CHRONIC FATIGUE SYNDROME

MICHAEL A. PAPPAS · 2026 · Case ID: A26034389

MIXED

Summary

The veteran, who served from February 7, 2006, to February 6, 2010, appeals the denial of service connection for chronic fatigue syndrome (CFS), hypersomnia, narcolepsy, varicose veins, panic disorder, and degenerative arthritis in the left ankle. The veteran also appeals the denial of service connection for costochondritis and weight gain/obesity, claiming these conditions are secondary to his service-connected obstructive sleep apnea (OSA). The Board denied claims for CFS, hypersomnia, narcolepsy, varicose veins, and panic disorder, finding no current diagnosis or sufficient evidence to establish a link to service or to his service-connected OSA. For CFS, the Board noted the lack of diagnosis in service treatment records and the negative findings in a May 2023 Gulf War examination, concluding the veteran was not competent to diagnose CFS. For hypersomnia and narcolepsy, the Board found no current diagnosis or persistent symptoms separate from OSA, and no pre-decisional error in not ordering additional VA exams. Varicose veins and panic disorder claims were denied due to lack of current diagnosis or persistent symptoms, and the benefit-of-the-doubt rule was found inapplicable as evidence weighed against the claims. Service connection for degenerative arthritis in the left ankle was granted as secondary to the service-connected right ankle disability, based on the Board's finding that the Veteran's pain and functional impairment from the left ankle could not be satisfactorily disassociated from the right ankle condition, citing medical literature on compensatory postural changes. The claims for costochondritis and weight gain/obesity secondary to OSA were remanded due to inadequate medical opinions, specifically the lack of rationale for denying a link to OSA for costochondritis and the need for an opinion on whether obesity is secondary to OSA, considering recent CAVC precedent.

Rationale

No current diagnosis of CFS in service treatment records.; No current diagnosis of CFS in post-service medical records.; May 2023 Gulf War examination found no signs/symptoms of undiagnosed illness.; Veteran not competent to diagnose CFS.; Evidence weighs against finding of CFS.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251211-630525

Full Decision Text

Citation Nr: A26034389
Decision Date: 04/14/26 Archive Date: 04/14/26

DOCKET NO. 251211-630525
DATE: April 14, 2026

ISSUES

1. Entitlement to service connection for chronic fatigue syndrome.

2. Entitlement to service connection for hypersomnia.

3. Entitlement to service connection for narcolepsy.

4. Entitlement to service connection for varicose veins in leg.

5. Entitlement to service connection for panic disorder.

6. Entitlement to service connection for degenerative arthritis in ankle, left.

7. Entitlement to service connection for costochondritis.

8. Entitlement to service connection for weight gain, to include obesity.

ORDER

Entitlement to service connection for chronic fatigue syndrome (CFS) is denied.

Entitlement to service connection for hypersomnia is denied.

Entitlement to service connection for narcolepsy is denied.

Entitlement to service connection for varicose veins in leg is denied.

Entitlement to service connection for panic disorder is denied.

Entitlement to service connection for a left ankle disability manifested by pain as secondary to a right ankle disability is granted, subject to the laws and regulations governing the payment of monetary benefits.

REMANDED

Entitlement to service connection for costochondritis is remanded.

Entitlement to service connection for weight gain, to include obesity as secondary to service-connected obstructive sleep apnea is remanded.

FINDINGS OF FACT

1. The Veteran does not have a current diagnosis of CFS

2. The evidence of record persuasively weighs against finding that the Veteran has had CFS at any time during or approximate to the pendency of the claim; and his symptoms of fatigue are not shown to be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness attributable to service in the Persian Gulf.

3. The Veteran does not have a current diagnosis of hypersomnia.

4. The evidence of record persuasively weighs against finding that the Veteran has had hypersomnia, separate from his already service-connected obstructive sleep apnea, at any time during or approximate to the pendency of the claim.

5. The Veteran does not have a current diagnosis of narcolepsy.

6. The evidence of record persuasively weighs against finding that the Veteran has had narcolepsy at any time during or approximate to the pendency of the claim.

7. The Veteran does not have a current diagnosis of varicose veins.

8. The evidence of record persuasively weighs against finding that the Veteran has had varicose veins any time during or approximate to the pendency of the claim.

9. The Veteran does not have a current diagnosis of panic disorder.

10. The evidence of record persuasively weighs against finding that the Veteran has had a panic disorder at any time during or approximate to the pendency of the claim.

11. The Veteran's left ankle disability, manifested by pain causing functional impairment rising to the level of impacting earning capacity, cannot be satisfactorily disassociated from his service-connected right ankle disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness, medically unexplained chronic multisymptom illness or as secondary to service-connected sleep apnea have not been met. 38 U.S.C. §§ 1110, 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317, 4.88a.

2. The criteria for entitlement to service connection for hypersomnia, to include as secondary to service-connected obstructive sleep apnea has not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for entitlement to service connection for narcolepsy, to include as secondary to service-connected sleep apnea has not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for entitlement to service connection for varicose veins, to include as secondary to service-connected sleep apnea has not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. The criteria for entitlement to service connection for a panic disorder, to include as secondary to service-connected sleep apnea has not been met. 38 U.S.C. §§ 1110, 5107
38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. The criteria for entitlement to service connection for a panic disorder, to include as secondary to service-connected sleep apnea has not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

6. The criteria for service connection a left ankle disability as secondary to a right ankle disability have been met. 38 U.S.C. §§ 1110, 5107, 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from February 7, 2006 to February 6, 2010.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2025 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO).

In the December 2025, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. The Board notes that while the Veteran indicated he was appealing a September 2025 rating decision on his VA Form 10182, the Veteran requested higher level review of this rating decision, which resulted in the January 2025 rating decision. Hence, the Board construes the Veteran's VA Form 10182 as appealing the January 2025 rating decision, which incorporates all of the evidence the RO considered in the September 2025 rating decision, including the Veteran's contentions raised in his January 2025 Higher-Level Review (HLR), Informal Conference with the Agency of Original Jurisdiction (AOJ). The Board notes that the Veteran's representative cites the January 2025 rating decision in his Informal Hearing Presentation (IHP), referencing the Veteran's contentions depicted in the January 2025, HLR, Informal Conference. See March 27, 2026, IHP.

Therefore, the Board may only consider the evidence of record at the time of January 2025 rating decisions on appeal. 38 C.F.R. § 20.301. If evidence was submitted after the AOJ issued the rating decision on appeal, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the 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.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 C.F.R. §§ 1110, 1131. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995).

For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (
for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995).

For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection.

An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on an undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are considered competent to report objective signs of illness. Id.

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. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of an undiagnosed illness or a medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b).

A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A medically unexplained chronic multisymptom illness 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 will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii).

For VA purposes, a diagnosis of chronic fatigue syndrome requires: (1) new onset of debilitating fatigue severe enough to reduce daily activities to less than 50 percent of the usual level for at least six months; (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: (i) acute onset of the condition; (ii) low grade fever; (iii) nonexudative pharyngitis; (iv) palpable or tender cervical or axillary lymph nodes; (v) generalized muscle aches or weakness; (vi) fatigue lasting 24 hours or longer after exercise; (vii) headaches (of a type, severity or pattern that is different from headaches in the premorbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, and/or (x) sleep disturbance. 38 C.F.R. § 4.88(a).

Entitlement to service connection for chronic fatigue syndrome.

The Veteran asserts that he has chronic fatigue syndrome as a result of his service-connected obstructive sleep apnea. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference. The Board notes that the Veteran is also a Persian Gulf Veteran and has considered whether there is evidence that
; (vii) headaches (of a type, severity or pattern that is different from headaches in the premorbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, and/or (x) sleep disturbance. 38 C.F.R. § 4.88(a).

Entitlement to service connection for chronic fatigue syndrome.

The Veteran asserts that he has chronic fatigue syndrome as a result of his service-connected obstructive sleep apnea. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference. The Board notes that the Veteran is also a Persian Gulf Veteran and has considered whether there is evidence that the Veteran's claimed disability is an undiagnosed illness or a medically unexplained chronic multisymptom illnesses. See 38 U.S.C. § 1117 and 38 C.F.R. § 3.317.

Discussion and Analysis

The Veteran's service treatment records are silent for any signs, symptoms, treatment for, or diagnosis of chronic fatigue syndrome. The Veteran was diagnosed with sleep apnea during service, for which he has been service connected. See March 11, 2011, Rating decision, effective February 7, 2010, the day following his discharge from service.

The Board notes that in March 2024, after obtaining necessary authorization, the RO requested private treatment records that the Veteran indicated were relevant to his claim (Eye Site Center, Sun-Hill Optical and Dr. T.). See March 2024, Notification Letter. The Board notes that Dr. T did not respond to this request. As efforts have been made to obtain these records, the Board finds that it has met its duty to assist and will proceed with the current evidence available

In a May 2023 Gulf War examination, a VA examiner documented that there were no diagnosed illnesses for which no etiology was established. The examiner reported that there were no additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptomatic illnesses (to include fatigue, neurological signs or symptoms neuropsychological signs or symptom, sleep disturbances, etc.) The examiner reported that the Veteran did not have any additional signs and/or symptoms that impact his ability to work that are not addressed in other questionnaires. See May 2023, Gulf War Examination.

As there was no diagnosis of a disability, the Veteran's signs and symptoms could not be considered a medically unexplained chronic multisymptom illness. See 38 C.F.R. § 3.317(a)(2)(ii). Service connection under this regulation still requires the finding of a disability, and here, the evidence weighs against a finding of the contended CFS. The examiner also determined were no additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptomatic illnesses

The Board has reviewed the Veteran's private and VA treatment records; however, the Board observes that there are no private or VA medical records which confirm a diagnosis of chronic fatigue syndrome. The Board acknowledges the Veteran's argument that he has CFS due to his service-connected obstructive sleep apnea. The Board also acknowledges the representative's argument that the Veteran manifests signs and symptoms of CFS. The Board notes that the representative has not pointed to any evidence in the claims file prior to the rating decision on appeal indicating the Veteran carries a diagnosis of CFS. Here, the Board finds the May 2023 Gulf War examination probative as to whether the Veteran carries a current diagnosis of CFS.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). Absent proof of a current disability, there can be no valid claim, for a direct service or secondary service theory of entitlement. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Here, the evidence does not establish that the Veteran has a current diagnosis of CFS. In the absence of a current disability, the analysis ends, and the claim of entitlement to service connection for CFS, to include as secondary to sleep apnea, must be denied. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, supra.

The Board acknowledges that the Veteran believes he has a current diagnosis of CFS that is related to his service or in the alternative, his service connected OSA.
. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Here, the evidence does not establish that the Veteran has a current diagnosis of CFS. In the absence of a current disability, the analysis ends, and the claim of entitlement to service connection for CFS, to include as secondary to sleep apnea, must be denied. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, supra.

The Board acknowledges that the Veteran believes he has a current diagnosis of CFS that is related to his service or in the alternative, his service connected OSA. See January 2025, Higher Level Review Conference; see also, March 27, 2026, Informal Hearing Presentation (IHP). The Board must determine on a case-by-case basis whether a particular medical issue is within the competence of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran in this case is not shown to possess any pertinent medical training or expertise that would make him competent to render an opinion as to the diagnosis of CFS. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Making this determination requires specific knowledge of the onset and development of disabilities in the body system. Thus, to the extent that the Veteran's lay statements express an opinion that he has CFS and they are not competent medical opinions and cannot be assigned any probative weight.

In sum, the Board finds that evidence of record persuasively weighs against finding that the Veteran has had CFS at any time during or approximate to the pendency of the claim; and his symptoms of fatigue are not shown to be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness attributable to service in the Persian Gulf. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).

Accordingly, the benefit of the doubt doctrine is not for application, and the claims for service connection must be denied. 38 U.S.C. § 5107.

Entitlement to service connection for hypersomnia.

Entitlement to service connection for narcolepsy.

The Veteran contends that his hypersomnia and narcolepsy claims are related to his service-connected obstructive sleep apnea. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference.

The Veteran's service treatment records are silent for any signs, symptoms, treatment for, or diagnosis of hypersomnia or narcolepsy. The Veteran was diagnosed with sleep apnea during service, for which he has been service connected. See March 11, 2011, Rating decision, effective February 7, 2010, the day following his discharge from service.

The Board notes that post service medical records do not contain any evidence of treatment for or a diagnosis or hypersomnia or narcolepsy. The Board notes that in a May 2023 Sleep apnea examination, the Veteran's diagnosis of sleep apnea was confirmed. The examiner indicated that the Veteran's sleep apnea was productive of persistent day time hypersomnolence, snoring and witnessed apnea. The Board notes that the Board notes there are no private or VA medical records which confirm a diagnosis of hypersomnia or narcolepsy.

Upon review of the evidence, the Board concludes that the Veteran does not have evidence of a diagnosis of hypersomnia or narcolepsy and has not had hypersomnia or narcolepsy at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).

The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown,
confirm a diagnosis of hypersomnia or narcolepsy.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). Absent proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992).

While the Veteran believes that he has a diagnosis or hypersomnia or narcolepsy, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and training. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not demonstrated he has the necessary medical training to render a diagnosis. The Board assigns probative weight to the May 2023 Sleep Apnea examination that documented the Veteran's hypersomnolence as attributable to his sleep apnea.

The Board observes that the Veteran was not afforded a VA examination for his hypersomnolence or narcolepsy claim. The Board acknowledges the argument from the Veteran's representative that an examination to evaluate the various aspects of his sleep disorder was required. A medical examination or opinion is considered necessary when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A.

The Board notes that the first element of McLendon requires competent evidence of a current disability or persistence or recurrent symptoms of a disability. Here, the Board does not find competent lay or medical evidence of record to indicate either a diagnosis of hypersomnia or narcolepsy-or persistent symptoms of hypersomnolence or narcolepsy-separate from the Veteran's already service-connected obstructive sleep apnea.

Hence, the Board does not find there was pre-decisional error in not providing an additional VA examination for this Veteran's service connection claims. As noted above, the evidence does not establish that the Veteran has a current diagnosis or persistent symptoms of hypersomnolence, or narcolepsy separate from his already service-connected obstructive sleep apnea. See March 2011 rating decision; see also, June 23, 2023, Rating Decision Narrative re: persistent daytime hypersomnolence. In the absence of a current disability, the analysis ends, and the claims of entitlement to service connection for sleep apnea must be denied. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, supra.

Entitlement to service connection for varicose veins.

The Veteran contends that his varicose veins are secondary to his obstructive sleep apnea. Alternately, the Veteran contends that his varicose veins began during service. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference.

The Veteran's service treatment records are silent for any signs, symptoms, treatment for, or diagnosis of varicose veins.

The Board notes that in March 2024, after obtaining necessary authorization, the RO requested private treatment records that the Veteran indicated were relevant to his claim (Eye Site Center, Sun-Hill Optical and Dr. T.). See March 2024, Notification Letter. The Board notes that Dr. T did not respond to this request. As efforts
ive sleep apnea. Alternately, the Veteran contends that his varicose veins began during service. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference.

The Veteran's service treatment records are silent for any signs, symptoms, treatment for, or diagnosis of varicose veins.

Post service, a review of the Veteran's private and VA treatment records includes no complaint, treatment or diagnosis for varicose veins. Therefore, the Board finds that the first element of service connection (a current disability), has not been met.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). Absent proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992).

While the Veteran believes that he has a diagnosis for varicose veins, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and training. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not demonstrated he has the necessary medical training to render a diagnosis.

The Board acknowledges that the Veteran has not been provided with a VA examination for his service connection claim for varicose veins. However, the elements of McLendon discussed earlier in this decision have not been met. The first element of McLendon requires competent evidence of a current disability or persistent or recurrent symptoms of a disability. The medical evidence of record includes no complaints of pain or recurrent symptoms associated with varicose veins. In his January 2025 Higher Level Review conference, the Veteran stated that this condition started in service; however, there is no competent evidence that the Veteran has a current disability or manifests persistent or recurrent symptoms of a varicose vein disability. Therefore, there was no pre-decisional duty to assist error in not providing an examination.

In reaching this conclusion, the Board has considered and applied the benefit-of-the-doubt rule. "When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant." 38 U.S.C. § 5107(b). "Evidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other." Lynch v. McDonough, 21 F. 4th 776 (Fed. Cir. 2021); see also Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001).

In this case, the evidence persuasively favors a finding that the Veteran has not shown any evidence of a diagnosis of varicose veins or persistent symptoms associated with varicose veins to warrant a VA examination. Thus, the benefit-of-the-doubt rule does not change the outcome on this issue. The claim is denied.

Entitlement to service connection for panic disorder.

The Veteran contends that his claimed panic disorder is secondary to his obstructive sleep apnea. Alternately, the Veteran contends that his panic disorder veins began during service. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference.

The Veteran's service treatment records are silent for any signs, symptoms, treatment for, or diagnosis for a panic disorder.

The Board notes that in March 2024, after obtaining necessary authorization, the RO requested private treatment records that the Veteran indicated were relevant to his claim (Eye Site Center, Sun-Hill Optical and Dr. T.). See March 2024, Notification Letter. The Board notes that Dr. T did not respond to this request. As
to his obstructive sleep apnea. Alternately, the Veteran contends that his panic disorder veins began during service. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference.

The Veteran's service treatment records are silent for any signs, symptoms, treatment for, or diagnosis for a panic disorder.

Post service, a review of the Veteran's private and VA treatment records includes no complaint, treatment or diagnosis for a panic disorder. The Board notes that in a March 30, 2020, Mental Disorders examination, the Veteran was diagnosed with an alcohol use disorder under Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There was no other psychiatric diagnosis rendered for the Veteran. The Veteran has since been denied service connection for an alcohol use disorder. Here, the Board finds that the first element of service connection (a current disability with respect to a panic disorder), has not been met.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). Absent proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992).

While the Veteran believes that he has a diagnosis for a panic disorder, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and training. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not demonstrated that he has the necessary medical training to render a psychiatric diagnosis.

The Board acknowledges that the Veteran has not been provided with an additional VA examination regarding his service connection claim for a panic disorder. However, the elements of McLendon discussed earlier in this decision have not been met. The first element of McLendon requires competent evidence of a current disability or persistent or recurrent symptoms of a disability.

In his January 2025 Higher Level Review conference, the Veteran stated that this condition started in service; however, there is no competent evidence that the Veteran has a current disability or manifests persistent or recurrent symptoms reflecting a panic order. Hence, the Board finds that there was no pre-decisional duty to assist error in not providing an examination for purposes of this service connection claim.

In this case, the evidence persuasively favors a finding that the Veteran has not shown any evidence of a diagnosis for a panic disorder to warrant a VA examination. Thus, the benefit-of-the-doubt rule does not change the outcome on this issue. The claim is denied.

Entitlement to service connection for degenerative arthritis in ankle, left.

The Veteran contends that service connection for a claimed left ankle disability is warranted as secondary to his service-connected right ankle, status post right ankle sprains. In his claim for service connection, the Veteran asserts that having to unevenly dispense his weight upon his left ankle because of my right ankles condition caused him to overcompensate, over work, and over stress the left ankle, and overtime, developing arthritis. Alternatively, the Veteran contends that this condition began during service. See March 3
diagnosis for a panic disorder to warrant a VA examination. Thus, the benefit-of-the-doubt rule does not change the outcome on this issue. The claim is denied.

Entitlement to service connection for degenerative arthritis in ankle, left.

The Veteran contends that service connection for a claimed left ankle disability is warranted as secondary to his service-connected right ankle, status post right ankle sprains. In his claim for service connection, the Veteran asserts that having to unevenly dispense his weight upon his left ankle because of my right ankles condition caused him to overcompensate, over work, and over stress the left ankle, and overtime, developing arthritis. Alternatively, the Veteran contends that this condition began during service. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference.

The Veteran's service treatment records are silent for any complaints, treatment or diagnosis for a left ankle disability. The Board notes that there are multiple service treatment records documenting injury and treatment for the Veteran's right ankle.

Post service, January 2022 VA treatment records indicate the Veteran has concerns with 7 out of 10 pain in both of his knee and ankles. It is noted that the Veteran states that at this time, he is currently not taking any over-the-counter pain medications.

In a May 2023, Ankle Conditions examination, the Veteran was diagnosed with the residuals of ankle injury status post right ankle sprain. The examiner noted the Veteran is service connected for residuals of ankle injury status post right ankle sprains. The examiner noted subjective/objective complaints of pain/tenderness in the left ankle.

In an April 2024 Ankle Conditions examination for his left ankle, the examiner did not render a diagnosis for the left ankle. The Veteran's right ankle was diagnosed as degenerative arthritis in the right ankle, post-traumatic. The examiner noted that the Veteran denied flare-ups of the ankle.

The examiner noted the Veteran's complaint that he has constant pain with difficulty on prolonged standing, walking, weight bearing and squatting. The examiner noted the Veteran's report that his ankles invert easily, more on the right than the left. The examiner reported that the Veteran applies ice, does range of motion exercises and takes ibuprofen. The Veteran denied using orthotics for the condition. The examiner documented that range of motion for the left ankle was all normal. The examiner Veteran was able to perform repetitive use testing with at least three repetitions. The examiner reported that there was no evidence of pain or objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue.

The examiner reported that there is no significant degenerative joint disease or significant or acute bony abnormality seen in the left ankle. The examiner noted that pes planus is likely present in the bilateral foot. The examiner noted that there is evidence of pain on passive range of motion testing. The examiner reported there is no evidence of pain when the joint is used in non-weight bearing.

Addressing functional impairment related to the condition listed in the diagnosis section, the examiner noted difficulty with prolonged standing, walking, weight bearing or squatting.

In an August 2024 medical opinion, the examiner rendered a negative nexus opinion for the left ankle. The examiner determined that the Veteran's left ankle condition was less likely than not, proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that there is no pathology to warrant a diagnosis.

The Board observes that the examiner's opinion does not take into consideration the degree of pain the Veteran experiences related to his left ankle and the degree of functional impairment related solely to the left ankle with respect to standing, walking, weight bearing or squatting. Upon review of VA treatment records and the March 2023 and April 2024 Ankle Condition reports, the Board finds that the Veteran's level of ankle pain and the resulting functional impairment rises to the level of impacting his earning capacity (i.e., standing, walking, weight bearing and squatting), and therefore constitutes a disability for VA compensation purposes. disability. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018).

With regards to a nexus to service or a service-connected disability, affording the Veteran reasonable doubt in his favor, the Board
related solely to the left ankle with respect to standing, walking, weight bearing or squatting. Upon review of VA treatment records and the March 2023 and April 2024 Ankle Condition reports, the Board finds that the Veteran's level of ankle pain and the resulting functional impairment rises to the level of impacting his earning capacity (i.e., standing, walking, weight bearing and squatting), and therefore constitutes a disability for VA compensation purposes. disability. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018).

With regards to a nexus to service or a service-connected disability, affording the Veteran reasonable doubt in his favor, the Board finds that the Veteran's left ankle disability has not been satisfactorily disassociated from his service-connected right ankle disability.

The Board notes that in an August 2024 Ankle Conditions examination for the right ankle, the examiner opined that the Veteran clearly and unmistakably has a degenerative arthritis of the right ankle condition as noted on right ankle x-rays dated April 22, 2024. The examiner stated that upon medical literature review on uptodate.com, it is noted that compensation for a major unilateral lower extremity dysfunction is frequently known to be the etiology or a contributing factor in many pathological conditions, that affect the knees, hips, ankles, feet and lower back to include the lower leg muscle groups. The examiner explained that with postural changes from an ankle condition which the Veteran clearly has, it can cause the individual to compensate and subsequently leads to a redistribution of weight with repetitive movements during ambulation. The examiner stated that overtime, the postural changes, additional pressure is placed on the joints and muscles can shift and become weak. The examiner stated that this leads to instability and causes misalignment of the lower extremities and causes chronic pain. See August 2024, Ankle Conditions Medical Opinion.

Tracking the rationale from the August 2024 Ankle Conditions examination, it is reasonable for the Board to infer-to a degree as likely as not-that the Veteran's left ankle disability was either caused or aggravated by his service-connected right ankle disability-i.e., "upon medical literature review on uptodate.com it is noted that compensation for a major unilateral lower extremity dysfunction is frequently known to be the etiology or a contributing factor in many pathological conditions, that affect the knees, hips, ankles...with postural changes from an ankle condition which the Veteran clearly has, it can cause the individual to compensate and subsequently leads to a redistribution of weight with repetitive movements during ambulation." See August 2024, Ankle Conditions Medical Opinion, pg. 2; see also, March 3, 2024, VA Form 21-526EZ.

The Board observes that while the August 2024 examiner rendered a negative nexus opinion due to the failure to recognize pain and resulting functional impairment rising to the level of impacting earning capacity as constituting a disability (in the absence of an underlying diagnosis), the examiner did afford medical reasoning sufficient to support a grant of service connection on a secondary service connection basis-upon the Board's factual finding of a left ankle disability. In sum, affording the Veteran all reasonable doubt in his favor, the Board finds that the Veteran's left ankle disability, manifested by pain causing functional impairment rising to the level of impacting earning capacity, cannot be satisfactorily disassociated from his service-connected right ankle disability. Therefore, the Board finds that his service connection claim is warranted, and the claim is hereby granted.

REASONS FOR REMAND

Entitlement to service connection for costochondritis is remanded

The Veteran contends that his costochondritis is secondary to his service-connected obstructive sleep apnea. See March 3, 2024, VA Form 21-526EZ; January 2025, Higher Level Review, Informal Conference; March 27, 2026, Informal Hearing Presentation (IHP).

The Board notes that the Veteran's service treatment records are silent for any complaint, treatment or diagnosis for costochondritis.

A March 2024 examiner confirmed the Veteran's diagnosis of costochondritis. See March 26, 2024, Bones and Other Skeletal Conditions examination.

In an August 2024 medical opinion, an examiner rendered a negative nexus opinion. The examiner determined that the Veteran clearly and unmistakably has a costochondritis condition as noted on compensation and pension exam dated March 26, 2024. The examiner reasoned that upon medical literature review on uptodate.com, costochondritis is not caused by obstructive sleep apnea. Therefore, the examiner concluded, the costochondritis condition is less likely than not proximately due to or the result of the sleep apnea condition.

The Board finds that the rationale for the negative nexus opinion is conclusory, offering no explanation as to
diagnosis of costochondritis. See March 26, 2024, Bones and Other Skeletal Conditions examination.

The Board finds that the rationale for the negative nexus opinion is conclusory, offering no explanation as to why costochondritis is not due to obstructive sleep apnea. The Board also notes that the examiner does not address whether the Veteran's costochondritis was aggravated by his service-connected obstructive sleep apnea. See El-Amin v. Shinseki, 26 Vet. App. at 140. Hence, the Board finds that the AOJ failed to obtain an adequate medical opinion prior to issuing the January 2025 rating decision. Relying on the inadequate August 2024 medical opinion constitutes a pre-decisional duty to assist error that must be remedied on remand. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

Entitlement to service connection for weight gain, to include obesity as secondary to obstructive sleep apnea is remanded.

The Veteran contends that his weight gain is due to service. Alternatively, the Veteran contends that his weight gain is secondary to his service-connected obstructive sleep apnea. See March 3, 2024, VA Form 21-526EZ; see also, January 2025, Higher Level Review, Informal Conference; March 27, 2026, Informal Hearing Presentation (IHP). The Board notes that although the Veteran asserted his claim as one for weight gain, the Board has expanded his claim to include obesity as the January 2025 rating decision found that the Veteran is obese. See Clemmons v. Shinseki, 23 Vet. App. 1 (2009).

The January 2025 rating decision on appeal found that the Veteran shows a history of weight gain and a Body Mass Index (BMI) of 41. The RO also noted that service connection cannot be granted on a secondary basis since obesity or weight gain alone is not considered a disability for purposes of secondary service connection.

However, in the recent precedential case of Adams v. Collins, 38 Vet. App. 273 (2025), the U.S. Court of Appeals for Veterans Claims (CAVC) noted that obesity is a disability if it results in a functional impairment of earning capacity, see Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The CAVC invalidated the portion of VA's General Counsel Opinion VAOPGCPREC 1-17 to the extent it determined obesity per se is not a disability. However, the finding in VAOPGCPREC 1-17 that obesity, and by extension, weight gain, is not a "disease" for purposes of 38 U.S.C. §§ 1110 and 1131, and therefore not entitled to service connection on a direct basis, remains valid.

Here, there is no medical opinion as to whether the Veteran's obesity is related to his service-connected obstructive sleep apnea. In light of the above, the Board finds that remand is necessary to satisfy a regulatory or statutory duty to provide an adequate medical opinion addressing whether the Veteran's obesity is secondary to his service-connected obstructive sleep apnea. 38 C.F.R. § 20.802(a).

Accordingly, these matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician to assess the nature and etiology of the Veteran's costochondritis. A new examination is not required unless deemed necessary by the examiner to render the addendum medical opinion. Following a review of the entire claims file, including this remand, the clinician should respond to the following:

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 costochondritis (1) due to or the result of, or (2) aggravated by service-connected obstructive sleep apnea.

The examiner should note that causation and aggravation are two separate inquiries, and both must be addressed. All opinions should be supported by a medical explanation or rationale and should not be conclusory.

2. Schedule the appropriate VA examination. A rationale for all opinions and a discussion of
necessary by the examiner to render the addendum medical opinion. Following a review of the entire claims file, including this remand, the clinician should respond to the following:

2. Schedule the appropriate VA examination. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The VA examiner should provide the following opinions:

A) Is the Veteran obese, and if so, does the obesity result in functional impairment of earning capacity?

B) If the obesity does result in functional impairment of earning capacity, is it at least as likely as not that the obesity was caused by a service-connected disability, to include the service-connected obstructive sleep apnea?

C) If the obesity does result in functional impairment of earning capacity, is it at least as likely as not that the obesity was aggravated by (worsened in severity by) a service-connected disability, to include the service-connected obstructive sleep apnea?

Michael A. Pappas

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Little, Calvin

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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