UNDIAGNOSED ILLNESSES

SCOTT W. DALE · 2026 · Case ID: A26038565

MIXED

Summary

The Veteran served from September 1989 to March 1995, including Persian Gulf service from 1992 to 1994, with conceded toxic exposures including burn pits and nerve agents. The Veteran sought service connection for Chronic Fatigue Syndrome (CFS), asthma, and bilateral knee conditions. The Board denied service connection for CFS, finding no current diagnosis and that the Veteran's symptoms were contemplated by existing service-connected conditions like fibromyalgia and PTSD. The Board noted that while the Veteran is competent to report symptoms, he is not competent to diagnose CFS. The denial for CFS was based on the lack of objective evidence supporting a diagnosis and the fact that his symptoms were covered by other conditions. Service connection for asthma and bilateral knee conditions were remanded. For asthma, the remand is due to pre-decisional errors concerning outstanding non-VA treatment records and the need for an addendum medical opinion to clarify the nature and etiology of his breathing difficulties, including whether they constitute an undiagnosed illness. For the bilateral knee conditions, the remand is for outstanding records and adequate medical nexus opinions to determine if the disabilities are related to in-service wear and tear, including from parachute training, as prior VA opinions were deemed inadequate or inconsistent.

Rationale

No current diagnosis of CFS; Symptoms contemplated by other service-connected conditions (fibromyalgia, PTSD); No objective evidence to support CFS diagnosis

Special Benefit

NO SPECIAL BENEFIT

Docket No.

231127-398070

Full Decision Text

Citation Nr: A26038565
Decision Date: 04/24/26 Archive Date: 04/24/26

DOCKET NO. 231127-398070
DATE: April 24, 2026

ORDER

Service connection for chronic fatigue syndrome (CFS) is denied.

REMANDED

Entitlement to service connection for a disability manifested by breathing difficulties, to include asthma, is remanded.

Entitlement to service connection for right knee strain is remanded.

Entitlement to service connection for left knee strain is remanded.

FINDING OF FACT

There is no diagnosis of CFS during or contemporaneous to the appeal period; and there have been no signs or symptoms of an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI) for the claimed condition; as the Veteran's complaints of fatigue or other potential symptoms of CFS are contemplated by other diagnosed conditions.

CONCLUSION OF LAW

The criteria for service connection for CFS have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1119, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317, 3.320.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from September 1989 to March 1995, including in the Persian Gulf from 1992 to 1994.

This matter initially came to the Board on appeal from June 2023 and August 2023 decisions a VA Regional Office, as the agency of original jurisdiction (AOJ), which responded to the Veteran's August 2022 claim for service connection. In his November 2023 VA Form 10182, the Veteran elected the Direct Review option. Thus, the Board may not consider, and has not considered, any evidence that was received or submitted after issuance of the decision on appeal. 38 C.F.R. § 20.301.

In a February 2025 decision, the Board denied service connection for asthma and CFS due no diagnosis, and for bilateral knee disabilities due to no nexus, as well as hypertension. The Veteran appealed to the Court of Appeals for Veterans Claims. In an October 2025 Order, the Court vacated and remanded that decision pursuant to a Joint Motion for Partial Remand (JMPR) only for the denials of service connection for asthma, CFS, and bilateral knee disabilities. (The denial of service connection for hypertension was not appealed, and that Board denial remains in effect.)

The Board now recharacterizes the issues of service connection for asthma and CFS as stated above in order to contemplate all conditions within the appeal period that are manifested by the described symptoms, with or without a diagnosis.

For the denied issue, 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 that evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the issues, 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 the remanded issues, the AOJ will have all evidence available to review, including any evidence that the Board cannot consider at this time.

1. Service connection for CFS or fatigue as an undiagnosed illness is denied.

The Veteran seeks service connection for CFS, which he has otherwise referenced as fatigue, daytime sleepiness, and insomnia, due to exposures to nerve agents, mustard agents, and other environmental hazards including burn pits during his service in Iraq from 1992 to 1994 with duties involving destruction of chemical warfare. See, e.g., March 2022 VA Gulf War protocol examination; November 2022 lay statement; January 2024 appellate brief and October 2025 JMPR.

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, 5107; 38 C.F.R. § 3.303. Generally, service connection requires three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

The Veteran's toxic exposures, or toxic exposure risk activities (TERA), from his service in Iraq are consistent with
disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. Generally, service connection requires three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

The Veteran's toxic exposures, or toxic exposure risk activities (TERA), from his service in Iraq are consistent with his service records and have been conceded.

Thus, he has eligible Persian Gulf War service in the Southwest Asia theater of operations; and he is presumed to have hazardous environmental exposures or TERA, to include burn pits and other toxins (BPOT), during such service. See 38 U.S.C. §§ 1117, 1118, & 1119; 38 C.F.R. §§ 3.317 & 3.320. Based on such service, the Veteran is eligible for presumptive consideration of a qualifying chronic disability resulting from symptoms of an undiagnosed illness or a diagnosed but medically unexplained chronic multi-symptom illness (MUCMI), specifically including CFS, that manifested after such service. 38 C.F.R. § 3.317. An illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive, but not where both the etiology and pathophysiology of the illness are partially understood. Stewart v. Wilkie, 30 Vet. App. 383, 389 (2020).

In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

In this case, service connection for CFS must be denied due to no current disability at any time during the pendency of the claim or recent to the filing of the claim, to include through an undiagnosed illness or MUCMI. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Furthermore, any functional loss with impairment of earning capacity due to perceived symptoms of CFS without an underlying diagnosis does not establish a disability. Cf. Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018).

There is no diagnosis of CFS in the Veteran's VA treatment records since 2022, and the March 2023 VA examiner noted generally that the Veteran reported subjective symptoms but had no objective evidence to support a diagnosis of CFS.

The prior Board decision denied this service connection for CFS due to no diagnosis. In the October 2025 JMPR, the parties agreed that the prior Board decision failed to address a raised theory of service connection based on fatigue as a sign or symptom of an undiagnosed illness under 38 C.F.R. § 3.317.

The Board has considered this theory; however, further review reveals that the Veteran's complaints for his CFS claim are contemplated by other diagnoses.

The Board observes that the Veteran reported current and prior non-VA primary care when he established VA care in August 2022. However, such records do not have a reasonable possibility of assisting in substantiating his claim for CFS. Rather, the available records are sufficient to show his complaints and diagnoses, including relevant testing, during the appeal period, or recent in time to the claim. Thus, no further assistance is required in this regard. See 38 C.F.R. § 3.159.

The Veteran is competent to report his observable symptoms such as fatigue, but he is not competent to diagnose CFS because it is a complex disorder that requires medical training or expertise to interpret his history and any relevant testing.

Under 38 C.F.R. § 4.88b, Diagnostic Code (DC) 6354, VA defines CFS as "[d]ebilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, or confusion), or a combination of other signs and symptoms." Ratings are assigned based on resulting incapacitation or restriction of routine daily activities, as compared to the pre-illness level. Similarly, as stated in a March 2023 VA examination report for CFS, a diagnosis of CFS for VA purposes requires:

(1) New onset
fatigue, but he is not competent to diagnose CFS because it is a complex disorder that requires medical training or expertise to interpret his history and any relevant testing.

(1) New onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and

(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 ten signs or symptoms: acute onset of the condition, low-grade fever, non-exudative pharyngitis, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), migratory joint pains, neuropsychologic symptoms, or sleep disturbance.

The Veteran's service-connected fibromyalgia and posttraumatic stress disorder (PTSD) both contemplate his symptoms of fatigue or sleep disturbance and neuropsychologic symptoms, to include depression and anxiety. The rating criteria for fibromyalgia also include headaches and widespread musculoskeletal pain and tender points; and his assigned 40 percent rating since 2022 is for nearly constant or constant symptoms that are refractory to treatment. See 38 C.F.R. § 4.71a, DC 5025. The rating criteria for PTSD, to include his assigned 30 or 50 percent ratings since 2021, include chronic sleep impairment and other neuropsychologic symptoms. See 38 C.F.R. § 4.130, DC 9411. Similarly, the February 2022 VA examination for PTSD noted his symptoms as including sleep disturbance, insomnia, feeling fatigued, and concentration difficulties.

Additionally, the Veteran was diagnosed with severe obstructive sleep apnea (OSA) by a September 2022 VA home sleep study for complaints including insomnia, disturbed and unrefreshing sleep, and daytime somnolence (sleepiness). A March 2023 VA examination for OSA reflects snoring and persistent daytime hypersomnolence. Similarly, the rating criteria for OSA include sleep disorder breathing and persistent day-time hypersomnolence. 38 C.F.R. § 4.97, DC 6847.

An April 2023 VA treatment record also noted fatigue, headaches, and lack of concentration that the Veteran attributed to difficulty sleeping because his nostrils became blocked and caused difficulty breathing while sleeping. He is service-connected for allergic rhinitis, which contemplates obstruction of nasal passages (which would logically affect breathing). See 38 C.F.R. § 4.97, DC 6522.

In summary, the evidence is not in at least relative equipoise for a current disability under any raised theory, to include as specified in the October 2025 JMPR. Thus, there is no reasonable doubt to resolve in the Veteran's favor. The appeal is denied.

REASONS FOR REMAND

2. Entitlement to service connection for a disability manifested by breathing difficulties, to include asthma, is remanded.

The Veteran seeks service connection for asthma, which he has described as feeling short of breath or getting winded easily, based on his Persian Gulf service.

In March 2022, VA examination reports for respiratory conditions and Gulf War general medical protocol noted the Veteran's reports of shortness of breath since about 1994 after his separation from service. He recalled seeking treatment at one point and having an inhaler; then his breathing was "okay" until about ten years ago (or around 2012), when he began having shortness of breath mainly with activity of mild exertion. He denied a diagnosis of asthma or bronchitis and had not been evaluated for the condition. The examiner found no diagnosis of asthma based on pulse oxygen of 96% on room air and chest x-rays for the examination with no acute intrathoracic process and no abnormal findings for the lungs.

During an April 2023 VA respiratory examination, the Veteran reported an onset of his complaints in 2000 and that he had been diagnosed with asthma many years ago, although he denied any past or current use of inhalers. He described difficulty breathing "for a long time
his breathing was "okay" until about ten years ago (or around 2012), when he began having shortness of breath mainly with activity of mild exertion. He denied a diagnosis of asthma or bronchitis and had not been evaluated for the condition. The examiner found no diagnosis of asthma based on pulse oxygen of 96% on room air and chest x-rays for the examination with no acute intrathoracic process and no abnormal findings for the lungs.

During an April 2023 VA respiratory examination, the Veteran reported an onset of his complaints in 2000 and that he had been diagnosed with asthma many years ago, although he denied any past or current use of inhalers. He described difficulty breathing "for a long time," getting winded easily and chest tightness after walking more than one-half block, and intermittent wheezing. This examiner noted a diagnosis of asthma in 2000, apparently based on the Veteran's reports. However, the July 2023 VA examiner found no diagnosis of asthma and stated that the diagnosis by the April 2023 VA examiner was not supported by medical evidence.

The prior Board decision denied service connection for asthma due to no diagnosis. In the October 2025 JMPR, the parties agreed that the prior Board decision failed to address a raised theory for this issue based on respiratory symptoms potentially being a sign or symptom of an undiagnosed illness under 38 C.F.R. § 3.317.

Upon further file review, the Board finds that a remand is needed due to pre-decisional errors for outstanding records and an addendum medical opinion.

Specifically, there is a suggestion of potentially relevant non-VA primary care records that may assist in determining the nature and etiology of the Veteran's breathing difficulties, to include whether they are from a diagnosable condition separate from his service-connected allergic rhinitis, based on his history, tests, etc.

In a November 2022 statement for his claim, the Veteran recalled being told that he had scar tissue in his mid-lung during emergency treatment at Porter Hospital in 2017. An August 2022 VA treatment record noted a current outside doctor (Dr. J.C.) and a prior doctor in the Franciscan system. There are minimal records in the file from the Franciscan system. The April 2023 VA examination noted that the Veteran was seeing a civilian doctor at Crown Point clinic. Any available records from these providers should be obtained, with the Veteran's cooperation as needed.

Additionally, VA treatment records include a February 2022 request for PFT results from a community (non-VA) provider; and March 2022 PFT results that were interpreted to show a mild restrictive defect. It is unclear whether the Veteran was seen at other times by that non-VA provider, and these results were not addressed by the VA examiners. In a November 2022 lay statement, the Veteran reported being told by a VA provider that PFT results in March 2022 showed 80 percent lung capacity; those may be the reports he was referencing, as the March 2022 VA examination had no PFT results. Any outstanding records should be requested.

Additionally, PFT results in April 2023 for the VA examination noted that the Veteran had been referred for possible asthma, and he had a mild cough on the day of the examination and mild difficulty performing maneuvers. The overall system interpretation was "significant pre-post change," but the Veteran "passed" the screening criteria. Although the July 2023 examiner stated that the April 2023 PFT results, additional clarification of the findings on the report would be helpful.

After all available records are obtained, an addendum medical opinion is needed to address the March 2022 and April 2023 PFT results, as well as any other relevant evidence that may be obtained pursuant to the remand directives.

3. Entitlement to service connection for right knee strain is remanded.

4. Entitlement to service connection for left knee strain is remanded.

The Veteran seeks service connection for his bilateral knee disabilities due to an injury or wear and tear in service, particularly a bad last jump in airborne parachute training. See, e.g., February 2022 VA examination; October 2025 JMPR.

The prior Board decision denied service connection for both knees due to no nexus. In the October 2025 JMPR, the parties agreed that the prior Board decision did not provide adequate reasons and bases for whether VA opinions in February 2022 and October 2022 were adequate to address the asserted injury in service.

Upon further review, the Board finds that a remand is needed due to pre-decisional errors to obtain outstanding records and adequate medical nexus opinions.

As noted in the JMPR, the February 2022 VA examiner only addressed the right knee and gave a negative nexus based on the Veteran's
last jump in airborne parachute training. See, e.g., February 2022 VA examination; October 2025 JMPR.

Upon further review, the Board finds that a remand is needed due to pre-decisional errors to obtain outstanding records and adequate medical nexus opinions.

As noted in the JMPR, the February 2022 VA examiner only addressed the right knee and gave a negative nexus based on the Veteran's denial of any current or prior knee problems. The examination addressed the right knee in connection with a claim for right lower extremity and hip conditions related to a back condition. The Veteran denied specific knee pain but reported symptoms in the right buttock, calf or lower leg, and foot that he believed were related to a back injury from a bad landing in his last (7th) training jump in service. He stated that his right knee was "okay." The examiner noted no treatment or diagnosis for knee complaints in service records, to include at separation, or in the first few years after service. The Veteran reported working in the same industry for the past 20 years (about 2002) and in office setting for 11 years with a desk to allow sitting and standing.

The October 2022 VA examiner gave a negative nexus to exposures or TERA in the Persian Gulf, reasoning that the bilateral knee strain was due to "wear and tear on joint" and the Veteran reported an onset of knee pain in 2000. At this time, he reported treating his knee pain since 2000 with over-the-counter medications. The JMPR noted that this appeared inconsistent with the prior denial of knee issues.

The Veteran's DD Form 214 confirms that he completed airborne training and received a parachutist badge. He is not competent to give an opinion on the etiology of his knee complaints due to his complex history and multiple potential etiologies. A medical opinion is needed to address whether the current conditions are related to wear and tear during service, to include from parachute jumping.

Additionally, as noted above for the asthma claim, there is an indication of outstanding non-VA primary care records. They may also assist in substantiating these claims, to include clarifying the nature and etiology of his knee complaints.

The matters are REMANDED for the following actions:

1. Request the Veteran to complete a VA Form 21-4142 or provide treatment records for outstanding non-VA treatment records for his claimed knee conditions and asthma or breathing difficulties, to include from Porter Hospital for emergency treatment for breathing issues in 2017, and for primary care from the Franciscan system, Dr. J.C., or Crown Point Clinic in Indiana.

Then, make reasonable requests for any sufficiently identified records. If any sufficiently identified records cannot be obtained, notify the Veteran and appointed representative (if any) of the efforts made and any additional efforts VA will make, and allow an opportunity to respond and provide any missing records.

2. After completing the directed records development to the extent possible, obtain a medical opinion to address the nature and etiology of the Veteran's claimed asthma or breathing difficulties, to include as undiagnosed illness. The examiner should respond to the following:

(a.) Are the Veteran's reported signs and symptoms at least as likely as not characteristic (or not) of a known clinical diagnosis, to include asthma?

In making this determination, any necessary diagnostic testing should be completed. All signs, symptoms, and clinical findings should be recorded. Also, please state if any signs or symptoms are attributable to his allergic rhinitis.

(b.) If objective indications of a chronic disability cannot be attributed to a known clinical diagnosis, is there affirmative evidence that such undiagnosed illness was not incurred during the Veteran's Persian Gulf service in the Southwest Asia theater of operations, or that it was caused by an injury, disease, or event that occurred after such service?

(c.) If objective indications of a chronic disability can be attributed to a known clinical diagnosis, please state whether the etiology and the pathophysiology of the condition are each (1) inconclusive, (2) partially understood, or (3) fully understood? Responses must be based on this Veteran's case, not the population as a whole.

(d.) If both the etiology and pathophysiology of the current diagnosis are partially understood or fully understood, then the examiner should state whether it is at least as likely as not that the current disability was incurred in, or is otherwise related to, the Veteran's Persian Gulf service in Iraq.

The examiner should address both the individual effects and the synergistic and combined total effects of
service?

The examiner should address both the individual effects and the synergistic and combined total effects of the Veteran's toxic exposure risk activities (TERA), to include from mustard gas, nerve agents, other chemicals, BPOT and other presumed exposures in the Southwest Asia theater of operations. See VBMS VA memo labeled "Other" received 4/7/2023; Military Personnel Record received 1/31/2022 (list of possible chemical exposures through duties at page 10); C&P Exam received 3/1/2022 (Gulf War exam, remarks at page 2 summarizing exposures).

(e.) In responding to the above, along with other relevant evidence and research, please consider or comment on the following, as indicated:

i. The March 2022 PFT results in VA treatment records interpreted to show a mild restrictive defect. See VBMS CAPRI received 11/21/22 (at page 240).

ii. The April 2023 PFT results noting a mild cough on the day of the examination, great effort but mild difficulty performing maneuvers, overall system interpretation of "significant pre-post change," and the Veteran "passed" the screening criteria. See VBMS C&P exam received 4/26/2023 (dated 4/25/2023).

iii. The Veteran's competent reports of the nature and timing of his observable symptoms, to include shortness of breath, chest tightness, getting winded easily, and intermittent wheezing, primarily with activities or mild exertion. See VBMS C&P Exams received 3/1/2022 (two reports - both noting onset about ten years earlier); C&P exam received 4/25/2023 (noting onset in 2000).

iv. The Veteran's recollection of being told that he had scar tissue in the mid-lung during emergency treatment in 2017; and his reports of toxic exposures in Iraq, to include sarin nerve gas/agent and mustard agent. See VBMS Buddy/Lay Statement received 11/14/2022.

(f.) For all requests above, the examiner should explain the reasons behind any opinions expressed and conclusions reached. The examiner may not reject the Veteran's competent lay reports as to the nature and timing of observable symptoms solely due to a lack of medical documentation, but a lack of contemporaneous treatment may be weighed along with other evidence. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the likelihood is at least approximately balanced or nearly equal, if not higher.

3. After completing the directed records development to the extent possible, obtain addendum medical opinions to address the nature and etiology of the Veteran's bilateral knee disabilities. The examiner should respond to the following based on file review and relevant research:

(a.) Were the current bilateral knee disabilities at least as likely as not incurred in or otherwise related to the Veteran's report of a bad landing during a 7th training jump for a parachute badge, or to wear and tear from military training or other physical activities in service from 1989 to 1995?

(b.) The examiner should consider the following, along with other relevant evidence or research:

i. The Veteran's report of an onset of bilateral knee pain in 2000 that he treated with over-the-counter medications; and the October 2022 VA examiner's opinion that his bilateral knee strain was due to wear and tear on the joint. See VBMS C&P Exam received 10/24/2022.

ii. The Veteran's post-service work in the same industry since about 2002 and in an office setting for 11 years with an ergonomic desk to allow sitting and standing. See VBMS C&P Exam received 3/2/2022 (dated 2/28/2022).

The examiner should explain the reasons behind any opinions expressed and conclusions reached. The examiner may not reject the Veteran's competent lay reports as to the nature and timing of observable symptoms solely due to a lack of medical documentation, but a lack of contemporaneous treatment may be weighed along with other evidence. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility
10/24/2022.

4. Thereafter, the AOJ must readjudicate the Veteran's appealed issues in light of the totality of evidence of record. If any benefit sought is not granted to the fullest extent, the AOJ must provide the Veteran and his representative with a copy of the readjudication and afford them an appropriate period to respond.

Scott W. Dale

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Christa Wheatley

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.

Analyze in VA Law Explorer