Citation Nr: 0005475 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 98-20 275 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a chronic disability claimed to be manifested by a nervous condition with sleep disturbances, on a direct basis or due to a Persian Gulf War-related undiagnosed illness. 2. Entitlement to service connection for a chronic disability claimed to be manifested by pain in multiple joints, on a direct basis or due to a Persian Gulf War- related undiagnosed illness. 3. Entitlement to service connection for a chronic disability claimed to be manifested by a skin rash, on a direct basis or due to a Persian Gulf War-related undiagnosed illness. 4. Entitlement to service connection for a chronic disability claimed to be manifested by fatigue, on a direct basis or due to a Persian Gulf War-related undiagnosed illness. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Acosta, Counsel INTRODUCTION The veteran served on active duty from March 1981 to December 1992. The above matters come before the Board of Veterans' Appeals (Board) on appeal from a March 1998 rating decision of the Department of Veterans Affairs (VA) Waco, Texas, Regional Office (RO). A travel board hearing was held on October 27, 1999, in Waco, Texas, before Jeff Martin, who is a Member of the Board's Section deciding this appeal and was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 1991). A transcript of the hearing is of record. FINDINGS OF FACT 1. The veteran is a Persian Gulf War veteran. 2. It has not been objectively shown that the veteran currently suffers from a chronic psychiatric disability manifested by a nervous condition with sleep disturbances, or from an undiagnosed chronic illness with objective indications of nervousness and sleep disturbances. 3. The veteran's complaints of pain in multiple joints have been attributed to his service-connected bilateral carpal tunnel syndrome, right knee disability, residuals of a left wrist fracture and lumbosacral spine disability, as well as to the nonservice-connected degenerative disc disease of the right shoulder and right ankle. 4. It has not been objectively shown that the diagnosed degenerative disc disease of the right shoulder and right ankle, which were first diagnosed almost five years after service, are causally related to service. 5. It has not been objectively shown that the veteran currently suffers from an undiagnosed chronic illness, with objective indications of pain in multiple joints. 6. It has not been objectively shown that the veteran currently suffers from a skin disability manifested by a skin rash, or from an undiagnosed chronic illness with objective indications of a skin rash. 7. It has not been objectively shown that the veteran currently suffers from a disability manifested by fatigue, or from an undiagnosed chronic illness with objective indications of fatigue. CONCLUSIONS OF LAW 1. The veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by a nervous condition with sleep disturbances, on a direct basis or due to a Persian Gulf War-related undiagnosed illness, that is well grounded, i.e., capable of substantiation. 38 U.S.C.A. §§ 1117, 5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 2. The veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by pain in multiple joints, on a direct basis or due to a Persian Gulf War- related undiagnosed illness, that is well grounded, i.e., capable of substantiation. 38 U.S.C.A. §§ 1117, 5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 3. The veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by a skin rash, on a direct basis or due to a Persian Gulf War-related undiagnosed illness, that is well grounded, i.e., capable of substantiation. 38 U.S.C.A. §§ 1117, 5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 4. The veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by fatigue, on a direct basis or due to a Persian Gulf War-related undiagnosed illness, that is well grounded, i.e., plausible or capable of substantiation. 38 U.S.C.A. §§ 1117, 5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran contends that he is entitled to be service- connected for a nervous condition with sleep disturbances, pain in multiple joints, a skin rash and fatigue, either on a direct basis or as objective, verifiable symptoms of chronic disabilities resulting from undiagnosed Persian Gulf-related illnesses. At the outset, the Board notes that a person who submits a claim for veteran's benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999, hereinafter referred to as "the Court") has defined a well grounded claim as a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). When a veteran has presented a well grounded claim within the meaning of 38 U.S.C.A. § 5107(a) (West 1991), VA has a duty to assist the veteran in the development of his claim. 38 U.S.C.A. § 5107(a) (West 1991). In general, service connection may be established for a disability if it is shown that the disability resulted from disease or injury that was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Service connection may also be granted for any disease or injury diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (1999). In Caluza v. Brown, 7 Vet. App. 498 (1995), the Court set out three requirements that must be met in order for a claim of service connection to be considered well grounded. First, there must be competent evidence of a current disability (a medical diagnosis). Second, there must be competent evidence of incurrence or aggravation of a disease or injury in service (lay or medical evidence). Third, there must be competent evidence of a nexus between the injury or disease in service and the current disability (medical evidence). The third requirement can be satisfied by a statutory presumption that certain diseases that manifest within certain prescribed periods are related to service. See, Caluza, at 506. In discussing every claimant's duty to submit a claim that is well-grounded, i.e., plausible or capable of substantiation, the Court has also said that, in cases in which the law and not the evidence is dispositive, a claim of entitlement to VA benefits shall be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law. See, in this regard, Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA statutes and regulations also provide additional means for Persian Gulf veterans to qualify for service connection for a disability. See 38 U.S.C.A. § 1117 (West 1991); 38 C.F.R. § 3.317 (1999). In the present case, the record shows that the veteran served on active duty in Southwest Asia during the Persian Gulf War between January and June 1991. He therefore is considered a Persian Gulf War veteran, for VA disability compensation purposes, and the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, to be discussed in the following paragraphs, apply to the appealed claims for service connection. VA may pay disability compensation to a Persian Gulf veteran who exhibits objective indications of a chronic disability that resulted from an undiagnosed illness, or combination of undiagnosed illnesses, that became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more disabling not later than December 31, 2001. See, 38 U.S.C.A. § 1117 (West 1991); and 38 C.F.R. § 3.317 (1999). To qualify for service connection under 38 U.S.C.A. § 1117, the claimed disability must be one that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii) (1999). The disability must be shown by "objective indications of chronic disability," including 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)(2) (1999). The disability must have existed for six months or more. Disabilities that exhibit intermittent episodes of improvement and worsening over a six month period will be considered chronic. The six month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(3) (1999). Under the above regulation, signs or symptoms which may be manifestations of undiagnosed 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) (1999). First Issue Entitlement to service connection for a chronic disability claimed to be manifested by a nervous condition, with sleep disturbances, on a direct basis or due to a Persian Gulf War-related undiagnosed illness: A review of the file reveals no evidence of complaints of nervous problems or sleep disturbances during service, and normal psychiatric and neurological evaluations of the veteran in the reports of medical examinations that were conducted in January 1981, July 1987, August 1991 and October 1992, the latter having been conducted for separation purposes. Also, it is noted that, in a medical questionnaire that was filled out in February 1992, less than a year after the veteran's return from the Persian Gulf area, the veteran answered "no" to the question of "what diseases or injuries did you have while in the Southwest Asia Region," and gave similar negative answers to questions regarding whether he currently had nightmares, trouble sleeping or recurring thoughts about his experiences during Desert Shield Storm. Likewise, in his report of medical history for separation purposes of October 1992, the veteran denied ever having had, or currently having, frequent trouble sleeping, depression, or excessive worry, and nervous trouble of any sort. The report of a February 1993 VA general medical examination reveals no complaints of nervousness or sleep disturbances, and a normal clinical evaluation of the veteran's psychiatric status and personality. Neurologically, the veteran's knee and ankle reflexes were reported as normal, and the examiner referred the reader to the report of a VA neurological consultation of the same date "for evaluation of bilateral carpal tunnel syndrome," a disease for which the Board notes that the veteran was thereafter service-connected, in an April 1993 rating decision. The report of that VA neurological evaluation is of record and it reveals no abnormalities other than the service-connected bilateral carpal tunnel syndrome. According to the report of a December 1993 VA Persian Gulf War medical examination, the veteran complained of a six to eight-month history of sleep disturbances. The pertinent impression was listed as "sleep disturbance, probably situational," and it is noted that the veteran was then referred to a VA psychiatrist, in order to rule out depression and further investigate the veteran's complaints of sleep disturbances. According to the medical consultation sheet reflecting the above VA psychiatric consultation of December 1993, the veteran was a 31-year old college student who had just completed 12 years of active duty in the Army and whose only complaint at the time of the examination was of sleep disturbance. On mental status examination, the veteran was described as alert, oriented times three, friendly and with a spontaneous speech. He denied depression and excessive worry. His thought process was intact. There was no unusual thought content and he reported no decrease in energy or loss of, or diminished, interest in activities. There were no suicidal thoughts, no undue self-criticism, the affect was appropriate, with a good range of emotional expression, and there was no psychiatric history. Recent psychological stressors were reported as including the birth of his first child, his "getting out" of the Army, and his having started college. The assessment was listed as insomnia, and the examiner noted that he gave the veteran some advice about sleep habits (such as exercise and "study time change"), that it was his opinion that the "suggested sleep disturbance may be related to recent life changes," and that he had offered the veteran psychological testing, which the veteran had accepted. According to the report of an October 1995 VA mental disorders examination, the veteran reported that he was still married, that he and his wife now had a two-and-a-half years old son, and that the veteran was still pursuing a bachelor's degree in social work, with excellent grades. He also reported that he was employed through a work-study program at Central Texas College, where his duties involved registering students and answering questions for them, a job that he described as "easy, less stress than anything else I do." He said that he also did volunteer work for the Red Cross. The examiner noted that, on a prior examination, it had been suggested that the veteran's reported sleep disturbance was situational and related to recent life changes, which were again referred to as the "birth of his first child, [his] discharge from service, [and his] beginning school." The above report also reveals that the veteran said that he was "not able to go to sleep" and that his Veteran's Benefits counselor had advised him to file a claim for a "nervous disorder." The veteran explained that, while in service, he was able to fall asleep easily at 10:00 p.m. and jump out of bed at 5:00 a.m., "ready to go," but that he now found that he could not sleep until 11:30 p.m., or midnight, and that he then awakened at 5:30 or 6:00 a.m., not feeling rested. He reported that his son now slept through the night, so he did not feel that his child contributed to his sleep disturbance. He noted that sometimes it was more difficult for him to go to sleep when there was something stressful going on, such as a test. In general, however, he said that he did not feel uptight or nervous, and he described his mood as "happy, funny, humorous," and recalled that his nickname while in the military was "[redacted]." He further said that he did not perceive his experiences in the Persian Gulf as particularly stressful, other than the stress of being away from home. He did voice concern about exposure to oil fires and the possible effect that said exposure may have had on his health. He denied any disturbing dreams about his experiences in the Persian Gulf and reported that his memories of his Persian Gulf experience were "good ones." According to the above report, the veteran arrived on time for the interview, he was alert, oriented, cooperative and pleasant. He responded appropriately to questions. His mood was "euthymic," and his affect was within normal range. His thought processes were logical and goal-directed. He had absolutely no complaints of any mood or anxiety disorder, his only concern being with what he perceived as a sleep disturbance. He reported that he did not smoke, that he used alcohol very infrequently, and that he only had minimal caffeine intake. The examiner noted that a review of the file did not reveal any treatment for sleep disturbance or psychiatric disorder during service, the veteran's only contact with mental health services having been in December 1993, with his complaint of initial and terminal sleep disturbance. The examiner further noted that psychological testing, both personality and cognitive, had been completed at that time and that it "did not support any psychiatric diagnosis." In the opinion of the subscriber of the above mental disorders report, the veteran was competent and capable of managing his funds, and there was no impairment in social or occupational functioning that could be attributed to any psychiatric problem. He also noted that no diagnosis was warranted on Axis I or Axis II and that, although the veteran complained of difficulty initiating sleep and early awakening, he did not appear to meet "Criteria B" for primary insomnia, which required clinically significant distress, or impairment in social, occupational, or other important areas of functioning, and that he did not see "clinically significant diagnoseable insomnia." In an August 1996 statement, the veteran's spouse indicated that the veteran, to whom she had been married since 1985, had suffered from trouble sleeping at night and had become more irritable since returning from the Persian Gulf War, problems that he had never had prior to the war. A similar statement was submitted by the veteran's mother-in-law in December 1996. According to the report of a September 1997 VA systemic conditions medical examination, the veteran complained of an irregular sleep pattern, as well as irritability. The examiner, however, found no evidence of a specific systemic infection and, regarding the question of whether there had been mental changes, referred the reader to the report of a VA psychological consultation, which the Board notes was conducted two days later, still in September 1997, in the form of a mental disorders examination. The report of the above VA mental disorders examination reveals that the veteran reported that he was not currently under psychiatric care, and complained of irritability and fatigue, as well as of other multiple physical problems involving the shoulder, elbow, skin, ankles, knees, etc.. The veteran said that he was currently enrolled in college, working towards a degree in social work, and that he also worked part time, for about 20 hours per week, counseling sexual assault victims. On examination, the above report describes the veteran as alert, oriented in all spheres and cooperative during the interview. He was appropriately dressed and adequately groomed. His mood was very calm and his affect was appropriate to his mood. He reported what the examiner described as "some difficulty falling asleep at night," and explained that he attempted to go to sleep between 10:00 and 12:30 p.m., at which time he began to "reflect on things during the day." He also said that the pain in his knee and lower back caused pain and, thus, difficulty falling asleep. The veteran also said, however, that he typically stayed asleep throughout the night and that, when he woke up at about 6:00 am, he generally felt rested. According to the above report, the veteran reported no significant appetite problems and denied any current suicidal or homicidal ideation or intent. The examiner noted that the veteran's thought processes were goal-directed and that his thought content was logical. There was no evidence of any perceptual disturbances or any impairment to his ability to concentrate, nor recent memory or remote memory problems. The veteran reported that he was doing well in his school subjects, that he had a good relationship with both his four- year old son and his wife of 12 years, and that he enjoyed the sexual aspect of his relationship with his wife. The examiner then rendered the following opinion and diagnoses: The [veteran] does not appear to be presenting with any clinically significant psychiatric problems. He reports a number of medical problems. At this point in time his medical problems do not appear to be interfering with his psychological functioning. Consequently there appears to be no psychiatric issues which are interfering with his ability to function socially or occupationally. He is competent to manage any VA funds [that] are due to him. Axis I diagnosis: No diagnosis. Axis II diagnosis: No diagnosis. Axis III diagnosis: See medical record. Axis IV diagnosis: Psychosocial stressors, health problems. Axis V diagnosis: Current GAF [score of] 80. The report of a September 1999 VA peripheral nerves medical examination confirms the prior diagnosis of a bilateral carpal tunnel syndrome, a condition for which, as noted earlier, the veteran is already service connected. Finally, at the October 1999 travel board hearing, the veteran said that, during the Persian Gulf War, he took three to four "nerve agent pills" on a daily basis for about two or three days and that, after the war ended, he was exposed to "the oil fires." Regarding his nervous disorder and sleep disturbance allegations, he said that he started noticing the "condition" in February 1993, when he started feeling very sleepy all the time and could not go to sleep at night. He also said that he usually got to sleep at midnight and that he woke up at about five in the morning, "feeling exhausted still." Regarding his nervous symptoms, he described them as a twitching of his left eye and of some of his muscles, mostly in his arms. He denied having experienced any change in his mental status after the war, but said that there had been some change in his emotional status, as he sometimes got "a little irritable." At the travel board hearing, the veteran also said that the physicians that he had seen since 1993 had always blamed his sleep disturbance problem on his going to school, going to work and having a newborn in the house, but that he thought that "that wasn't the problem," because both his wife and mother-in-law lived with him and took care of his son. He further noted that "[t]here's something else wrong and I can't figure out what it is." In reviewing the present claim for service connection on a direct basis, the Board finds that there is no competent evidence in the file demonstrating that at least the Caluza criteria of inservice incurrence of a present disability and a nexus between the claimed present disability and service have been met. It also appears that the Caluza criterion of a present disability has not been met either because, while an impression of insomnia was rendered in December 1993, the most recent competent medical evidence in the file essentially negates support for a finding that there is current manifestation of any psychiatric disability, and it is also apparent that no diagnosis has been rendered to this effect. In reviewing the present claim for service connection under the provisions pertaining to claims based on Persian Gulf War-related undiagnosed illnesses, the Board finds that at least the Caluza criterion of a present disability has not been met in the present case, as no objective indications of chronic disability have been found to exist, as required by the pertinent regulation. Since service, the veteran's complaints have primarily related to problems sleeping and, while the condition being claimed is, as mentioned, "undiagnosed," the fact remains that examiners have attributed his difficulties in this regard to situational factors arising since service, and have not recognized "signs or symptoms," either neurological or neuropsychological in nature, which are necessary to support a claim of this nature. In view of the above, the Board concludes that the veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by a nervous condition with sleep disturbances, on a direct basis, or due to a Persian Gulf War-related undiagnosed illness, that is well grounded, i.e., capable of substantiation. Second Issue Entitlement to service connection for a chronic disability claimed to be manifested by pain in multiple joints, on a direct basis or due to a Persian Gulf War-related undiagnosed illness: A review of the service medical records reveals evidence of an April 1985 complaint of bilateral knee pain, several complaints of right knee pain, lower back pain and bilateral wrist/hand difficulties, starting as early as 1983, as well as objective evidence of a soft tissue injury to the left forearm and a right wrist abrasion in February 1983, a left wrist fracture in October 1986, and a diagnosis of right carpal tunnel syndrome in 1992. As noted earlier in this decision, the veteran is currently service-connected for bilateral carpal tunnel syndrome. He is also service- connected for a lumbosacral spine disability diagnosed as spondylosis deformans at the L3-L4 level, for the residuals of a fracture of the left distal radius and for patellofemoral pain syndrome of the right knee. In his post-Persian Gulf War medical questionnaire of February 1992, the veteran made no reference to multiple joint pains, and it is noted that his references to problems with his musculoskeletal system in his report of medical history for separation purposes of October 1992 only referred to his left wrist fracture and lower back pain. The report of the February 1993 VA general medical examination reveals a history of right carpal tunnel syndrome, complaints of similar symptomatology in the left hand, and a history of swelling in the right knee, as well as complaints of weakness and tingling in both hands and intermittent back pain. On examination, there was a normal range of motion in the neck, in all planes, as well as in the shoulders, elbows, forearms, wrists, hands and fingers. The lower back had normal lumbar lordosis and no tenderness or spasm, the knees had normal configuration with no effusion in either joint, intact internal and external ligaments and normal ranges of motion, bilaterally. The feet were normal, there was a normal range of motion in the ankle joints and normal structure and flexibility of the toes. The pertinent diagnoses were listed as carpal tunnel syndrome of both hands, synovitis of the right knee, and lumbar muscle strain. The report of the February 1993 VA Persian Gulf War medical examination reveals complaints of bilateral shoulder pain, worse on the right, right knee and elbows, and a negative history of injuries to the shoulders or elbows. It was noted that the veteran had bilateral carpal tunnel syndrome since 1989 and that the "non-injured joints" had mild pain. The veteran said that he did not recall when the pains actually began, and he denied swollen joints. The examination of the musculoskeletal system was essentially normal, with full ranges of motion, and no swelling, in all joints, and the pertinent impression was listed as arthralgias, etiology uncertain, and low back pain. VA outpatient medical records that were produced between 1993 and 1995 reveal medical treatment for the veteran's musculoskeletal problems arising from the diagnosed (and service-connected) bilateral carpal tunnel syndrome, right knee disability and lower back disability. The report of a September 1995 VA spine examination reveals complaints of lower back pain, objective evidence of no postural abnormalities, fixed deformities, spasms, or sensory deficits, and a diagnosis of spondylosis deformans at the L3- L4 level, while X-Rays obtained on the same date revealed evidence of degenerative changes at the same levels of the veteran's lumbosacral spine. The report of a September 1995 VA joints examination reveals complaints of constant pain in the right knee, and objective evidence of no swelling, deformity, or instability, but with positive evidence of retropatellar tenderness and pain on moving the patella medially/laterally. X-Rays obtained at that time were reported to be negative, but the diagnosis was listed as patellofemoral pain syndrome [of the right knee], probably chondromalacia. In their statements of 1996, both the veteran's spouse and mother-in-law indicated that the veteran had been complaining of pain in all joints since returning from the Persian Gulf War, and a statement to the same effect was also subscribed by the veteran, in August 1996. VA X-Rays of some of the veteran's joints that were obtained in September 1997 revealed evidence of a rounded calcification projected over the right shoulder joint space, a mild soft tissue swelling over the lateral malleolus of the right ankle, with no fracture, a small calcaneal spur also in the right ankle, a bipartite right patella, mild spondylosis at the L3-L4 level, with slight posterior subluxation of L3 and L4, and minimal narrowing of the L4-L5 disc. The report of a September 1997 VA joints examination reveals complaints of constant joint problems/discomfort, mainly in the right ankle, right knee, back and right shoulder, with no relief on medication. On examination, the carriage and gait were normal, posture was erect, there was "no significant swelling of any of the claimed affected joints," no deformity in any bodily joint, no effusion of either knee joint, non-floating patellae, and intact internal and external ligaments. Ranges of motion of the shoulder and knee joints were described as normal, and the diagnosis was listed as mild degenerative joint disease, multiple joints. The report of an August 1999 VA spine examination reveals complaints of lower back pain and an essentially normal lower back, other than for the painful and limited motion, a statement to the effect that the X-Rays revealed an "unchanged" degree of severity of the lower back degenerative disc disease (DDD) at the L3-L4 level, and a diagnosis of chronic low back pain, due to mild spondylosis, L3-L4, with slight posterior subluxation at the same level, per a prior X-Ray, and DDD unchanged radiologically since 1995. The report of an August 1999 VA joints examination reveals complaints of right knee pain and functional impairment, with objective findings of a normal gait and stance, good coordination, no swelling, effusion, redness, ankylosis or instability, but with guarded flexion. It also reveals complaints of painful motion of the right wrist, but with no swelling, effusion or redness in either wrist, and the ability to achieve full range of motion in both wrists. X- Rays of both wrists were interpreted as normal and an X-Ray of the right knee was likewise interpreted as normal, other than for a bipartite patella. The diagnoses were listed as bilateral carpal tunnel syndrome, right more than left, by history, and chronic right knee [pain], with patellofemoral syndrome and bipartite patella. Finally, at the travel board hearing of October 1999, the veteran indicated that, in his opinion, all his joints were affected by the claimed condition, which he said was manifested by a continuous, sharp pain. As noted earlier, the veteran is currently service-connected for bilateral carpal tunnel syndrome and for disabilities of the right knee, left wrist and lumbosacral spine. Therefore, it naturally follows that any subjective complaints in the file of pain in those joints should not be taken into consideration in reviewing the present matter of service connection for pain in multiple joints, as pain is an essential ingredient of every disability and, as such, it has been taken into account in the ratings that have been assigned for each such service-connected disability. To grant service connection for pain in the veteran's wrists, right knee and lumbosacral spine, either on a direct basis or under the Persian Gulf War provisions, would clearly constitute pyramiding, and that is an action that VA regulation specifically prohibits. See, in this regard, 38 C.F.R. § 4.14 (1999). In reviewing the present claim for service connection on a direct basis, the Board finds that the Caluza criterion of a present disability appears to have been met in the present case, as a mild DDD of the veteran's right shoulder and right ankle have been diagnosed. However, there is no competent evidence in the file demonstrating that the two remaining Caluza criteria have been met, as there is no competent evidence demonstrating the inservice incurrence of either disability and the existence of a nexus, or causal relationship, between these disabilities, which were first diagnosed almost five years after service, and service. In reviewing the present claim for service connection under the provisions pertaining to claims based on Persian Gulf War-related undiagnosed illnesses, the Board notes that the benefit sought on appeal cannot be granted under these provisions either because the veteran's complaints of multiple joint pains have been attributed to the known diagnoses of carpal tunnel syndrome, patellofemoral right knee pain syndrome, residuals of a left radius fracture, spondylosis deformans at the L3-L4 level, and DDD of the right shoulder and right ankle. There remain no signs and symptoms of a medical nature that are "chronic," and otherwise recognizable as a manifestation of a disability that is presently "undiagnosed." In view of the above, the Board concludes that the veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by pain in multiple joints, on a direct basis, or due to a Persian Gulf War-related undiagnosed illness, that is well grounded, i.e., capable of substantiation. Third Issue Entitlement to service connection for a chronic disability claimed to be manifested by a skin rash, on a direct basis or due to a Persian Gulf War-related undiagnosed illness: A review of the file reveals that, in June 1983, that is, prior to his Persian Gulf service, the veteran complained of a rash of unknown origin on the left side of his face, distal to the ear, which the examiner described as a small, round, scaly lesion behind the left ear, of about one inch in diameter, with no redness. The assessment was listed as a possible ringworm, or tinea capitis, and the veteran was prescribed antifungal medication. The service medical records also reveal that the veteran was noted to have a mildly pruritic rash on the anterior aspect of his lower legs in October 1989, still prior to his Persian Gulf service. The rash was described this time as consisting of two to four-mm. in diameter red, non-raised, non- blanching, discrete spots, with no crusting or oozing, and no healed patches. The partially-legible assessment was listed as a discrete, essentially asymptomatic, non-raised, non- blanching rash, and it was noted that a viral element was suspected, as the veteran had admitted to viral upper respiratory infection symptoms three to five days earlier. The examiner also wrote that he "doubt[ed] purpura." No skin-related complaints other than the above were noted during service and the Board notes that, in his post-Persian Gulf medical questionnaire of February 1992, the veteran denied having any rash, skin infection or sores. Likewise, he denied, in his separation report of medical history of October 1992, ever having had, or currently having, skin diseases, and his skin was clinically evaluated as normal, in the report of medical examination of the same date. The report of the February 1993 VA general medical examination reveals no complaints of any skin problems, with objective findings of clear skin. According to the report of the December 1993 VA Persian Gulf medical examination, the veteran said that his rash on both legs had begun before going to Saudi Arabia, approximately in September 1990. He also said that, whenever he got a cold, it got more intense and that, after the cold, it got better and the rash went away. On examination there were one to two-mm. macules, purpuric and mostly on the lower legs, but also extending up to the waist line. The skin was not broken, and the pertinent impression was listed as a "preexisting rash - not related to Persian Gulf experience." A VA dermatological examination was conducted in October 1995, pursuant to the veteran's complaints of a five to six- year history of a skin rash on the legs, sometimes on the arms. According to the report of this examination, the veteran said that the condition had last flared up one-and-a- half weeks prior to the examination, but that it had resolved spontaneously. On physical examination, the skin was again noted to be clear, the assessment was listed as "no pathology," and no medication was accordingly prescribed. According to the report of a September 1997 skin examination, the veteran stated that he had a rash on the anterior aspect of both legs that was diagnosed during service in 1990, and that it manifested in the form of red spots on the legs, with no vesicles. The eruptions were reportedly in the wintertime, they did not produce itching, and he received no treatment for them. The symptoms fluctuated, since the eruption would "come and go." On examination, however, it was noted that no eruption was seen and that, therefore, no color photographs could "demonstrate this." The subscribing examiner also noted that no tests were appropriate at this time, and he listed the diagnosis as a complaint of eruption of legs, by history, not seen at this examination, etiology unknown. Finally, at the travel board hearing of October 1999, the veteran acknowledged that the first time he noticed his rash was in 1989, prior to his Persian Gulf service. He also said that no diagnosis was rendered at the time, that the rash was in the lower portion ("bottom") of his legs, that it also went up to his pelvic area, his underarms and the triceps area, and that he was told that the rash was probably his body's way of reacting to a virus. The veteran further stated that the rash recurred in 1991, that he did not go to the doctor until December 1992, when he was again told that his body was just reacting to a virus, and that the last recurrence had been about six months prior to the travel board hearing. He also indicated that the rash scratched and itched. In reviewing the present claim for service connection on a direct basis, the Board finds that there is no competent evidence in the file demonstrating that at least the Caluza criteria of the manifestation of a present disability and a nexus between the claimed present disability and service have been met. As shown above, no chronic skin disability has been diagnosed and there is no competent evidence in the file demonstrating that any claimed present disability is causally related to service. In reviewing the present claim for service connection under the provisions pertaining to claims based on Persian Gulf War-related undiagnosed illnesses, the Board finds that at least the Caluza criterion of a present disability has not been met in the present case, as no objective or medical indications of a "chronic" disability have been clinically stated to exist, as required by the pertinent regulation. In view of the above, the Board concludes that the veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by a skin rash, on a direct basis, or due to a Persian Gulf War-related undiagnosed illness, that is well grounded, i.e., capable of substantiation. Should evidence clinically substantiating a current chronic disability of the skin be obtained or developed, and which also affords a basis for relating such disability to service, the veteran is encouraged to submit such evidence in an effort to reopen his claim. Fourth Issue Entitlement to service connection for a chronic disability claimed to be manifested by fatigue, on a direct basis or due to a Persian Gulf War-related undiagnosed illness: A review of the file reveals no evidence of complaints of fatigue, or a diagnosis of a chronic disability manifested by fatigue, at any time during service, as well as the veteran's denial, in his post-Persian Gulf questionnaire of February 1992, of having fever, fatigue, weight loss or yellow jaundice. Also, it is noted that, in his report of medical history for separation purposes in October 1992, the veteran denied ever having had, or currently having, asthma, pain or pressure in the chest or chronic cough, but he also indicated that he had had, or currently had, shortness of breath. This last statement was clarified in the same report with a notation to the effect that the shortness of breath was on deep inspiration, with substernal discomfort, but no chest pain. The clinical evaluation of the veteran's lungs and chest in his report of medical examination of the same date was, however, normal. According to the report of the December 1993 VA Persian Gulf War examination, the veteran said that he left active duty in December 1992, that he had started school full time in September 1993, and that he had started to notice fatigue in the late afternoon. He explained that he did his studying from 6:00 to 8:00 p.m. and that it was after 8:00 p.m. when he started "revving up." However, the physical examination was essentially negative, and no impression pertinent to the claimed chronic disability manifested by fatigue was rendered. As noted earlier in this decision, the veteran reported "no decrease in energy" when he underwent the VA psychiatric examination of December 1993. No pertinent diagnosis was rendered in this report, however. Also as noted earlier in this decision, the veteran complained of fatigue when he underwent his September 1997 VA mental disorders examination but, again, no pertinent diagnosis was rendered at that time. None of the medical records in the file reveal a diagnosis of the claimed chronic disability manifested by fatigue, or objective indications of symptoms of fatigue due to an undiagnosed illness. Finally, at the travel board hearing of October 1999, the veteran said that he did not feel fatigued while in the military, but that he started feeling fatigued in the first part of 1993, when he started feeling "I guess sleepy during the daytime, yawning all the time, not getting enough sleep." Currently, he said that, in addition to the fatigue, he also suffered from headaches, a sore throat and other symptoms that made him, a 37-year old individual, feel as if he were living in a 60-year old's body. In reviewing the present claim for service connection on a direct basis, the Board finds that there is no competent evidence in the file demonstrating that the Caluza criteria have been met. As shown above, no complaints of fatigue, nor a diagnosis of a disability manifested by fatigue, were recorded during service, no chronic disability manifested by fatigue has ever been diagnosed, and there is no competent evidence in the file demonstrating that any claimed present disability is causally related to service. In reviewing the present claim for service connection under the provisions pertaining to claims based on Persian Gulf War-related undiagnosed illnesses, the Board finds that none of the Caluza criteria have been met in the present case, to include the "present disability" criterion, as no objective indications or medical signs of a chronic disability have been noted to exist, as required by the pertinent regulation. It is also necessary to point out that, with regard to this issue, it is not documented that the veteran has complained of fatigue, intermittent or otherwise, over at least a six- month period, such as would support a requisite finding of there being "chronic" disability. In view of the above, the Board concludes that the veteran has failed in his initial duty to submit a claim of entitlement to service connection for a chronic disability claimed to be manifested by fatigue, on a direct basis, or due to a Persian Gulf War-related undiagnosed illness, that is well grounded or capable of substantiation. Final considerations applicable to the four claims on appeal: Regarding the Caluza criterion of a nexus between a claimed present disability and service, the Board notes that the only evidence in the file suggesting a possible nexus, or causal relationship, between the claimed conditions and service in the present case consists of the statements rendered by the veteran, his spouse and mother-in-law to that effect. Regrettably, the Board must note that, even accepting these statements as true, the veteran cannot meet his initial burden under 38 U.S.C.A. § 5107(a) by simply presenting lay opinions, insofar as there is no indication in the record that any of the subscribers of these opinions possesses the requisite medical knowledge or education to render a probative opinion involving medical diagnosis or medical causation. See, Edenfield v. Brown, 8 Vet. App. 384, 388 (1995); Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); and Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Also, and finally, the Board notes that the veteran has not reported that any competent evidence exists that, if obtained, would establish claims for service connection that might be considered to be well grounded, i.e., plausible or capable of substantiation. Under these circumstances, VA has no further duty to assist the veteran in developing the four matters on appeal. Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). (CONTINUED ON THE NEXT PAGE) ORDER 1. Service connection for a chronic disability claimed to be manifested by a nervous condition, with sleep disturbances, both on a direct basis, and due to a Persian Gulf War-related undiagnosed illness, is denied. 2. Service connection for a chronic disability claimed to be manifested by pain in multiple joints, both on a direct basis, and due to a Persian Gulf War-related undiagnosed illness, is denied. 3. Service connection for a chronic disability claimed to be manifested by a skin rash, both on a direct basis, and due to a Persian Gulf War-related undiagnosed illness, is denied. 4. Service connection for a chronic disability claimed to be manifested by fatigue, both on a direct basis, and due to a Persian Gulf War-related undiagnosed illness, is denied. JEFF MARTIN Member, Board of Veterans' Appeals