Citation Nr: 18131206
Decision Date: 08/31/18	Archive Date: 08/31/18

DOCKET NO. 13-31 126
DATE:	August 31, 2018
ORDER
Entitlement to service connection for a chronic pain disorder, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is denied.
Entitlement to service connection for a bilateral foot disorder, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is denied.

FINDINGS OF FACT
1.  The Veteran does not have a chronic disability manifested by joint pain, to include as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness, such as fibromyalgia.  His symptoms of joint pain did not manifest in service, are not otherwise related thereto, and have been attributed to other service-connected disabilities and nonservice-connected disorders.
2.  The Veteran does not have a chronic bilateral foot disability, to include as due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness.  His symptoms of hypersensitivity of the bilateral feet did not manifest in service and are not otherwise related thereto.


CONCLUSIONS OF LAW
1.  Fibromyalgia was not incurred active service. 38 U.S.C. §§ 101 (24), 1110, 1117, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317.
2.  A disability manifested by joint pain, to include as due to an undiagnosed illness, was not incurred in active service. 38 U.S.C. §§ 101(24), 1110, 1117, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317.
3.  A disability manifested by hypersensitivity of the bilateral feet, to include as due to an undiagnosed illness, was not incurred in active service. 38 U.S.C. §§ 101(24), 1110, 1117, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from October 2004 to January 2006 and from September 2008 to September 2009.  He had additional service in the United States Army Reserve.
These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision.
In March 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the Agency of Original Jurisdiction (AOJ).  A transcript of the hearing has been associated with the record.
In June 2016, the Board remanded the case for further development.  That development has been completed, and the case has since been returned to the Board for appellate review.
In an October 2017 rating decision, the AOJ granted service connection for impingement syndrome of the left shoulder and assigned a 20 percent evaluation, effective from September 30, 2009.  The AOJ’s grant of service connection for a left shoulder disability constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997).  Therefore, that matter is no longer on appeal, and no further consideration is necessary.

Service Connection
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a).  To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service—the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)).  The absence of any one element will result in denial of service connection.
Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).
The disorders at issues in this case are not considered chronic diseases as enumerated for VA compensation purposes.  As such, the provisions for continuity of symptomatology after discharge are not for application in this case. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317.  Under that section, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War.  For disability due to undiagnosed illness and medically unexplained chronic multi-symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1). 
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 VA determines in regulations warrants a presumption of service connection. 38 C.F.R. § 3.317 (a)(2).  An undiagnosed illness is a condition that, by history, physical examination, and laboratory tests, cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1).  To fulfill the requirement of chronicity, the illness must have persisted for six months. 38 U.S.C. § 1117, 38 C.F.R. § 3.317.
Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b).
A medically unexplained chronic multi-symptom illness is 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 VA determines meets the criteria in paragraph 3.317(a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness.  A medically unexplained chronic multi-symptom 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 multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii).

Chronic Pain
The Veteran has claimed that he has a chronic pain disorder in parts of his body that have no diagnosed condition.  Specifically, during the March 2016 hearing, he indicated that he had pain in his neck, shoulders, low back, legs, feet, and arms.  He stated that he felt like his body was being compressed and that he noticed his symptoms after he returned from his second deployment to Iraq in 2008 to 2009.  
In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for fibromyalgia or chronic joint pain.  
At the outset, the Board notes that the Veteran has already been granted service connection for impingement syndrome of the left shoulder; impingement syndrome of the right shoulder; left and right hip conditions, diagnosed as sacroiliac joint dysfunction with degenerative changes associated with mechanical low back pain; and cervical spine degenerative disc disease. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (separate evaluations may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition).
The Veteran’s service treatment records are negative for any complaints, treatment, or diagnosis of fibromyalgia or unspecified joint pain.  In fact, in an August 2008 post-deployment health assessment, the Veteran denied treatment for general weakness, muscle aches, back pain, and numbness or tingling to hands or feet.  He did indicate that he was treated at sick call for swollen, stiff, or painful joints.  Specifically, he related that he had minor concerns related to right shoulder pain from wearing gear.  However, he also noted that the problems were not still bothering him.  In a related August 2008 report of medical assessment, the Veteran related that his overall health was the same as when he was last examined by military personnel in July 2007.  He denied suffering any injuries for which he did not seek medical care.  He also noted that he was treated for shoulder pain and tendinitis in Camp Baharia, Iraq, during deployment.  The examining medical provider noted that the Veteran had right shoulder pain due to wearing a heavy pack, but that he had no current problem.  The Board again notes that, while there are complaints pertaining to the Veteran’s right shoulder, he has already been granted service connection for impingement syndrome of the right shoulder. 
The Veteran was afforded a VA general medical examination in May 2010.  During the examination, the Veteran denied any significant health problems except for orthopedic problems.
During a May 2010 VA orthopedic examination, the Veteran complained of low back, bilateral shoulder, and bilateral foot pain.  He stated that he had constant pain or discomfort awareness in his low back, bilateral shoulders, and bilateral feet.  The VA examiner diagnosed the Veteran with bilateral shoulder impingement syndrome and mechanical low back pain.  
In a November 2010 VA treatment note, the Veteran reported that he had chronic and constant pain all over his body that began during his second deployment.
In a February 2012 VA neurology consultation note, the neurologist indicated that the Veteran had an EMG study in February 2012 that was limited due to tolerability.  Peroneal motor and sural sensory on the right lower extremity were tested and were normal.  A cervical, thoracic, and lumbar spine MRI showed only mild cervical stenosis at C5-6, C6-7.  The neurologist raised the possibility that the Veteran had small fiber neuropathy versus complex regional pain syndrome.  A cranial nerve examination was normal.  
In a March 2012 VA rheumatology consultation note, the rheumatologist noted that the Veteran had fixed hyperesthesia in both feet.  A consultation was requested to review ANA results that were 1:160 homogeneous.  It was noted that ANA was ordered given the Veteran’s complicated history and various pain complaints.  The reviewing rheumatologist related that an extensive work-up had been completed to date, but there had been no clarification of etiology.  He agreed with the VA neurologist’s detailed evaluation and the differential diagnosis generated.  He stated that he had similar uncertainties about what process could have given a fixed distribution of the Veteran’s symptoms without apparent progression since onset.  He also provided:
I am doubtful the isolated ANA shifts my post-test probability of a specific occult systemic autoimmune disease given such an extensively negative work-up for organ dysfunction or other findings to narrow the differential diagnosis.  Incidental ANA 1:160 positivity is rare in children (likely ~2%) and increases gradually with age to ~10-15% age >65, more common in females than males, so while not diagnostic it is somewhat atypical in a 27[-year old] male and raises question of diseases that cause ANAs, celiac, sarcoid, autoimmune thyroiditis with preserved thyroid function, occult infection, amyloid, neoplasm.  Complex regional pain syndrome (no ANA association) without progression to skin and bone changes after this duration seems unusual.  How any of these produce “fixed” neuropathy is difficult to explain as I would expect at least insidious progression.  The degree to which expanded lab testing suggested below would help is very uncertain to me but given Pt seems significantly impaired by this process may be justified.  At some point it may make sense to proceed to biopsy to rule in or out nerve abnormalities that would then support ongoing expansion of lab/radiographic testing that are generally non-specific (skin for small fiber neuropathy, question if sural nerve biopsy useful given limited but normal EMG and would defer to Neurology on this question).
The VA rheumatologist also included several possible considerations, including systemic sclerosis, eosinophilic fasciitis, amyloid/light chain disease, celiac disease, neurosacroidosis, and basilar meningeal involvement with cranial nerve dysfunction.  
During a June 2012 VA pain clinic consultation, the examining physiatrist noted that the Veteran presented with complaints of bilateral foot, neck, shoulder, low back, and “whole body” pain.  He was diagnosed with hypersensitivity and pain in his whole body and, specifically, in his feet; some chronic low back pain that was predominantly myofascial in nature with some possible sacroiliac irritation; neck and shoulder pain with no clear etiology; possible thoracic outlet syndrome; and severe deconditioning.
During a September 2013 VA non-degenerative arthritis examination, the examiner noted that the Veteran was claiming service connection for chronic pain in his back, shoulders, hips, and feet.  The examiner reported that VA laboratory results did not show any specific diagnosis for chronic pain and fatigue and that chronic pain and fatigue diagnoses were ruled out.  The examiner stated that a previous VA examiner felt that the Veteran’s chronic pain and fatigue symptoms were consistent with his multiple body complaints associated with his shoulder, back, hips, and feet and that he did not have one systemic problem.  The examiner noted that the Veteran described separate aches and pains in these joints and his feet.  The examiner reported that the Veteran had pain attributable to an arthritis condition in his thoracolumbar spine, sacroiliac joints, shoulders, and feet.  The examiner indicated that the Veteran did not have any involvement of any systems, other than the joints, attributable to an arthritis condition.  The examiner opined that it was not at least as likely as not that the Veteran had any service-related chronic pain syndrome.  Rather, his pain was consistent with physical causes.  In addition, the examiner indicated that the Veteran’s symptoms and range of motion findings were inconsistent with chronic pain syndrome and that his laboratory results and EMG findings were not consistent with chronic disease of the feet.  He opined that the joint and feet pain were separate and individual and that there was no syndrome or disease that could link the complaints.
In a January 2016 VA Gulf War examination report, the examiner noted that the Veteran had no diagnosed illnesses for which no etiology was established.  The examiner reported that there was no evidence or diagnosis of a systemic joint condition or multi-system condition.  During the examination, the Veteran complained of chronic bilateral shoulder pain, neck pain, and upper, mid, and lower back pain.  He also complained that his arms went numb when he wore body armor.  He stated that there was evidence of focal bilateral shoulder pain, a notation of right carpal tunnel syndrome, and that the Veteran reported shoulder bone spurs, which could be the reasons for bilateral arm numbness while using body armor.  The examiner opined that there was no evidence to support a condition due to environmental exposures during service.  He related that cervical spine x-rays showed mild cervical disc degeneration and that the Veteran’s complaints appeared to be focal due to use and mechanical in nature.
During an October 2017 VA fibromyalgia examination, the Veteran reported that he had chronic pain in his shoulders, back, and feet and that the pain in those areas radiated to other areas.  He indicated that he had never been diagnosed with fibromyalgia.  The VA examiner indicated that the Veteran did not have any findings, signs, or symptoms attributable to fibromyalgia.  In fact, the examiner noted that the Veteran was tender to none of the 18 typical tender points on examination.  The examiner reported that no generalized pain disorder or fibromyalgia was diagnosed; therefore, she was unable to provide an opinion as to a possible relationship to service.  Rather, she noted that the Veteran’s current pain symptoms were attributable to his specific conditions previously diagnosed as hyperesthesia of the feet; cervical degenerative disc disease with spinal stenosis; lumbar degenerative disc disease; and bilateral shoulder conditions, including right shoulder supraspinatus tendinitis and degenerative joint disease, and left shoulder rotator cuff tendinitis and subacromial bursitis.  
There is no medical opinion otherwise indicating that the Veteran had fibromyalgia or joint pain related to his military service.
The Board does acknowledge the statements by the Veteran and his representative that he has chronic joint pain that is related to his military service.  However, they are not competent to provide an opinion regarding the diagnosis and etiology of his reported symptoms.  Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, the diagnosis and etiology of fibromyalgia and joint pain, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer).  The questions of diagnosis and etiology in this case go beyond a simple and immediately observable cause-and-effect relationship, particularly considering his multiple medical conditions. 
Moreover, even assuming the lay assertions regarding etiology are competent, the Board nevertheless finds the VA medical opinions to be more probative, as they are based on a review of the record and the examiners’ own medical expertise, training, and knowledge.  The examiners supported their conclusions with a rationale and considered the Veteran’s medical history.
For the foregoing reasons, the Board finds that the claims for service connection for fibromyalgia and joint pain, to include as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, must be denied.  The most probative evidence of record indicates that the Veteran does not have fibromyalgia and that any joint pain is attributable to causes other than his military service.  For these reasons, the preponderance of the evidence is against the claims. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

Feet
The Veteran has claimed that he developed hypersensitivity to his feet as a result of being issued cold weather boots rather than desert boots during his 2008 to 2009 deployment to Iraq.  Specifically, he reported that, while he was transitioning back to the United States, he worked on a baggage claim detail for four days.  The Veteran stated that he wore his issued cold weather Gore-Tex boots in 130- to 140-degree heat and that he was unable to take his boots off to clean his feet until he was on the plane on his way back to the United States.  He related that he went to the bathroom on the plane, took his boots and socks off, and pulled flesh off his feet with his socks.  The Veteran stated that he used a first aid kit on the plane to wrap his feet.  He reported that his feet when numb for approximately one to two months following the incident, and from that point, he had a constant pins and needles sensation in his feet. See March 2016 hearing transcript.
In addition, during the March 2016 hearing, the Veteran’s representative asserted that the Veteran’s bilateral foot disorder may be an undiagnosed illness because there was no known cause and no explanation for what caused the Veteran’s chronic foot pain. 
The Veteran’s service treatment records are negative for any complaints, treatment, or diagnosis of any bilateral foot disorder.  In fact, in an August 2008 post-deployment health assessment, the Veteran denied treatment for numbness or tingling to hands or feet.  In a related August 2008 report of medical assessment, the Veteran also related that his overall health was the same as when he was last examined by military personnel in July 2007.  He denied suffering any injuries for which he did not seek medical care.  
During a May 2010 VA general medical examination, the Veteran denied any specific injuries or trauma directly to his feet.  He complained of hypersensitivity to touch of the skin of his feet in the plantar and dorsal surfaces.  He denied any joint or arthritic complaints.  He noted that the area affected was from the ankle below both medial and lateral malleolus down in a stocking-like distribution.  The Veteran reported that the hypersensitivity began in approximately August 2009.  He related that he was traveling home from Iraq after wearing boots in over 100-degree weather for two to three days straight.  He stated that he finally removed his boots while on the airplane and that his socks were stuck to his feet.  The Veteran reported that, when he pulled off his socks, his skin came off like a burn.  He described his feet as macerated with his skin sloughing off with his socks.  He stated that his feet had been very sensitive since that time and that he had pins-and-needles and burning sensations with contact on the skin of his feet.  On examination, the Veteran’s feet were normal to inspection, and he had normal skin.  His neurological examination was remarkable for normal cranial nerves II through XII intact.  He had normal motor strength in his lower extremities.  Sensation was intact in his lower extremities.  The examiner noted that the Veteran’s feet were “very hypersensitive” with even light touch of the feet in the plantar and dorsal surfaces.  Babinski testing was normal, but the examiner noted that it was uncomfortable for the Veteran, which was mostly indicative of hypersensitive feet with paresthesias.  The examiner diagnosed the Veteran with hypersensitivity or hyperesthesia and paresthesias of the feet.  She noted that the Veteran had normal sensory and objective examinations of the feet.  She opined that the Veteran’s paresthesias and hypersensitivity of the feet were likely related to the incident that he described in August 2009.
In a November 2010 VA treatment note, the Veteran reported that he injured his feet during his second deployment when he had to wear cold weather boots for the entire time that he was in Iraq because he was not issued desert boots.  He related that layers of skin came off his feet while he was on his way home from deployment.  He stated that his feet were hypersensitive to all touch and that he had to wear socks at all times.  He was diagnosed with peripheral neuropathy of the feet with a trench foot variation.  
A February 2012 VA EMG study was limited.  The report noted that, due to hyperalgesia, the Veteran had a heightened response to electrical stimulation and even placement of the surface electrodes on the dorsum of the right foot.  The EMG study was normal with limitations.  The report indicated that there was no electrodiagnostic evidence for peripheral polyneuropathy.  The interpreter noted that the Veteran demonstrated frank allodynia, hyperalgesia, and a history of injury consistent with complex regional pain syndrome, but small fiber neuropathy should also be considered.
In a February 2012 VA neurology consultation note, the neurologist indicated that the Veteran had an 18-month history of pain and sensitivity in his feet.  The Veteran reported that he was unable to obtain appropriate footwear during his second tour in Iraq in 2009 and that he wore winter Gore-tex boots during the entire summer of 2009.  The Veteran stated that, while he was returning from deployment in August 2009, he took his boots off after two to three days of constant wear and that his skin peeled off and caused “blister-like” pain on the bottoms and sides of his feet below the ankle.  He related that the stinging went away after a few weeks, but approximately one month later, he noticed that the ground felt like sandpaper under his bare feet and that his feet became very sensitive around that time.  He complained of a heightened sensation in all modalities of his feet.  The Veteran indicated that the distribution of his symptoms had not changed since that time.  He denied any chemical or environmental exposures during deployment.  He did note that he was electrocuted several times while showering due to poor electrical grounding.  The neurologist indicated that the Veteran had an EMG study in February 2012 that was limited due to tolerability.  Peroneal motor and sural sensory on the right were tested and were normal.  Cervical, thoracic, and lumbar spine MRI showed only mild cervical stenosis at C5-6, C6-7.  The neurologist raised the possibility that the Veteran had small fiber neuropathy versus complex regional pain syndrome.  Motor function and coordination were normal, and a sensory examination was intact.  The neurologist noted that there was normal sensation in all modalities to the mid-portion of the feet on the top and sides and under the feet bilaterally with identical distribution.  He stated that all modalities were hyperesthetic with the Veteran very uncomfortable and withdrawing his feet from testing.  
In his February 2012 consultation note, the VA neurologist diagnosed the Veteran with a differential diagnosis, including a small fiber neuropathy (given the normal EMG), complex regional pain syndrome (given association with onset following trauma), or functional etiology.  He explained that the Veteran could have a small fiber neuropathy given the normal EMG and prominent pain and hyperesthesia.  He noted that the symmetrical distribution fit with a small fiber neuropathy, but the involvement of the entire bottom of the foot with only half involvement of the top of the foot is unusual.  He indicated that the symptoms came to maximum distribution at onset and have not changed, which is unusual for small fiber neuropathy.  The neurologist indicated that complex regional pain syndrome was also a possibility and that the Veteran’s symptoms were temporally associated with the trauma of wearing heavy boots in hot temperatures in Iraq.  He reported that most complex regional pain syndrome was brought on by trauma to large nerves and that the trauma in this case would be to the surface of the feet.  In addition, he indicated that it would be unusual for the distribution of complex regional pain syndrome to be identical on both feet, given that the overheating trauma involved both feet.  The neurologist also reported that the Veteran had some facilitation of his reflexes on examination and that he was symptom-free at rest and with activity as long as his shoes and socks were on, which was somewhat unusual the degree of hyperesthesia seen on sensory and motor testing.  He concluded that a functional etiology was possible, but it would be a diagnosis of exclusion.
In a March 2012 VA rheumatology consultation note, the rheumatologist noted that the Veteran had fixed hyperesthesia in both feet.  He related that an extensive work-up had been completed to date, but there had been no clarification of etiology.  He agreed with the VA neurologist’s detailed evaluation and the differential diagnosis generated.  He stated that he had similar uncertainties about what process could have given a fixed distribution of the Veteran’s symptoms without apparent progression since onset.   
During a June 2012 VA pain clinic consultation, the examining physiatrist noted that the Veteran complained of bilateral foot pain limited to the soles and sides of his feet.  The Veteran reported that he wore cold weather boots for approximately four days without removing them in 150-degree weather.  He stated that, when he removed the boots, some skin sloughed and peeled and caused pain in the bottoms and sides of his feet that persisted over the last several years.  On examination, the Veteran withdrew his feet with some apprehension on palpation of the dorsum of the feet.  The sides and soles of the feet and tops and bottoms of the toes were very sensitive to palpation.  The Veteran reported severe pain during palpation, but he could stand on his feet during the examination and did not demonstrate any significant pain behavior.  He was diagnosed with hypersensitivity and pain in his feet.
During a September 2013 VA peripheral nerves examination, the examiner diagnosed the Veteran with bilateral feet hypersensitivity.  The Veteran reported that he was not treated in service for his feet.  He explained that he took off his boots on his way home from Iraq and that the skin tissue on his feet fell off.  He stated that he was evaluated by a physician before he separated from service, but he was told that nothing could be done until he could be treated after service.  The Veteran related that he was not treated for his feet until a couple of years after he separated from service.  At that time, he indicated that his feet were extremely tender and painful to touch and after standing.  He denied any trauma or injury to his feet.  On examination, the Veteran had mild, constant pain and paresthesias and/or dysesthesias in his bilateral lower extremities attributable to a peripheral nerve condition.  Reflex and sensory examinations of the bilateral lower extremities were normal, and an EMG study of the right lower extremity was normal.  The examiner stated that he did not have an explanation for the cause of the Veteran’s hypersensitive feet.  Therefore, he opined that it was not at least as likely as not that the hypersensitivity was service-related or aggravated by the wearing of body armor or the rigors of service.  
During an October 2017 VA feet examination, the VA examiner diagnosed the Veteran with fixed hyperesthesia in both feet, status-post extensive work-up to date without clarification of etiology.  The examiner opined that the Veteran’s hyperesthesia in both feet had an unknown etiology.  He indicated that the Veteran had differential diagnoses, which included a small fiber neuropathy given a normal EMG, complex regional pain syndrome given association with an onset following trauma, or functional etiology in 2012.  The examiner stated that none of these possibilities could reasonably be related to the thermal injury that occurred in 2009 as described by the Veteran.  The examiner related that the most likely cause was functional etiology.  He also opined that this unexplained etiology was less likely than not due to an undiagnosed illness or medically unexplained chronic multi-system illness resulting from service in Southwest Asia during the Gulf War.
The Board does acknowledge that the May 2010 VA examiner opined that the Veteran’s paresthesias and hypersensitivity of the feet were likely related to the incident that he described in August 2009.  However, as discussed above, the service treatment records are negative for any complaints pertaining to his feet.   The examiner also did not provide rationale for that opinion.  Moreover, the September 2013 VA examiner opined that it was not at least as likely as not that the hypersensitivity was service-related or aggravated by the wearing of body armor or the rigors of service.  In addition, the October 2017 VA examiner indicated that the most likely cause was functional etiology and stated that the unexplained etiology was less likely than not due to an undiagnosed illness or medically unexplained chronic multi-system illness resulting from service in Southwest Asia during the Gulf War.
The Board finds the October 2017 VA examiner’s opinion to be highly probative, as the examiner reviewed the complete record, including test results, and considered the Veteran’s contentions and statements.  The examiner also provided rationale for the conclusion reached and specifically addressed the thermal injury reported by the Veteran, referring to the September 2012 explanation regarding why it was an unlikely cause of the current complaints.
The Board does acknowledge the statements by the Veteran and his representative that his bilateral foot disorder is related to his military service.  However, they are not competent to provide an opinion regarding the diagnosis and etiology of his reported symptoms.  Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, the diagnosis and etiology of the Veteran’s hyperesthesia falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer).  The questions of diagnosis and etiology in this case go beyond a simple and immediately observable cause-and-effect relationship, particularly in light of the differential diagnoses and extensive medical work-ups. 
Moreover, even assuming the lay assertions regarding etiology are competent, the Board nevertheless finds the October 2017 VA medical opinion to be more probative, as it was based on a review of the record and the examiner’s own medical expertise, training, and knowledge.  The examiner supported the conclusions with a rationale and considered the Veteran’s medical history.
For the foregoing reasons and bases, the Board finds that the claim for service connection for a bilateral foot disorder, to include as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, must be denied.  For these reasons, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).
 
J.W. ZISSIMOS
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K. Osegueda, Counsel 

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