Citation Nr: 1641626 Decision Date: 10/27/16 Archive Date: 11/08/16 DOCKET NO. 13-24 345 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for arthritis of the right shoulder. 2. Entitlement to service connection for arthritis of the left shoulder 3. Entitlement to service connection for arthritis of the right elbow. 4. Entitlement to service connection for arthritis of the left elbow. 5. Entitlement to service connection for arthritis of the right wrist. 6. Entitlement to service connection for arthritis of the left wrist. 7. Entitlement to service connection for arthritis of the right hip. 8. Entitlement to service connection for arthritis of the left hip. 9. Entitlement to service connection for a bilateral knee disability. 10. Entitlement to service connection for a low back disability. 11. Entitlement to service connection for cervical muscle strain with degenerative disc disease at C3-7. 12. Entitlement to service connection for the residuals of cheekbone injuries, status post rebuilt face. 13. Entitlement to service connection for calcification of the eye socket and facial sinus cavities. 14. Entitlement to service connection for sinus problems secondary to calcification of the eye socket and facial sinus cavities. 15. Entitlement to service connection for a separated stomach wall. 16. Entitlement to service connection for sleep problems other than sleep apnea secondary to arthritic pain. 17. Entitlement to service connection for swallowing problems, to include as secondary to cervical muscle strain with degenerative disc disease at C3 to C7. 18. Whether new and material evidence has been received to reopen a claim for service connection for the residuals of a broken nose. 19. Entitlement to service connection for the residuals of a broken nose on a de novo basis. 20. Whether new and material evidence has been received to reopen a claim for service connection for epididymitis. 21. Whether new and material evidence has been received to reopen a claim for service connection for bilateral hearing loss. 22. Whether new and material evidence has been received to reopen a claim for service connection for tinnitus. 23. Whether new and material evidence has been received to reopen a claim for service connection for a condition of the ear drums. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from July 1963 to August 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Portland, Oregon, Regional Office (RO) of the Department of Veterans Affairs (VA). In a February 2016 statement, the Veteran withdrew his previous request for a hearing before a Veteran's Law Judge. In addition to the Veteran's current claim of service connection for sleep problems secondary to arthritic pain, the record shows that he submitted a separate claim of entitlement to service connection for sleep apnea that was denied in an August 2016 rating decision. This decision has not been appealed, and the matter of service connection for sleep apnea is not before the Board. In fact, there is medical evidence that seemingly confirms that the Veteran has sleep problems that may result at least in part from factors other than sleep apnea. 4/27/2016 Virtual VA, Capri#3, pp. 1-13. The issue has been characterized accordingly. The issues of entitlement to service connection for arthritis of the right hip, arthritis of left hip, arthritis of the right wrist, arthritis of the left wrist, arthritis of the right elbow, arthritis of the left elbow, arthritis of the right shoulder, arthritis of the left shoulder, residuals of cheekbone injuries, calcification of the eye socket and sinuses, a sinus disability, sleep problems, and the residuals of a broken nose on a de novo basis are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The service treatment records are negative for evidence of complaints or injury pertaining to the knees, cervical spine, or back; the Veteran denied all pertinent symptomatology at the time of his discharge. 2. The preponderance of the competent medical evidence is against a finding of any relationship between the Veteran's current bilateral knee disability, low back disability, and cervical spine disability and active service, to include parachute jumps during service. 3. Arthritis of the knees, cervical spine, and low back was not shown during service or within one year of discharge from service. 4. Entitlement to service connection for an epigastric hernia has already been established; the service treatment records are negative for any other disability manifested by separation of the stomach wall, and there is no evidence of a current disability resulting from separation of the stomach wall. 5. Medical opinion attributes the Veteran's difficulty in swallowing to cervical osteophytes and post-operative changes from a thyroidectomy, neither of which are service-connected disabilities; service treatment records are negative for dysphagia, and no competent evidence attributes the Veteran's current disability to active service. 6. The Veteran's claims of service connection for the residuals of a broken nose, bilateral hearing loss, tinnitus, a condition of the ear drums, and epididymitis were denied in a June 1991 Board decision. 7. The June 1991 Board decision noted that there was no evidence of a facial trauma during service or until many years after discharge from service. 8. Evidence received since June 1991 includes indications that the Veteran sustained a facial trauma in the distant past, which would have likely included his nose. 9. The June 1991 Board decision noted that the Veteran had received treatment for epididymitis during active service, but denied his claim on the basis that there was no current disability that resulted from the episode in service. 10. Evidence received since June 1991 fails to include a current diagnosis of epididymitis or a similar disability. 11. The June 1991 Board decision noted that the Veteran had a current diagnosis of bilateral hearing loss, but denied his claim on the basis that the evidence failed to relate his hearing loss to active service. 12. Evidence received since the most recent denial of the Veteran's claim in March 1993 does not include any information or opinion that purports to relate the Veteran's current hearing loss to active service. 13. The June 1991 Board decision noted that the Veteran had a current diagnosis of tinnitus, but denied his claim on the basis that the evidence failed to relate his tinnitus to active service. 14. Evidence received since the most recent denial of the Veteran's claim in March 1993 does not include any information or opinion that purports to relate the Veteran's tinnitus to active service and in fact indicates that there is no longer any current disability. 15. The June 1991 Board decision noted that the Veteran was treated for a perforation of the right tympanic membrane in service, but denied his claim on the basis that there was no evidence of a current disability resulting from this perforation. 16. Evidence received since the most recent denial of the Veteran's claim in March 1993 does not include any information or opinion that purports to show a diagnosis of a current disability due to the perforation of the Veteran's right tympanic membrane. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a bilateral knee disability have not been met, and a bilateral knee disability is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.303(a), 3.307, 3.309 (2015). 2. The criteria for entitlement to service connection for a low back disability have not been met, and a low back disability is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.303(a), 3.307, 3.309 (2015). 3. The criteria for entitlement to service connection for cervical muscle strain with degenerative disc disease at C3-7 have not been met, and a cervical spine disability is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.303(a), 3.307, 3.309 (2015). 4. The criteria for service connection for a separated stomach wall have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. § 3.303(a) (2015). 5. The criteria for service connection for swallowing problems, to include as secondary to cervical muscle strain with degenerative disc disease at C3 to C7, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.303(a), 3.310(a) (2015). 6. The June 1991 Board decision that denied entitlement to service connection for the residuals of a broken nose, bilateral hearing loss, tinnitus, a condition of the ear drums, and epididymitis is final. 38 U.S.C.A. § 7104(b) (West 2014); 38 C.F.R. § 20.1105 (2015). 7. New and material evidence having been received, the claim for service connection for the residuals of a broken nose is reopened. 38 C.F.R. § 3.156(a) (2015). 8. New and material evidence has not been received to reopen the claim of service connection for epididymitis. 38 C.F.R. § 3.156(a) (2015). 9. New and material evidence has not been received to reopen a claim of service connection for bilateral hearing loss. 38 C.F.R. § 3.156(a) (2015). 10. New and material evidence has not been received to reopen a claim of service connection for tinnitus. 38 C.F.R. § 3.156(a) (2015). 11. New and material evidence has not been received to reopen a claim of service connection for a condition of the ear drums. 38 C.F.R. § 3.156(a) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). In this case, the Veteran was provided with complete VCAA notification in October 2009 and January 2014 letters that contained all the information required by Pelegrini v. Principi, 18 Vet. App. 112 (2004) and Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). They were provided to the Veteran prior to the initial adjudication of his claims. The duty to notify has been met. The Board also finds that the duty to assist has been met. The Veteran was afforded VA examinations of his knees, cervical spine, and thoracolumbar spine in June 2013. The examiner reviewed the record and provided appropriate opinions. Although VA was not obligated to provide the Veteran examinations in regards to his claims to reopen previously denied claims for service connection for epididymitis, hearing loss, tinnitus, or ear drum problems, examinations were conducted, and when current diagnoses were noted the examiners provided etiological opinions. The Veteran's VA treatment records have also been obtained, as have pertinent private medical records. He requested a hearing but withdrew this request before it was conducted. The Veteran has not been provided VA examinations for his claimed separated stomach wall or swallowing problems. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. In regard to the claim for a separated stomach wall, there is no competent evidence that the Veteran has a current disability other than his service connected epigastric hernia. While there is evidence of dysphagia, the evidence also shows that it is related to non-service connected disabilities, and there is nothing in the record to associate this disability with active service. Therefore, the McLendon standard has not been met, and examinations were not required. There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. If arthritis become manifest to a degree of 10 percent within one year of separation from active service, it is presumed to have been incurred during active service, even though there is no evidence of arthritis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic diseases listed in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997), overruled on other grounds by Walker v. Shinseki. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Musculoskeletal Claims, to include Arthritis The Veteran contends that his arthritis of the knees, neck, and low back is the result of active service. He believes his arthritis is the result of the many parachute jumps he made during service. The Veteran's service treatment records are negative for evidence of injury, complaints, or treatment pertaining to knees, neck, or low back. The July 1964 discharge examination shows that the Veteran's lower extremities were normal. His neck and spine were also normal. On the Report of Medical History completed by the Veteran at this time, he answered "no" to a history of swollen or painful joints; arthritis or rheumatism; bone, joint, or other deformity; lameness; and trick or locked knee. 2/1/1990 VBMS, STR - Medical, pp. 2-5. Post service records show that the Veteran was seen in December 1996 by a private examiner for several complaints, including the right knee. An injury was noted to have occurred in October 1996. The Veteran reported that there was no previous injury to the right knee. There was no swelling but the Veteran said that he was unable to fully flex it. On examination, there was significant limitation of motion of the neck. The impression was a soft tissue strain, and an X-ray study showed a significant three-level disease at C 3, 4, 5, 6, and 6-7. The thoracic area was also tender. Range of motion of the right knee was reduced. 2/24/1997 VBMS, Medical Treatment Record - Non-Government Facility, In a January 1997 statement submitted in connection with a claim for non-service connected pension benefits, the Veteran noted that he was being treated and evaluated for an on the job injury that affects his right knee, upper back, and neck. 1/23/1997 VBMS, VA 21-4138 Statement in Support of Claim, p. 1. The Veteran was seen by his private doctor for a lower back problem in August 1997 and September 1997. He reported having a problem for quite some time and that it was getting worse. The impression was mechanical lower back pain. A magnetic resonance imaging study showed a rather severe stenosis at L3-L4 with a fragment below the plate of L3. The examiner indicated that the Veteran's situation was serious and that he needed to be seen by a neurosurgeon. 11/13/2009 VBMS, Medical Treatment Record - Non-Government Facility, pp. 1-12. VA treatment records dated August 2009 indicate that the Veteran was treated for complaints of pain in his neck, back and joints. 10/30/2009 VBMS, Capri, pp. 7-8. In a February 2011 letter, the Veteran's VA doctor states that he has provided longitudinal endocrinology care for the Veteran due to thyroid cancer since 1997. Since that time, the Veteran had developed severe degenerative joint disease involving both of his shoulders, pelvis, and cervical spine. As the Veteran served in the airborne and participated in parachute jumps, it seemed likely that these activities could have set the stage for his declining musculoskeletal health. 3/10/2011 VBMS, Medical Treatment Record - Government Facility, p. 1. The Veteran was afforded a VA examination of his knees, cervical spine and thoracolumbar spine in June 2013. The claims file was reviewed by the examiner. The Veteran was noted to have a history of low back pain, initially in service in 1963. He reported having upwards of 20 overall jumps. The Veteran believed his problems with the back, neck, and knees stemmed from those jumps. The diagnosis of the thoracolumbar examination was degenerative disc disease of the lumbar spine. The diagnosis for the cervical spine was degenerative changes with associated cervical spasm. Arthritis of both the thoracolumbar and cervical portions of the spine was confirmed by X-ray study. Regarding the knees, the diagnosis was osteoarthritis of the bilateral knees, which was again confirmed by X-ray evidence. 6/14/2013 Virtual VA, C&P Exam, pp. 1-22. The June 2013 examiner opined that it was less likely than not that the Veteran's back disability, neck disability, or bilateral knee disability was incurred in or caused by active service. The rationale for each of these disabilities was that it was degenerative in nature and more likely due to age than to the 20 completed jumps between 1963 and 1964. It was not likely that the jumps contributed to the severity of this condition. 6/14/2013 Virtual VA, C&P Exam, pp. 22 - 29. A VA sleep clinic note dated October 2014 says that the Veteran complained of pain in every joint. He took morphine every 6 hours. The disability dated from road construction in 1997. He was also noted to have been involved in a parachute injury during service in which he had become tangled with another jumper. 12/3/2015 Virtual VA, Capri, p. 294. On a December 2014 VA chest X-ray, the Veteran was noted to have degenerative changes of the thoracic spine, with prominent anterior osteophytosis. 12/3/2015 Virtual VA, Capri, p. 236. A May 2016 VA treatment note states that the Veteran was seen for routine care. He had back and neck issues and ongoing pain, but his only radicular pain was of the right lower extremity in the inner thigh area. At the end of the visit, the assessments included osteoarthritis of the cervical and lumbar spine and bilateral knees. 5/31/2016 Virtual VA #1, Capri, pp. 5-7. After considering the foregoing, the Board finds that entitlement to service connection for a bilateral knee disability, a low back disability, and cervical muscle strain with degenerative disc disease at C3-7 is not supported by the evidence. Although the service treatment records are completely negative for evidence of injury to or complaints regarding the neck, back, or knees, the Veteran has presented credible statements pertaining to the amount of parachute jumps he completed. The awards and decorations listed on his DD 214 include the Parachutist Badge. Therefore, the evidence supports a finding that the Veteran sustained at least some degree of trauma to his joints during service. Furthermore, the current treatment records and the June 2013 VA examination confirm that the Veteran has current disabilities of the neck, back, and knees. Thus, the first two criteria for service connection have been met. However, in order to establish entitlement to service connection, it is not enough to show injury in service and a current disability. The evidence must also show a relationship between the two. In this case, the preponderance of the competent evidence is against such a finding for each of the Veteran's claimed disabilities. The Board has considered the Veteran's belief that his disabilities are the result of his parachute jumps in service. The Veteran is competent to report these events, as well as his subsequent symptoms. However, there is no evidence that the Veteran has any medical training, and he is not competent to provide evidence as to more complex medical questions addressing the etiology of the degenerative changes in his joints. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Turning to the competent medical opinions, in regard to the degenerative changes of the cervical spine, the February 2011 examiner opined that it seemed likely that the Veteran's parachute jumps "could have set the stage for his declining musculoskeletal health." However, this opinion finds a mere possibility of a relationship, but does not express the requisite certainty for the veteran to prevail. In essence the opinion is speculative. Statements from doctors which are inconclusive as to the origin of a disease cannot fulfill the nexus requirement. Warren v. Brown, 6 Vet. App. 4, 6 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In Obert v. Brown, the Court held that a medical opinion expressed in terms of "may," also implies "may or may not" and is too speculative to establish a plausible claim. Bostain v. West, 11 Vet. App. 11 Vet. App. 124 (1998); Obert v. Brown, 5 Vet. App. 30 (1993). In contrast, the June 2013 examiner opined that it was less likely than not that the Veteran's neck disability was incurred in or caused by active service. That examiner reasoned that the current disorders were degenerative in nature and more likely due to age then the 20 completed jumps between 1963 and 1964. It was also not likely that the jumps contributed to the severity of this condition. The Board finds that this opinion is the most probative because it is expressed with a higher degree of certitude, and because it provides an alternate explanation for the development of the cervical spine disability. Therefore, a nexus between the Veteran's current cervical spine disability and service is not established. Regarding the low back and bilateral knee disabilities, these were not directly addressed in the February 2011 opinion other than to note the Veteran's declining musculoskeletal health. Once again, the June 2013 examiner opined that it was less likely than not that the Veteran's back disability or bilateral knee disability was incurred in or caused by active service. The rationale remained that these disabilities were degenerative and more likely due to age then the 20 completed jumps, and it was not likely that the jumps contributed to their severity. As this is the only competent opinion on the matter, a nexus between the Veteran's bilateral knee disabilities and low back disability, and active service is not established. The Board has also considered whether or not the cervical strain claimed by the Veteran is due to active service, but must find that it is not. There is no evidence of a cervical strain in service, including at discharge. In fact, the initial evidence of a cervical strain was not shown until after an on the job injury in 1996, more than 32 years after discharge. The current examination did not include a diagnosis of a strain. The Board has considered entitlement to service connection for the Veteran's degenerative changes of the cervical spine, thoracolumbar spine, and knees on a presumptive basis, but this is not supported by the evidence. Arthritis was not shown for any of these joints during service or within the first year following discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Finally, the Board finds that continuity of symptomatology has not been established for the cervical spine, the low back, or the knees. Any assertion by the Veteran that he has experienced more or less continuous knee, back, or neck symptoms since discharge is contradicted by his denial of all pertinent symptomatology at the time of his July 1964 discharge. The Veteran asserts that he denied his disabilities in order to avoid any delay with his discharge, but the Board notes that he answered "yes" questions regarding some unrelated disabilities. The Veteran's private treatment records from 1996 to 1997 indicate that he sustained a work related injury sometime around October 1996. The follow up records show that the Veteran specifically denied having a right knee disability prior to that time. His records state that the injury affected his neck, back, and right knee. These records also tend to indicate that they were related to a worker's compensation claim, which suggests that the Veteran previously believed his disabilities were due to a cause other than service. Continuity of symptomatology is not established for any of the claimed disabilities. The Board must conclude that service connection for a bilateral knee disability, a low back disability, and cervical muscle strain with degenerative disc disease at C3-7 is not warranted on any basis. Separated Stomach Wall The Veteran's service treatment records show that he was treated for an epigastric hernia. Service connection has been in effect for this disability since December 1989. Therefore, no additional discussion of the hernia is necessary. The service treatment records are negative for evidence of any other injury, complaints or treatment pertaining to a separated stomach wall. The July 1964 discharge examination found that the abdomen and vicera were normal. The Veteran answered "yes" to a history of a rupture on the Report of Medical History obtained at that time. However, the only reference in the physician's summary was to the epigastric hernia. There was no additional reference to separation of the stomach wall. 2/1/1990 VBMS, STR - Medical, pp. 2-5. The current medical records are negative for any evidence of a disability manifested by separation of the stomach wall. The Board finds that entitlement to service connection for separation of the stomach wall is not established. There is no evidence that this disability ever existed or currently exists. The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131 (West 1991); see Degmetich v. Brown, 104 F.3d 1328 (1997). As there is no evidence of a disability manifested by separation of the stomach wall, aside from the service connected epigastric hernia, entitlement to service connection is not warranted. Swallowing Problems The Veteran contends that the arthritis in his cervical spine makes it difficult to swallow. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In this instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The evidence in this case includes the report of a November 2014 VA otolaryngology consultation. The Veteran was noted to have dysphagia, which was the result of a combination of cervical osteophytes and post-operative changes from a thyroidectomy. 12/3/2015 Virtual VA, Clinical Documents, p. 256. However, the Board must find that entitlement to service connection for swallowing problems is not warranted. As previously noted, entitlement to service connection for a cervical spine disability is denied. Therefore, service connection for swallowing problems secondary to the cervical spine disability may not be service connected either. Entitlement to service connection for a thyroidectomy has not been established or even claimed, so that service connection cannot be granted on that basis. 38 C.F.R. § 3.310(a). The Board has also considered entitlement to service connection for a disability manifested by swallowing problems on a direct basis. However, the service treatment records are negative for evidence of dysphagia. The July 1964 discharge examination found that the throat was normal. The Veteran answered "yes" to a history of ear, nose, or throat problems on the Report of Medical History he completed at that time, but the physician's summary shows that this was a reference to his eardrums and not his throat. Furthermore, there is no showing of continuity of symptomatology, either through the clinical record or the lay statements and there is no medical opinion that relates the Veteran's swallowing problems to active service. Entitlement to service connection for swallowing problems on a direct basis is not established. New and Material Evidence The record shows that entitlement to service connection for the residuals of a broken nose, bilateral hearing loss, tinnitus, a condition of the ear drums and epididymitis was denied in a June 1991 decision of the Board. When a claim is disallowed by the Board, it may not be thereafter be reopened and allowed, and no claim based upon the same factual basis shall be considered. When a claimant requests that a claim be reopened after an appellate decision and submits evidence in support thereof, a determination as to whether such evidence is new and material must be made and, if it is, whether it provides a new factual basis for allowing the claim. 38 U.S.C.A. § 7104(b); 38 C.F.R. § 20.1105. Therefore, the June 1991 denial of service connection for the residuals of a broken nose, bilateral hearing loss, tinnitus, a condition of the ear drums and epididymitis is final. A veteran may reopen a finally adjudicated claim by submitting new and material evidence. New evidence is defined as existing evidence not previously submitted to the VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New and material evidence is not required as to each previously unproven element of a claim. Furthermore, the question of whether to reopen a claim should be considered under the standard of 38 C.F.R. § 3.159(c)(4)(iii), consistent with McLendon v. Nicholson, 20 Vet. App. 79 (2006), for determining whether a VA examination is necessary. If the McLendon standard is met, the claim should be reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The United States Court of Veterans Appeals (Court) has stated that for the purpose of determining whether or not new and material evidence has been presented to reopen a claim, the evidence for consideration is that which has been presented or secured since the last time the claim was finally disallowed on any basis, and not only since the last time it was disallowed on the merits. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The evidence considered by the June 1991 Board decision for each of the Veteran's claims included his service treatment records, private medical records dating through 1986, VA records and examinations dating through 1990, lay statements from the Veteran's father, uncle, and friends dated in February and March 1990, and the transcript of a September 1990 hearing. Broken Nose The Board noted that the service treatment records did not document the Veteran's claimed broken nose. A deviated nasal septum was not shown until 1988, at which time surgical intervention was required. This was not shown to be related to any incident of the Veteran's active military service. Based on this evidence, the Board determined that neither a broken nose nor the residuals thereof was present during service or until many years after discharge from service. 6/25/1991 VBMS, BVA Decision, p. 1. The evidence received since June 1991 includes a September 2009 computed tomography (CT) scan of the sinus. This showed calcifications on the left side of the brain, which could represent a congenital malformation or some scarring. There was some scarring on the floor of the right eye socket bone. 10/30/2009 VBMS, Capri, pp. 1-8. The Veteran underwent a VA examination for the residuals of traumatic brain injuries (TBI) in March 2014. The September 2009 CT scan was reviewed, and the examiner noted a chronic appearing defect of the left lamina papyracea that had been displaced medially and, likely secondary to remote fracture, unchanged. There was also a chronic appearing defect in the floor of the right orbit which was well circumscribed and extends inferiorly in the max or sinus, which was likely a healed remote fracture. Finally, a small focus of coarsened calcification in the left external capsule was noted. The impressions included calcification in the left external capsule in the brain parenchyma, which most likely represented a cavernous malformation, but could also represent the sequelae of a prior infection or trauma. In addition, there was an impression of a remote left lamina papyracea and right orbital floor fractures. 3/25/2014 Virtual VA, C&P Exam, p. 6. The Board finds that the March 2014 interpretation of the September 2009 CT scan constitutes new and material evidence with respect to the Veteran's claim of service connection for the residuals of a broken nose. It is new in that the information contained in the CT scan was not before the Board in June 1991. The Board notes that with respect to the issue of materiality, the newly presented evidence need not be probative of all the elements required to award the claim as in this case dealing with a claim for service connection. Evans v. Brown, 9 Vet. App. 273, 284, (1996) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996) (table)). The newly presented evidence is presumed to be credible for purposes of determining whether or not it is new and material. Savage v. Gober, 10 Vet. App. 488 (1997). The March 2014 references to remote fractures is material because, when considered with the Veteran's contentions, tends to support the assertion that another soldier struck him in the face with a rock during service. As new and material evidence has been received, the claim for service connection for the residuals of a broken nose is reopened. This matter will be addressed further in the remand section at the end of the decision. Epididymitis The June 1991 Board decision noted that the Veteran's service treatment records showed treatment for epididymitis. However, as the discharge examination showed that the genitourinary system was normal, and as a March 1990 VA examination noted only a history of epididymitis that had resolved with antibiotic treatment, the Board determined that this episode was acute and transitory in nature, and resolved without residual disability. The Board concluded that the Veteran no longer had a current diagnosis of epididymitis. Evidence received since June 1991 includes private treatment records dating from 1996 to 1997 and VA treatment records dating from 2009 to 2015. These records are completely negative for a current diagnosis of epididymitis. A July 2011 VA treatment note states that the Veteran's wife had called to report that the Veteran had an ache in the left groin/testicle. The assessment was a possible stretched muscle, although the recent diagnosis of prostate cancer was also noted. 7/2/2013 Virtual VA, Capri, p. 199. In January 2014, a VA clinic received a call from the Veteran's spouse. The Veteran was complaining of right testicular pain. It was recommended that the Veteran come in for an evaluation as he could have a urinary tract infection or epididymitis, but he refused. 4/16/2014 Virtual VA, Capri, p. 170. Left testicular pain was reported in a February 2014 note. 4/16/2014 Virtual VA, Capri, p. 154. The Veteran was also afforded a VA examination of the reproductive system in March 2014. A diagnosis of a left testicle strain in 1964 was noted. A review of his medical records showed a diagnosis of prostate cancer in 2011 with surgery. Left testicle pain was mentioned in July 2011 and February 2014 but was otherwise not found in the VA notes going back to 1997. After examination, the examiner determined that the Veteran did not have a current disease or pathologic process of the testicle. The Veteran's medical records did not suggest a chronic condition and the examination was normal. 3/12/2014 Virtual VA, C&P Exam, p. 1. An April 2014 urology notes shows that the Veteran was followed up for prostate cancer. He denied having any testicular pain. 4/16/2014 Virtual VA, Capri, p. 1. The Board finds that the evidence received since June 1991 includes items that were not examined at the time of the June 1991 decision, and are therefore new. However, the Board must also find that none of this evidence is material. The June 1991 decision denied the Veteran's claim on the basis that there was no evidence of a current diagnosis of epididymitis or similar disability. None of the evidence received since June 1991 includes such a diagnosis. The examiner reached by telephone in January 2014 speculated that the Veteran might have epididymitis, but this was not based on an examination. The March 2014 VA examination was negative for epididymitis or any other disability of the left testicle. In the absence of a diagnosis of a current disability of the left testicle, the additional evidence is not material, and the Veteran's claim cannot be reopened. Hearing Loss, Tinnitus, Ear Drums Entitlement to service connection for impaired hearing is subject to the additional requirements of 38 C.F.R. § 3.385, which provides that service connection for impaired hearing shall not be established when hearing status meets pure tone and speech recognition criteria. Hearing status will be considered a disability for the purposes of service connection when the auditory thresholds in any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2015). The United States Court of Veterans Appeals (Court) has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). The June 1991 Board decision notes the service treatment records reflect that the Veteran was treated for a perforation of the right tympanic membrane. However, as the discharge examination showed that the ears were normal, and as a March 1990 VA examination found that the eardrums were normal without evidence of perforation, the Board determined that this episode was acute and transitory in nature, and resolved without residual disability. The Board determined that the Veteran did not have a current disability associated with the perforated eardrum. The Board decision also noted that the Veteran had a single, very slightly elevated threshold at one frequency of the left ear when he entered service, but that all other thresholds were normal and no diagnosis was made. His hearing was well within normal limits at discharge. The earliest evidence of hearing loss and tinnitus was on a March 1990 VA examination, which showed hearing loss that met the requirements of 38 C.F.R. § 3.385. The Veteran did not claim tinnitus at the examination. The Board found that chronic bilateral defective hearing, sensorineural hearing loss, and tinnitus were not shown for many years after service and not demonstrated to be of service origin. The record shows that the Veteran has attempted to reopen these three claims on two previous occasions. The most recent denial was by an unappealed March 1993 rating decision. Evidence received since March 1993 includes private treatment records dating from 1996 to 1997 and VA treatment records dating from 2009 to 2015. A September 2009 VA audiology consult note shows that the Veteran reported a remote history of tinnitus which no longer occurred. He also reported excessive military, occupational and recreational noise exposure with minimal hearing protection use. Finally, the Veteran reported possible tympanic membrane perforations in the military. On examination, the otoscopy was unremarkable bilaterally. The Veteran continued to have moderate sensorineural hearing loss bilaterally. 10/30/2009 VBMS, Capri, p. 2. The Veteran was afforded a VA examination for his claimed hearing loss and tinnitus in March 2014. The claims file was reviewed by the examiner. An audiological examination showed that the Veteran continued to have hearing loss as defined by 38 C.F.R. § 3.385. The diagnosis was sensorineural hearing loss of each ear. However, the examiner opined that the Veteran's hearing loss was not at least as likely as not due to active service. The rationale was that although the Veteran had noise exposure in service, his hearing was within normal limits for all frequencies tested at separation. The hearing loss of the left ear noted on the entrance examination was not aggravated, as it was also normal at discharge. The Veteran's reports of perforated eardrums in service were noted, but the examiner stated that there was no indication of any long standing conductive hearing loss consistent with middle ear damage. The Veteran denied currently having tinnitus. 3/3/2014 Virtual VA, C&P Exam, p. 1. August 2014 VA treatment notes show that the Veteran has a diagnosis of sensorineural hearing loss, asymmetrical. He was seen to be fitted with new hearing aids. On examination, the ear canals were clear bilaterally with normal appearing tympanic membranes. 12/3/2015 Virtual VA, Capri, 345. The remainder of the Veteran's VA treatment records is negative for a diagnosis of tinnitus, a condition of the eardrums, or an opinion relating his hearing loss to active service. The Board finds that the evidence received since 1993 is new, in that it contains additional information that was not previously considered. However, the Board must also find that none of the additional evidence is material in regards to any of the three claimed disabilities of the ears. The Board, in June 1991, acknowledged that the Veteran currently had a hearing loss. However, the Veteran's claim was denied on the basis that there was no evidence to relate the hearing loss to active service. None of the evidence received since the most recent consideration of the Veteran's claim in March 1993 includes such evidence. In fact, the March 2014 VA examiner specifically opined that the Veteran's hearing loss was not related to service or aggravated within service. In the absence of evidence that relates the Veteran's hearing loss to active service, the new evidence is not material. Similarly, the June 1991 Board decision found that there was no evidence to relate the Veteran's tinnitus to active service. The evidence received since March 1993 also fails to include any information or opinion that relates tinnitus to active service or shows continuous symptoms since service; in fact, the most recent evidence shows that the Veteran denies currently experiencing tinnitus. In the absence of such an opinion, the evidence is not material. Finally, the June 1991 Board decision denied the Veteran's claim of service connection for a condition of the ear drums on the basis that there was no evidence of a current disability. The evidence received since 1993 continues to be negative for any such disability, which means that it is not material. As the additional evidence received since March 1993 regarding the Veteran's hearing loss, tinnitus, and ear drum condition is not both new and material, his claims may not be reopened. ORDER Entitlement to service connection for a bilateral knee disability is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for cervical muscle strain with degenerative disc disease at C3-7 is denied. Entitlement to service connection for a separated stomach wall is denied. Entitlement to service connection for swallowing problems to include as secondary to cervical muscle strain with degenerative disc disease at C3 to C7 is denied. New and material evidence has been received to reopen the Veteran's claim for service connection for the residuals of a broken nose; to this extent only, the appeal is allowed. New and material evidence has not been received to reopen a claim for service connection for epididymitis; the appeal is denied. New and material evidence has not been received to reopen a claim for service connection for bilateral hearing loss; the appeal is denied. New and material evidence has not been received to reopen a claim for service connection for tinnitus; the appeal is denied. New and material evidence has not been received to reopen a claim for service connection for a condition of the ear drums; the appeal is denied. REMAND Arthritis The Veteran underwent VA examinations of the wrist, elbow, and shoulders in March 2014. X-ray studies confirmed arthritis of the wrist, elbows, and shoulders. However, for each of these joints the examiner opined that the Veteran's current wrist, elbow, and shoulder complaints and arthritis were less likely than not due to parachute jumps in service. The examiner explained that the X-rays showed multifocal hyperthrophic osseous changes that were consistent with idiopathic skeletal hyperostosis. The examiner was unable to link the Veteran's current complaints to the parachute jumps in service, and that the conditions were separate and independent of each other. 3/23/2014 C&P Exam #3, pp. 1-20. While the March 2014 VA examiner is correct in noting that the Veteran contends his current disabilities are the result of his parachute jumps in service, the Board notes that the potential award of service connection is not limited to arthritis that may have developed just on this basis. Instead, the Veteran is entitled to service connection for his claimed wrist, elbow, and/or shoulder disabilities if they are due to service on any basis, to include but not limited to his parachute jumps. Unfortunately, the opinions provided by this examiner appear to exclude consideration for disabilities of the wrists, elbows, and/or shoulders that may have been incurred in service due to other causes. If VA provides the Veteran with an examination, the examination must be adequate. 38 C.F.R. § 3.159(c)(4) (2015); Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board must return the March 2014 examination report to the examiner in order to obtain an addendum opinion that addresses whether or not service connection for any disability of the claimed joints may have been incurred in service on any basis. The Veteran contends that he has developed arthritis of the right and left hips due to active service. As with his other disabilities, he believes this arthritis is the result of parachute jumps. The record includes a VA Form 21-0820, Report of General Information, dated April 2014 which states that the Veteran's CAPRI records were provided to a VA examiner. The examiner was also informed of the pertinent facts from the service treatment records. This examiner opined that the Veteran's bilateral hip arthritis was less likely than not related to service, to include parachute jumps. Instead, the Veteran's disability was related to idiopathic skeletal hyperostosis, which is a disability unrelated to service that arose well after service. 4/16/2014 Virtual VA, VA 27-0820 Report of General Information, p. 1. As previously noted, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. In this case, the April 2014 opinion was not provided by the same examiner who conducted the March 2014 examination. The findings of that examination were not cited in the April 2014 opinion. Furthermore, while the March 2014 examination notes that X-ray studies of the elbows, wrists, and shoulders were obtained, there is no indication that any such studies of the hips were conducted. Finally, while the Report says that the Veteran's CAPRI records were reviewed and a description of the relevant information in the service treatment records was supplied to the examiner, there is no indication that the claims file itself was reviewed prior to rendering the opinion. Thus, the Board is unable to determine what evidence was used to reach this opinion, and whether or not the opinion was based on the entire evidentiary record. The evidence supports the Veteran's assertion that he participated in parachute jumps on active duty. The February 2011 VA examiner notes that the Veteran has pain in the pelvis, and says the parachute jumps may have set the stage for his disabilities. As the Veteran has symptoms of a current disability, the record indicates it may be associated with service, and the February 2011 opinion is not expressed with the requisite degree of certainty to enable a decision to be made, the Board finds that the Veteran must be scheduled for a VA examination of his hips. Residuals of a Traumatic Injury to the Nose and Face The Veteran contends that he has incurred several disabilities as a result of a facial injury during service. He asserts that he was hit in the nose and face with a rock by another soldier. The Veteran's service treatment records are negative for evidence of any injury to the face. They are also negative for sinusitis. The July 1964 discharge examination states that the head, face, neck, and scalp were normal, as were his sinuses. The Veteran answered "yes" to a history of ear, nose, or throat trouble on the Report of Medical History he completed at that time. The examiner's comments indicate that this was a reference to a pierced eardrum. The Veteran answered "no" to a history of sinusitis, and to bone, joint, or other deformity. 2/1/1990 VBMS, STR - Medical, pp. 2-5. However, the Veteran has submitted statements from his father, uncle, and three friends that support his assertion he was sustained a traumatic injury to the face during service. These statements are very consistent, with each reporting that the Veteran did not have a broken nose prior to service, that the Veteran's nose was visibly damaged after discharge from service, and that the Veteran told each of them that he was struck in the face by a rock during a fight with another soldier. See, for example, 3/30/1990 VBMS, VA Statement in Support of Claim, p. 1. They are competent to report this information, and there is no reason to doubt their credibility. At a September 1990 hearing, the Veteran testified that he had been in a fight with another soldier who, during the fight, picked up a rock and hit him in the face. He is also competent to make this assertion, and the lack of treatment for this injury in service is not enough to impact his credibility. Furthermore, the March 2014 VA examination for the residuals of traumatic brain injuries reviewed a September 2009 CT scan of the face, and noted several changes that were possibly consistent with trauma and remote fractures. 3/25/2014 Virtual VA, C&P Exam, p. 6. The Veteran has not been afforded a VA examination of any of the disabilities claimed as residuals of trauma to the face and nose. Given that there is competent evidence of a current disability as well as indications it may due to service, the Board finds that he should be scheduled for an examination to determine the nature and severity of any current disability resulting from a facial trauma in service. See McLendon. Sleep Problems Secondary to Arthritic Pains The Veteran contends that he has a sleep disability that results from his arthritis. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In this instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran denied having sleep problems on the July 1964 Report of Medical History obtained at separation, and he does not contend that his current sleep problems began during service. A December 2014 sleep clinic follow-up note states that a September 2014 sleep study had revealed mild obstructive sleep apnea. The current impressions were both mild sleep apnea, and insomnia. The insomnia component was likely multifactorial, including inadequate sleep hygiene, mood disorder, chronic pain, and untreated sleep apnea. 4/27/2016 Virtual VA, Capri#3, pp. 1-13. Thus, there is evidence of a second sleep disability that is at least in part due to factors other than, and in addition to, sleep apnea. The Veteran is not service connected for any disability that includes arthritis. However, he is service connected for the residuals of a TBI, the symptoms of which can include both pain and a mood disorder. The Veteran has yet to be afforded a VA examination in conjunction with this claim. Given the December 2014 findings, a VA examination is necessary. However, the record reflects that there is a proposal to severe service connection for the Veteran's TBI. Any examination should be contingent on service connection for TBI remaining in effect. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA orthopedic examination of the hips. All indicated tests and studies should be conducted. The claims file must be reviewed by the examiner, and this should be noted in the examination report. At the conclusion of the examination and record review, please express the following opinions: a) Does the Veteran have a current disability of the right and/or left hip? If so, what is the diagnosis of each disability? b) For each disability of the right and/or left hip that is current diagnosed, is it as likely as not that it was incurred in or due to active service, to include but not limited to parachute jumps during service? The reasons for all opinions should be provided. If the examiner is unable to provide an opinion without resorting to speculation, the examiner should state whether the inability is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that, if obtained, would permit the opinion to be provided. 2. Return the report of the March 2014 VA examination of the wrists, elbows, and shoulders to the examiner. The examiner should review the claims file as well as the previous opinion. Afterwards, the examiner should provide the following addendum opinions: a) Is it as likely as not that the Veteran's right wrist disability, left wrist disability, right elbow disability, left elbow disability, right shoulder disability and/or left shoulder disability was incurred in or due to active service on any basis, to include but not limited to parachute jumps during service? The reasons for all opinions should be provided. If the March 2014 examiner is not available, the claims file and March 2014 examination report should be forwarded to an examiner of comparable qualifications in order to obtain the requested opinions. An additional examination is not required unless deemed necessary by the examiner. If the examiner is unable to provide an opinion without resorting to speculation, the examiner should state whether the inability is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that, if obtained, would permit the opinion to be provided. 3. Schedule the Veteran for a VA examination of his head and nose. All indicated tests and studies should be conducted. The claims file must be reviewed by the examiner, and this should be noted in the examination report. At the conclusion of the examination and record review, please express the following opinions: a) In regard to the Veteran's claimed facial trauma during active service, is the nature of this trauma such that it would have more likely than not required immediate or near immediate medical treatment? Is it as likely as not that the Veteran's injuries from such a trauma would have healed without such treatment? b) Does the Veteran have a residual disability of the cheekbones or in the vicinity thereof? If yes, is this disability consistent with a facial trauma that would have occurred no later than August 1964? c) For the calcification of the eye socket and/or facial sinus cavities or vicinity thereof noted in the September 2009 study, is this disability consistent with a facial trauma that would have occurred no later than August 1964? d) Does the Veteran have a residual disability due to a broken nose? If yes, is this disability consistent with a trauma that would have occurred no later than August 1964? e) Does the Veteran have a current diagnosis of sinusitis or any other disability of the facial sinuses? If yes, was this disability incurred secondary to a facial trauma? If the Veteran has a sinus disability secondary to facial trauma, is the nature of this disability consistent with a facial trauma that would have occurred no later than August 1964, or the residuals thereof? The reasons for all opinions should be provided. If the examiner is unable to provide an opinion without resorting to speculation, the examiner should state whether the inability is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that, if obtained, would permit the opinion to be provided. 4. If the Veteran's service connection for TBI remains in effect, he should be scheduled for a VA examination of his insomnia. All indicated tests and studies should be conducted. The claims file must be reviewed by the examiner, and this should be noted in the examination report. At the conclusion of the examination and record review, please express the following opinions: a) Does the Veteran have a diagnosis of a sleep disability other than sleep apnea? b) For the insomnia noted at the sleep clinic in December 2014, as well as any other any current sleep disability other than sleep apnea noted in (a), is it as likely as not that this disability was incurred due to active service? c) If the answer to (b) is negative, is it as likely as not that the Veteran's insomnia and/or any other sleep disability exclusive of apnea was incurred due to his service connected traumatic brain injury? d) If the answers to (b) and (c) are both negative, is it as likely as not that the Veteran's insomnia and/or any other sleep disability exclusive of apnea was aggravated (increased in severity beyond natural progression) by his service connected traumatic brain injury? If so, can a baseline severity of the sleep disability prior to aggravation be identified? If so, describe that baseline. The reasons for all opinions should be provided. If the examiner is unable to provide an opinion without resorting to speculation, the examiner should state whether the inability is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that, if obtained, would permit the opinion to be provided. 5. If any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then return the case to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs