a left foot disability have not been met. 38 U.S.C. §§ 1110, 5107 (2024); 38 C.F.R. §§ 3.102, 3.303 (2025).

5. The criteria for service connection for a right foot disability have not been met. 38 U.S.C. §§ 1110, 5107 (2024); 38 C.F.R. §§ 3.102, 3.303 (2025).

6. The criteria for a 10 percent disability rating (but no higher) for right shoulder scar have been met. 38 U.S.C. §§ 1155, 5107 (2024); 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (Code) 7804 (2025).

7. The criteria for a compensable rating for tinea pedis of both feet have not been met. 38 U.S.C. §§ 1155, 51077 (2024); 38 C.F.R. § 4.118, Code 7813 (2025).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 1999 to April 2020.

The rating decision on appeal was issued in October 2020 and constitutes an initial decision; therefore, the modernized
4); 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (Code) 7804 (2025).

7. The criteria for a compensable rating for tinea pedis of both feet have not been met. 38 U.S.C. §§ 1155, 51077 (2024); 38 C.F.R. § 4.118, Code 7813 (2025).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 1999 to April 2020.

The rating decision on appeal was issued in October 2020 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In his May 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board of Veterans' Appeals (Board) hearing was held on November 18, 2024, before the undersigned Veterans Law Judge; a transcript of the hearing is in the record.

Based on the foregoing, the Board may only consider the evidence of record at the time of the November 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his attorney at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

For all adjudicated issues: If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, he may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

For all remanded issues: Any evidence the Board could not consider will be considered by the AOJ in the adjudication of those issues. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Generally, a veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Service connection may be established for a Persian Gulf Veteran for a qualifying chronic disability which manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1).

A "Persian Gulf Veteran" is a veteran with active service in the Southwest Asia theater of operations during the Persian Gulf War. It is not in dispute that the Veteran served in the Persian Gulf while on active duty.

A "qualifying chronic disability" means a chronic disability resulting from the following: (i) an undiagnosed illness, or (ii) a medically unexplained chronic multisymptom illness (MUCMI) that is defined by a cluster of signs or symptoms (such as, but not limited to, chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders). 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317.

A MUCMI means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, are not considered medically unexplained. 38 C.F.R. § 3.317(a).

"Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Signs or symptoms which may be manifestations of an undiagnosed illness or MUCMI include, but are not limited to, fatigue and headaches. 38 C.F.R. § 3.317. Objective medical evidence is not required. Gutierrez v Principi, 19 Vet. App. 1, 9 (2004).

Where lay evidence is competent, the Board must weigh the competent lay evidence against the other evidence of record in determining credibility. Buchanan v. Nicholson, 451 F.3d 1331, 1334-37 (Fed. Cir. 2006). However, the absence of corroborating records is an insufficient basis on which to find lay statements not credible. Id. at 1337.

Competent lay evidence means any evidence not requiring the proponent to have specialized education, training, or experience, but is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. ?38 C.F.R. § 3.159(a)(2). ?Generally, lay evidence is competent regarding a disease with "unique and readily identifiable features" that is "capable of lay observation." ?See Barr v. Nicholson,?21?Vet. App.?303, 308-09?(2007); Jandreau v. Nicholson,?492 F.3d 1372, 1376-77?(Fed. Cir. 2007). ?

A claimant is entitled to the benefit of the doubt when the positive and negative evidence is in approximate balance, which includes but is not limited to equipoise. See Lynch v. McDonough, 999 F.3d 1391, 1394 (Fed. Cir. 2021).

1. Entitlement to service connection for TBI

The Veteran's service treatment records (STRs) show that he sustained a TBI/concussion in 2007 while deployed, following a blast. He had another head injury after passing out and hitting his head on a bathroom sink.

In May 2020, the Veteran underwent a second level TBI evaluation consultation. During the consultation, he reported one serious OEF/OIF/OND deployment-related injury that occurred in 2007 that resulted in a blunt trauma. He did not lose consciousness but had a period of disorientation/confusion immediately following the incident. The VA provider determined that the Veteran sustained a TBI during deployment but that the current clinical symptom presentation was more consistent with behavioral health conditions. However, the report very clearly states that the Veteran is diagnosed with TBI and that he suffered a concussion without loss of consciousness during his deployment.

The August 2020 VA examiner concluded that the Veteran did not have a TBI or any residual of a TBI, while noting that the Veteran continues to have migraine headaches since his concussion during service. "He does not have any other signs of TBI." The examiner noted that the Veteran's memory was good and his judgment problems were more likely due to a behavioral health condition. Additionally, his "noise sensitivity, nausea symptoms are due to [m]igraine headaches."

The AOJ has entered a favorable finding that the Veteran received treatment for a head injury in service. See October 2020 rating decision. Under the AMA, the Board is bound by favorable findings by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104 (c).

In view of the totality of the evidence, the Board finds that the evidence is in relative equipoise as to whether the Veteran has a diagnosis of a TBI. Thus, resolving doubt in his favor,
's memory was good and his judgment problems were more likely due to a behavioral health condition. Additionally, his "noise sensitivity, nausea symptoms are due to [m]igraine headaches."

In view of the totality of the evidence, the Board finds that the evidence is in relative equipoise as to whether the Veteran has a diagnosis of a TBI. Thus, resolving doubt in his favor, the Board finds that it is at least as likely as not that the Veteran has a TBI and that such was incurred during his active duty service. Based on the foregoing, service connection for TBI is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310; Gilbert v. Derwinski,?1?Vet. App.?49?(1990).

2. Entitlement to service connection for a back disability

The Veteran's STRs include complaints of back pain. An April 2002 STR notes a diagnosis of mild lumbosacral sprain following the Veteran's report of back pain for one month. In an August 2010 post-deployment assessment, the Veteran reported back pain. In October 2016, he was diagnosed with sciatica following complaints of low back pain and sciatic nerve pain. During his May 2019 retirement report of medical history, he reported back pain.

During his September 2020 VA back examination, the Veteran reported intermittent low back pain since 2017 with no recent changes. His range of motion was normal with no pain noted on examination.

During his July 2024 Board hearing, the Veteran testified that he had back pain in 2008.

The Board acknowledges that post-service medical treatment records do not contain a diagnosis for back disability. However, pain with functional impairment can be considered a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Board finds it significant that the Veteran reported back pain on his service separation report of medical history and continues to note back pain. Thus, after resolving reasonable doubt in his favor, the Board concludes that the Veteran's back disability, however diagnosed, was incurred during service, and that service connection for such is warranted.

3. Entitlement to service connection for left foot disability

4. Entitlement to service connection for right foot disability

The Veteran's STRs include complaints of bilateral foot pain, and diagnoses of stress fractures and plantar fasciitis. However, his July 2019 retirement report of medical examination noted normal feet. Plantar fasciitis was listed in the "Summary of Defects and Diagnoses" section; under "Recommendations[,]" however, there were no further specialty consultations or referrals indicated, and the Veteran was encouraged to follow-up with any continued concerns with his primary care manager (PCM) until separation. In his May 2019 report of medical history, he reported foot trouble, specifically pain in the feet from it being broken in 2002, and numbness in his feet. The provider noted that the Veteran had not been seen for any orthopedic encounters (other than his back) and advised the Veteran to follow-up with any additional concerns.

During his September 2020 VA foot conditions examination, the Veteran reported the onset of bilateral foot pain in 2015. He was seen by podiatry and diagnosed with plantar fasciitis; he was treated with inserts and stretches and the condition resolved. He also had a stress fracture of the left third metatarsal in 2007, which resolved. The Veteran denied any current symptoms or treatment. He denied any pain, flare-ups, or functional loss/impairment of either foot. No diagnosis was provided.

During his November 2024 Board hearing, the Veteran testified as to issues with his feet during service but could not recall mentioning any current issues to his treatment providers. He testified that he buys insoles with arches, but confirmed that he had not formally been diagnosed with flat feet.

Generally, in the absence of proof of a present disability for which service connection is sought, there is no valid claim of service?connection. See Brammer v. Derwinski,?3?Vet. App.?223?(1992). Where pain causes functional impairment, however, a disability for VA compensation purposes exists even if there is no underlying diagnosis.?Saunders,?
loss/impairment of either foot. No diagnosis was provided.

Generally, in the absence of proof of a present disability for which service connection is sought, there is no valid claim of service?connection. See Brammer v. Derwinski,?3?Vet. App.?223?(1992). Where pain causes functional impairment, however, a disability for VA compensation purposes exists even if there is no underlying diagnosis.?Saunders,?886 F.3d at 1356. In this case, the Veteran has not alleged that his claimed disability has caused functional impairment in his earning capacity. ?As such, the instant case is distinguishable from?Saunders.

As the initial element of any service?connection?claim (a current disability) has not been met, further analysis of the claim is not necessary. ?In reaching the decision to?deny?this issue, the Board has considered the benefit-of-the-doubt doctrine; however, as the evidence is persuasively against the claim, that doctrine is not applicable.?38 U.S.C. § 5107; Gilbert,?1?Vet. App. at?49.

5. Entitlement to service connection for chest pain/costochondritis

The Veteran's STRs include complaints of chest pain. See February 2002 STR. Another STR listed costochondritis (Tietze's Syndrome) as a chronic illness, beginning in June 2008.

In a June 2009 health assessment, the Veteran denied heart trouble or chest pain. In June and August 2010 post-deployment health assessments, he denied chest pain or pressure. In a December 2012 pre-procedure questionnaire, he denied angina or chest pain.

During his May 2019 separation report of medical history, the Veteran denied any pain or pressure in his chest or any heart trouble or murmur; however, he reported having a pounding heart rate approximately four times a week. The provider noted that the Veteran was treated for this and was stable with no recent encounters. His chest x-ray was normal. Costochondritis was listed in the "Summary of Defects and Diagnoses" section; however, under "Recommendations[,]" there were no further specialty consultations or referrals indicated, and the Veteran was encouraged to follow-up with any continued concerns with PCM until separation.

During his September 2020 VA respiratory conditions examination, the Veteran reported the onset of chest wall pain in 2013 while having a significant cough; he was diagnosed with costochondritis and treated with nonsteroidal anti-inflammatory drugs. The condition resolved without further complaint; the Veteran denied any current treatment. The examiner determined that no diagnosis was warranted since the Veteran's condition was acute only in 2013.

During his November 2024 Board hearing, the Veteran testified that he was prescribed albuterol because he was having chest pain when he was coughing. The Board recognizes that there is some question, based on this testimony, as to whether the Veteran sought service connection for chest pain or for a respiratory disability. However, the Board concludes that there is no basis to recharacterize the issue as it currently stands because there has not been enough evidence presented to determine that the Veteran initially sought service connection for a respiratory disability. In his January 2020 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, the Veteran very clearly wrote "Chest Pain/Costochondritis"; there was no mention of any type of respiratory disability or indication that the Veteran meant something other than chest pain.

Generally, in the absence of proof of a present disability for which service connection is sought, there is no valid claim of service connection. See Brammer, 3 Vet. App.?at 223. Where pain causes functional impairment, however, a disability for VA compensation purposes exists even if there is no underlying diagnosis. Saunders,?886 F.3d at 1356. In this case, the Veteran has not alleged that his claimed disability has caused functional impairment in his earning capacity. ?As such, the instant case is distinguishable from?Saunders.

As the initial element of any service?connection?claim (a current disability) has not been met, further analysis of the claim is not necessary. ?In reaching the decision to deny this issue, the Board has considered the benefit-of-the-doubt doctrine; however, as the evidence is persuasively against the claim, that doctrine is not applicable.?38 U.S.C. § 5107; Gilbert,?1?Vet
purposes exists even if there is no underlying diagnosis. Saunders,?886 F.3d at 1356. In this case, the Veteran has not alleged that his claimed disability has caused functional impairment in his earning capacity. ?As such, the instant case is distinguishable from?Saunders.

Increased Ratings

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Individual disabilities are assigned separate diagnostic codes. See U.S.C. §1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7.

In evaluating a disability's severity, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period, a practice known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999).

The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation. See 38 C.F.R. §§ 3.951, 3.957.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

6. Entitlement to a compensable rating for a right shoulder surgical scar

The Veteran seeks a compensable disability rating for service-connected right shoulder scar. He is currently rated under Code 7802, which addresses burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. Under Code 7802, a 10 percent rating is assigned for an area or areas of 144 square inches (929 sq. cm.) or greater.

Under Code 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful. 38 C.F.R. § 4.118, Code 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Id. at Note (1). An additional 10 percent may be added if a scar is both unstable and painful. Id. at Note (2).

The Board finds that a 10 percent disability rating is appropriate. The September 2020 VA shoulder examiner noted a scar related to the Veteran's right shoulder disability that was not painful or unstable, did not have a total area equal to or greater than 39 square centimeters, and was not located on the head, face, or neck. Specifically, the scar was located on the right upper forearm and measured 4.5 centimeters by .2 centimeters. However, at his November 2024 Board hearing, the Veteran testified that his scar is approximately three to four inches. It was not painful, but "every now and then[,] it does have a tendency of having sharp pain in that area." It causes limitation of motion in the sense that he can no longer do certain exercises. The Veteran is competent to testify to such lay observable symptomatology, and the Board finds his statements to be credible. Jandreau, 492 F.3d at 1372. The Board notes that the Veteran does not contend that his scars are both unstable and painful.

Given the foregoing, the Veteran's scar is more appropriately rated under Code 7804 given his reports of having a tendency of sharp pain in that area. Resolving reasonable doubt in his favor, the Board concludes that the Veteran has a painful, but not unstable scar, during the period on appeal. Accordingly, he meets the criteria for a 10 percent disability rating, but no higher.

7. Entitlement to a compensable rating for tinea pedis

The Veteran currently has a noncompensable rating for his tinea pedis of both feet under Code 7813.

Code 7813 (evaluation of dermatophytosis) will be rated under a General Rating Formula for the Skin ("General Rating Formula"). See 38 C.F.R. § 4.118, Code 7813.

The General Rating Formula provides that a noncompensable rating is assigned for a skin condition for which no more than topical therapy is required over the past 12-month period and at least one of the following (1) characteristic lesions involving less than five percent of the entire body affected; or (2) characteristic lesions involving less than five percent of exposed areas affected. Or rate as disfigurement of the head, face, or neck (Code 7800) or scars (7801, 7802, 7804, or 7805), depending upon the predominant disability. See 38 C.F.R. § 4.118, General Rating Formula.

A 10 percent rating will be assigned if the disability meets one of the following: (i) characteristic lesions involving at least five percent, but less than 20 percent, of the entire body affected; or (ii) at least five percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent and a 60 percent rating will be assigned if characteristic lesions cover more percentage of the entire body or exposed area with more advanced treatment. Id.

The Board finds that the weight of the evidence is against a compensable rating for bilateral tinea pedis of the feet as there is no evidence that at any time under consideration the Veteran's tinea pedis of either foot affected at least five, but less than 20, percent of the entire body or exposed areas, or required intermittent systemic therapy such as with corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period, criteria required for a 10 percent rating under the General Rating Formula.

To this end, a September 2020 VA skin examination report reflects that the Veteran's tinea pedis affected less than five percent of the total body area and exposed area, and that the use of intermittent systemic therapy was not shown. The Veteran denied any treatment with medications and reported no visits to dermatology or his primary care physician for years for any skin complaint. The examiner specifically noted that the Veteran's skin condition did not cause scarring.

During his November 2024 Board hearing, the Veteran testified to using athlete's foot cream and powder on his feet every day; he reported scarring around his toes, between his toes, and along the arch of the foot. He testified that VA sent him to a specialist who helped, but only for a few days.

The Board acknowledges the Veteran's testimony but also notes that there is no evidence of any scarring of the Veteran's bilateral feet. However, even if the
use of intermittent systemic therapy was not shown. The Veteran denied any treatment with medications and reported no visits to dermatology or his primary care physician for years for any skin complaint. The examiner specifically noted that the Veteran's skin condition did not cause scarring.

The Board acknowledges the Veteran's testimony but also notes that there is no evidence of any scarring of the Veteran's bilateral feet. However, even if the Board were to consider the Veteran's testimony, there is no evidence that such scarring had an area of 144 square inches or greater, which would warrant a 10 percent rating under Code 7803 (for scars not of the head, face, or neck, that are not associated with underlying soft tissue damage) or that such scars are painful or unstable, which would warrant a compensable rating under Code 7804. There is also no evidence, even considering the Veteran's testimony, that his tinea pedis results in characteristic lesions involving at least five percent of the entire body or of exposed areas affected. Additionally, while the Veteran testified to seeing a specialist for his tinea pedis, there is no evidence of such a referral in his claim file.

Based on the foregoing, the Board finds that the evidence of record does not support a compensable rating for the Veteran's tinea pedis at any point during the period on appeal. The Veteran's tinea pedis affects his feet alone, covers less than five percent of his total skin area, and has required no greater than topical therapy. The evidence does not indicate that the Veteran requires immunosuppressive or systemic drugs to treat his tinea pedis. There is nothing in the record to support a compensable rating under the applicable rating criteria.

The Board has also considered whether a compensable rating is warranted under any other diagnostic code pertaining to the skin but concludes that a compensable rating under those Codes is not applicable in this case. Accordingly, a compensable rating is not warranted for the Veteran's tinea pedis at any time during the period on appeal. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the evidence is persuasively against the claim, that doctrine does not apply, and the claim is denied. See 38 U.S.C. § 5107.

REASONS FOR REMAND

1. Entitlement to service connection for constipation

This issue is remanded to correct a duty to assist error that occurred prior to the rating decision on appeal. Specifically, although the AOJ obtained a medical opinion, the Board finds this opinion inadequate. The September 2020 VA examiner concluded that the Veteran does not have a diagnosis of constipation but also that he has never been evaluated for any intestinal complaint by gastroenterology, calling the Veteran's complaints "subjective only." The Board finds this opinion inadequate to the extent that it failed to consider the Veteran's service in the Persian Gulf. Accordingly, a remand is necessary.

2. Entitlement to service connection for right thumb pain

3. Entitlement to service connection for right index finger pain

4. Entitlement to service connection for right long finger pain

5. Entitlement to service connection for right ring finger pain

6. Entitlement to service connection for right little finger pain

During his September 2020 VA examination, the Veteran reported hand and finger pain. The examiner determined that there was no objective evidence in the STRs or on examination to support the claim of a hand condition. Because the Veteran's reports were subjective only, no diagnosis was warranted. The Board finds this examination inadequate as it is based on an inaccurate factual premise, since the Veteran's STRs document reports of right hand and finger pain. Additionally, as discussed above, where pain causes functional impairment, a disability for VA compensation purposes exists even if there is no underlying diagnosis. See Saunders,?886 F.3d at 1356. Accordingly, a new examination is warranted.

Additionally, a remand is also necessary to correct a duty to assist error that occurred prior to the rating decision on appeal. Specifically, the AOJ did not obtain a VA examination regarding whether such disabilities are caused or aggravated by the Veteran's service-connected right shoulder bicipital tendon tear with degenerative arthritis ("right shoulder disability"). However, based on the evidence associated with the claim file prior to the rating decision on appeal, the Board finds that a VA examination/ medical opinion is required to determine whether any (or all) of the Veteran's right finger disabilities
VA compensation purposes exists even if there is no underlying diagnosis. See Saunders,?886 F.3d at 1356. Accordingly, a new examination is warranted.

Additionally, a remand is also necessary to correct a duty to assist error that occurred prior to the rating decision on appeal. Specifically, the AOJ did not obtain a VA examination regarding whether such disabilities are caused or aggravated by the Veteran's service-connected right shoulder bicipital tendon tear with degenerative arthritis ("right shoulder disability"). However, based on the evidence associated with the claim file prior to the rating decision on appeal, the Board finds that a VA examination/ medical opinion is required to determine whether any (or all) of the Veteran's right finger disabilities are caused or aggravated by his service-connected right shoulder disability.

7. Entitlement to a compensable rating for GERD

8. Entitlement to a compensable rating for migraines

In reviewing the Veteran's VA examinations and VA treatment records, it is clear that he takes medications to treat his service-connected GERD and migraines. It is not clear to what extent the examiners considered the ameliorative effects of medication when determining the severity of the Veteran's GERD and migraines. Accordingly, a medical examination is required that does not consider the ameliorative effects of any medication which the Veteran takes for these service-connected disabilities.

The matters are REMANDED for the following action:

1. Arrange for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) of the Veteran to determine the nature of his constipation. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, and interview and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following:

(a) Can the Veteran's complaints/reports of constipation be attributed to a known clinical diagnosis?

(b) If yes, then for EACH diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood?

(c) If the answer to (a) is yes, then for EACH diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood?

The determinations required under (b) and (c) must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole.

(d) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's diagnosed condition was incurred in, or is otherwise related to, his active duty service?

The examiner must consider the Veteran's total potential exposure through all applicable military deployments, as well as the synergistic, combined effect of all toxic exposure risk activities.

(e) Are any of the Veteran's symptoms and disability patterns objective indications of manifestations of a chronic undiagnosed illness?

(f) Alternatively, does the Veteran's constipation result in symptoms that cause functional impairment, and if so, what are the Veteran's symptoms?

(g) If the Veteran's constipation results in symptoms that cause functional impairment, then is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such is related to the Veteran's service?

(h) If the Veteran's constipation results in symptoms that cause functional impairment, are the symptoms attributable to irritable bowel syndrome (IBS) or another functional gastrointestinal disorders and/or another medically unexplained chronic multisymptom illness?

The examiner must provide a thorough explanation (rationale) for all opinions, citing to supporting factual data and/or medical literature, as appropriate.

2. Arrange for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) of the Veteran to determine the nature of his right thumb, index finger, long finger, ring finger, and little finger pain. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, and interview and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following:

(a) Can the Veteran's complaints/reports of pain in the fingers of his right hand be attributed to a known clinical diagnosis?

(b) If yes, then for EACH diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood?

(c) If the answer to (a) is yes, then for EACH diagnosis, is the pathophysiology of the Veteran's condition (
finger, and little finger pain. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, and interview and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following:

(a) Can the Veteran's complaints/reports of pain in the fingers of his right hand be attributed to a known clinical diagnosis?

(b) If yes, then for EACH diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood?

(c) If the answer to (a) is yes, then for EACH diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood?

The determinations required under (b) and (c) must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole.

The examiner must consider the Veteran's total potential exposure through all applicable military deployments, as well as the synergistic, combined effect of all toxic exposure risk activities.

(e) Are any of the Veteran's symptoms and disability patterns objective indications of manifestations of a chronic undiagnosed illness?

In answering the foregoing, the examiner's attention is directed to the following:

- A January 2013 STR that notes right hand pain beginning after redeployment.

- A February 2013 STR that notes pain over the thenar eminence and radial aspect of the right thumb

- An October 2014 STR that notes a complaint of numbness and tingling in the right thumb in relating to complaints of right shoulder pain.

3. Arrange for a telehealth interview with the Veteran (with complete examination only if deemed necessary) by an appropriate clinician who can assess the severity of his service-connected GERD and migraines. The clinician must review the entire record in conjunction with the interview and note such review was conducted. Pathology, symptoms (frequency and severity), and any associated impairment of function should be described in detail without considering the ameliorative effects of medication. Based on review of the record and interview and/or examination of the Veteran, the clinician should provide an opinion with detailed rationale that responds to the following:

(a) Identify the severity of the Veteran's GERD throughout the entire appeal period. The clinician must document what the Veteran's symptoms would be without using medication to treat his GERD.

(b) Identify the severity of the Veteran's migraines throughout the entire appeal period. The clinician must document what the Veteran's symptoms would be without using medication to treat his migraines.

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The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board.

E. I. VELEZ

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board T. Matta, 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.

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