Citation Nr: 1753412 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 12-26 921 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for thyroid cancer, status post-thyroidectomy, to include as due to in-service herbicide exposure and/or as caused or aggravated by service-connected type II diabetes mellitus. 2. Entitlement to a disability rating for bilateral hearing loss higher than 10 percent prior to May 9, 2017, and higher than 40 percent beginning May 9, 2017. 3. Entitlement to service connection for a low back disability. 4. Entitlement to service connection for right knee disability. 5. Entitlement to service connection for left knee disability. 6. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1967 to December 1968, to include service in the Republic of Vietnam. He had additional periods of service in the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal of May 2011 and June 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. When this case was last before the Board in December 2016, it was remanded for additional development. The case is now again before the Board for further appellate consideration. In a June 2017 rating decision, the RO granted a 40 percent rating for bilateral hearing loss effective, May 9, 2017. The record before the Board consists of electronic records within the Veterans Benefits Management System. The Veteran's claims of service connection for low back and bilateral knee disabilities and to TDIU 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 Veteran's thyroid cancer was not present in service or until many years thereafter, is not etiologically related to service, to include presumed herbicide exposure, and is not etiologically related to his service-connected type II diabetes mellitus. 2. For the period prior to May 9, 2017, the Veteran's hearing impairment was no worse than Level III in the right ear and Level II in the left ear. See 38 C.F.R. § 4.85, Table VI (2017). 3. For the period beginning May 9, 2017, the Veteran's hearing impairment has been no worse than Level VIII in the right ear and Level VII in the left ear. See 38 C.F.R. § 4.85, Table VI (2017). CONCLUSIONS OF LAW 1. The criteria for service connection for thyroid cancer have not been met. 38 U.S.C.A. § 1101, 1110, 1112, 1116, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 2. For the period prior to May 9, 2017, the criteria for a rating higher than 10 percent for bilateral hearing were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100 (2017). 3. For the period beginning May 9, 2017, the criteria for a rating higher than 40 percent for bilateral hearing have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.85, DC 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2017). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d) (2017). In addition, 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) (2017). Moreover, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b) (2017). Disability Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321 (a), 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the low rating will be assigned. 38 C.F.R. § 4.7 (2017). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Background and Analysis Service connection for residuals of thyroid cancer The Veteran seeks service connection for thyroid cancer, status post-thyroidectomy. The Veteran served in Vietnam, and as such, in-service exposure to herbicide agents has been conceded. Alternatively, he asserts that his thyroid cancer was caused or aggravated by his service-connected type II diabetes mellitus. Whenever the United States Secretary of Veterans Affairs (Secretary) determines, on the basis of sound medical and scientific evidence, that a positive association exists between (A) the exposure of humans to an herbicide agent, and (B) the occurrence of a disease in humans, the Secretary shall prescribe regulations providing that a presumption of service connection is warranted for that disease for the purposes of this section. 38 U.S.C.A. § 1116(b)(1) (West 2014). In making determinations for the purpose of this subsection, the Secretary shall take into account (A) reports received by the Secretary from the National Academy of Sciences under section 3 of the Agent Orange Act of 1991, and (B) all other sound medical and scientific information and analyses available to the Secretary. In evaluating any study for the purpose of making such determinations, the Secretary shall take into consideration whether the results are statistically significant, are capable of replication, and withstand peer review. 38 U.S.C.A. § 1116(b)(2) (West 2014). An association between the occurrence of a disease in humans and exposure to an herbicide agent shall be considered to be positive for the purposes of this section if the credible evidence for the association is equal to or outweighs the credible evidence against this association. 38 U.S.C.A. § 1116(b)(3) (West 2014). Thyroid cancer is not among the diseases specified in 38 U.S.C.A. § 1116. In addition, the Secretary has not determined, on the basis of sound medical and scientific evidence that a positive association exists between the exposure of humans to an herbicide agent and the occurrence of colon cancer in humans. Furthermore, the Secretary has published a list of specific conditions for which a presumption of service connection based on exposure to herbicides used in Vietnam during the Vietnam era is not warranted. This list includes thyroid cancer. See Notice, 75 Fed. Reg. 32540 (June 8, 2010); see also Notice, 75 Fed. Reg. 81332 (Dec. 27, 2010); Notice, 77 Fed. Reg. 47924 (Aug. 10, 2012); and Notice, 79 Fed. Reg. 20310 (Apr. 11, 2014). The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The STRs do not show any symptoms, complaints, or treatment related to the thyroid. Post-service medical records show the Veteran was diagnosed with thyroid cancer in April 2008, with a thyroidectomy performed that same month. Tests conducted in June 2008 showed residual disease was present. The record shows the Veteran continues to be monitored with regular blood tests and ultrasounds. In support of his claim, the Veteran has submitted various medical articles. In December 2011, he submitted an article entitled "AACE: Agent Orange Ups Some Thyroid Risks." The article stated that veterans who came in contact with Agent Orange were more likely to develop Graves' disease than those who avoided exposure. The study's author stated specifically the researchers had "also looked at other thyroid diagnoses, but . . . didn't find any significant differences in thyroid cancer or nodules." The Board notes at this juncture there is no evidence the Veteran has ever had Graves' disease. In December 2015, the Veteran's representative submitted an article entitled "Diabetes and Thyroid Cancer Risk: Literature Review." The article concluded that epidemiologic studies showed significant or nonsignificant increases in thyroid cancer risk in diabetic women and nonsignificant increases or no change in thyroid cancer risk in diabetic men. The author stated that the results were controversial, that the association between diabetes and thyroid cancer is probably weak, and that further studies were necessary to confirm their relationship. In March 2016, an advisory medical opinion was obtained from a VHA expert, an endocrinologist. The VHA expert stated he found it less likely than not the Veteran's thyroid cancer was etiologically related to his exposure to Agent Orange. In this regard, the VHA expert stated that while certain cancers had been associated with Agent Orange exposure, thyroid cancer was not considered a disease subject to presumptive service connection under VA regulations because no studies had found a sufficient amount of evidence to support an association between thyroid cancer and Agent Orange. The VHA expert noted he had reviewed the medical literature submitted by the Veteran, and he stated the first relevant article was an observational analysis of data from all VA healthcare sites by review of electronic medical records from October 1999 to December 2013 from patients with a diagnosis of thyroid cancer. He stated the study found a significantly higher proportion of self-reported Agent Orange exposure among thyroid cancer patients compared to the overall national VA patient population. The VHA expert stated that this study suggested that the VA patient population may have additional risk factors, such as Agent Orange exposure, that may contribute in part to an increased prevalence of thyroid cancer. The VHA expert stated, however, that of significant note was that the prevalence of thyroid cancer for male veterans was similar to that of the United States general population, and that a major limitation of the study was the self-reporting of Agent Orange exposure, which could not be verified. The VHA expert stated that the nature of the study did not allow for a complete and rigorous analysis of its findings, and that the study would serve to increase awareness of a possible connection between thyroid cancer and Agent Orange exposure, but that until such a time as more substantial evidence was presented, he considered the study's findings to be insufficient evidence of an association between Agent Orange exposure and thyroid cancer. The VHA expert added he found it was not at all likely that the Veteran's thyroid cancer was caused or aggravated by "agent orange exposure." However, when read in context, the Board has determined the VHA expert intended to state he found it not at all likely the Veteran's thyroid cancer was caused or aggravated by his type II diabetes mellitus. Specifically, the Board notes that the sentence in question appears in a section titled "[a]s to questions #2 and #3," which correlate to the preface to the VHA expert opinion, in which he made clear the first question he would address would relate to Agent Orange, and the second and third questions he would address would relate to whether the Veteran's type II diabetes caused or aggravated his thyroid cancer. Further, in the sentence following the text in question, the VHA expert stated there was no medical evidence that thyroid cancer is caused by or aggravated by diabetes mellitus. The VHA expert went on to state that even in the article submitted by the Veteran on the topic, it was stated that the association between diabetes and thyroid cancer was at best very weak. In addition, the VHA expert stated that in a later follow-up study, the same author concluded that thyroid cancer risk is not increased in diabetic patients. Also in March 2016, but following VA's receipt of the VHA expert opinion, the Veteran submitted an additional article entitled "Agent Orange Linked to Bladder Cancer, Thyroid Problems, Panel Says." The article stated that a new Institute of Medicine (IOM) study found there was stronger evidence of a link between Agent Orange and bladder cancer as well as thyroid problems, to include hypothyroidism, among Agent Orange-exposed veterans. In September 2016, a medical opinion was obtained from another VHA expert, a Chief of Endocrinology for a VA state healthcare system. That VHA expert indicated he had reviewed copies of the Veteran's records relating to his diagnoses of thyroid cancer and diabetes mellitus, in addition to the medical literature which had been submitted. The VHA expert opined it was not likely the Veteran's thyroid cancer was related to Agent Orange exposure. The VHA expert addressed the article submitted by the Veteran in March 2016 by stating that although a recent biennial report by IOM suggested an association with hypothyroidism or low thyroid function and Agent Orange exposure, there was no evidence the Veteran had altered thyroid function prior to his April 2008 thyroidectomy. The VHA expert explained that low thyroid function was very different from thyroid cancer, and that thyroid cancer was considered one of the many conditions for which there is inadequate information to make any etiological associations. The VHA expert also addressed the other articles submitted by the Veteran by noting that the article addressed by the other VHA expert only stood for the proposition that self-reported rates of exposure to Agent Orange were higher among veterans with thyroid cancer than those without thyroid cancer. The VHA expert then pointed out, as the VHA expert had earlier, that the overall prevalence rate of thyroid cancer in male veterans who served who served in Vietnam was similar to the rate in the general United States male population. The VHA expert concluded there was no available data to support the claim that the Veteran's thyroid cancer was caused by Agent Orange. With regard to the Veteran's type II diabetes mellitus, the VHA expert stated there were several reports which looked at an association between the condition and thyroid cancer. He stated that one report suggested that type II diabetes mellitus could increase thyroid size and that the number of nodules could increase with worsening glucose control. However, the VHA expert added that neither of these were risk factors for thyroid cancers. The VHA expert went on to state that none of the literature submitted by the Veteran supported an association between his type II diabetes mellitus and thyroid cancer. With regard to aggravation, the VHA expert stated there was no data to suggest that worsening glucose control was associated with a poorer prognosis for thyroid cancer, and he cited medical literature for this proposition. The VHA expert also noted the Veteran's glucose control had been very good since his diabetes diagnosis. The Veteran was afforded a VA examination in June 2017. The examiner opined the Veteran's thyroid cancer and residuals were less likely than not related to his service. In this regard, the examiner noted he had carefully reviewed the medical literature submitted by the Veteran. The examiner stated that the article submitted for the proposition that there was a positive relationship between Agent Orange and thyroid cancer was a descriptive and retrospective study, and that a causal relationship could not be made on the basis of it. The examiner further stated that the article's author failed to draw a conclusion that Agent Orange exposure increased the risk of thyroid cancer in Vietnam veterans. The examiner also opined the Veteran's thyroid cancer was less likely than not related to his type II diabetes mellitus on the basis that there was no definite conclusion in the medical literature that there was any positive causal relationship between the two conditions. The Board has carefully and thoroughly reviewed the foregoing, and the entire record, and has concluded that a preponderance of the evidence weighs against the Veteran's claim. In this regard, the Board notes that the three expert medical opinions discussed above all weigh against the Veteran's claim, and explain comprehensively why the medical literature submitted by the Veteran fails to constitute sufficient support for the claim. In this regard, the Board acknowledges the Veteran's representative's argument to the effect that the inconclusive nature of the articles and studies submitted by the Veteran should result in resolution of reasonable doubt in his favor. However, the Board notes the medical opinions above were based upon comprehensive reviews of not only the literature submitted by the Veteran, but also of his entire medical history and the entire record. The Board also acknowledges the Veteran's argument to the effect that because the thyroid is near the lungs, larynx, and trachea, and because cancers of lungs, larynx, and trachea are subject to presumptive service connection based on herbicide exposure; see 38 C.F.R. § 3.309(e); his thyroid cancer should be presumptively service connected as well. In this regard, the Board notes there is no evidence of record indicating the Veteran has sufficient medical training such that his opinion regarding the similarity of various cancers could be considered probative. In addition, the Board is, itself, not permitted to make medical findings. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Instead, the Board must rely on the opinions of medical experts, all of which, in this case, weigh against the Veteran's claim. Finally, the Board acknowledges the Veteran's submission of a December 2007 decision in an unrelated case in which the Board determined that the claimant's thyroid cancer was related to in-service Agent Orange exposure. However, in this regard, the Board notes that prior Board decisions are not precedential and a decision as to one appellant has no precedential weight with regard to the decision for a different appellant. 38 C.F.R. § 20.1303 (2017). Board decisions must be made based on the particular facts and applicable legal authority specific to the case before the Board. Id. As discussed above, the Board has determined that the competent, probative evidence in this case does not demonstrate that the Veteran's thyroid cancer was related to his in-service herbicide exposure, nor does it demonstrate the condition was caused or aggravated by his type II diabetes mellitus. Although the Veteran does not doubt that the Veteran sincerely believes his thyroid cancer was caused by his in-service herbicide exposure or was related to his type II diabetes mellitus, his lay opinion regarding these matters, which require medical expertise, is of less probative value than the expert medical opinions of record. Accordingly, after weighing all of the evidence, because the preponderance of the evidence is against the claim, service connection must be denied. Increased ratings for bilateral hearing loss Disability ratings for a hearing loss disability are derived from mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating schedule establishes 11 auditory hearing acuity levels based upon average puretone thresholds and speech discrimination. See 38 C.F.R. § 4.85 (2017). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a) (2017). Table VI, "Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination," is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(b) (2017). Table VIa, "Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average," is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on puretone threshold average. Table VIa is used when the examiner certifies that the use of the speech discrimination test is not appropriate due to language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of § 4.86. 38 C.F.R. § 4.85(c) (2017). "Puretone threshold average" as used in Tables VI and VIa is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz and divided by four. This average is used in all cases (including those under § 4.86) to determine a Roman numeral designation from Tables VI and VIa. 38 C.F.R. § 4.85(d) (2017). Table VII, "Percentage Evaluations of Hearing Impairment," is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in each ear. The horizontal rows represent the ear having the better hearing and the vertical columns represent the ear having the poorer hearing. The percentage evaluation is located at the point where the row and the column intersect. 38 C.F.R. § 4.85(e) (2017). Provisions for evaluating exceptional patterns of hearing impairment are as follows: (a) When the puretone thresholds at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hertz ) are 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately; (b) When the puretone thresholds are 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral; the numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86 (2017). The United States Court of Appeals for Veterans Claims (Court) has held that, "in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report." Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). By way of background, the Veteran was initially awarded service connection for bilateral hearing loss in an April 2006 rating decision, and a 10 percent initial rating was assigned. In December 2011, the Veteran filed a claim seeking an increased rating, and in the June 2013 rating decision on appeal, the RO continued the Veteran's 10 percent rating. On the basis of a May 2017 VA examination, the results of which are discussed below, the RO increased the rating to 40 percent, effective on the date of the examination. The record shows the Veteran was afforded a VA audiological examination in February 2013. On examination, puretone thresholds were as follows: HERTZ 1000 2000 3000 4000 RIGHT 35 75 75 65 LEFT 25 40 65 65 Speech discrimination was 84 percent in the right ear and 88 percent in the left ear. The examiner noted the Veteran's reports that his hearing loss annoyed his wife, and that he could not hear people talking. Applying the values above to Table VI results in a Level III Roman numeral designation for the right ear and a Level II Roman numeral designation for the left ear. Application of a Level III designation and a Level II designation to Table VII results in a noncompensable rating. The Board notes the readings reported in this evaluation do not meet the requirements for evaluation as an exceptional pattern of impairment under 38 C.F.R. § 4.86 (2017). Pursuant to a remand by the Board, the Veteran was afforded an additional VA audiological examination on May 9, 2017. At the examination, the Veteran's puretone thresholds were as follows: HERTZ 1000 2000 3000 4000 RIGHT 50 80 70 65 LEFT 40 60 60 70 Speech discrimination was 56 percent in the right ear and 56 percent in the left ear. The examiner noted the Veteran's reports that his hearing loss had become more and more frustrating, and that he constantly had to ask people to repeat themselves. Applying the values above to Table VI results in a Level VIII Roman numeral designation for the right ear and a Level VII Roman numeral designation for the left ear. Application of these Roman numeral designations to Table VII again results in a 40 percent rating. The Board notes the readings reported in this evaluation do not meet the requirements for evaluation as an exceptional pattern of impairment under 38 C.F.R. § 4.86 (2017). On review of the foregoing, the Board notes the February 2013 VA examination results warranted a noncompensable rating. However, the RO declined to seek a reduction in the Veteran's previously assigned 10 percent rating. On review, it is evident that the criteria for a rating higher than 10 percent were not met prior to May 9, 2017. Although the Veteran had hearing loss, the hearing loss did not warrant a rating higher than 10 percent under the Rating Schedule. Thus, the Board must deny a rating higher than 10 percent for the period prior to May 9, 2017. With regard to the period beginning May 9, 2017, the Board finds the 40 percent rating assigned by the RO is supported by the May 2017 VA examination results. However, upon review, it is evident that the criteria for a rating higher than 40 percent have not been met at any time during the period of the claim. Thus, the Board must deny a rating higher than 40 percent for the period beginning May 9, 2017. In reaching its decision, the Board has duly considered the benefit-of-the-doubt doctrine, but has determined that a preponderance of the evidence weighs against the Veteran's claim. As such, the doctrine is inapplicable, and the claim must be denied. ORDER Entitlement to service connection for thyroid cancer, status post-thyroidectomy, is denied. Entitlement to a rating higher than 10 percent for bilateral hearing loss for the period prior to May 9, 2017, is denied. Entitlement to a rating higher than 40 percent for bilateral hearing loss for the period beginning May 9, 2017, is denied. REMAND The Board notes at the outset that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In addition, a medical examiner is not free to simply ignore a veteran's lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Veteran seeks service connection for low back and bilateral knee disabilities. The record shows he currently has low back and bilateral knee arthritis. His STRs show he reported a back ache during service. Lay statements submitted by the Veteran and a fellow service member assert the Veteran suffered back and bilateral knee pain during service in relation to his duties lifting objects and jumping in and out of trucks. The Veteran has asserted that his low back and bilateral knee problems have persisted since service, and have continued to the present day. The Veteran was afforded VA examinations for his low back in February 2013 and May 2017, and for his knees in May 2017, pursuant to which VA examiners did not associate his conditions with service. However, as noted by the Veteran's representative in an October 2017 correspondence, upon review, none of the VA examiners addressed the lay statements submitted by the Veteran or, in the case of his bilateral knee disability, the statement submitted by a fellow service member. The Board notes that the statements in question relate directly to whether in-service low back and bilateral knee symptoms are related to the Veteran's current arthritis. Under these circumstances, the Board finds a remand for further examination is necessary in light of the competent lay evidence. As to the Veteran's TDIU claim, the Board finds the issue is inextricably intertwined with the claims for service connection for low back and bilateral knee disabilities. Specifically, the Board notes that a grant of either claim could impact whether the Veteran is entitled to a TDIU based on the combined effects of all service-connected disabilities. Therefore, the issue of entitlement to a TDIU must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1993) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Accordingly, the case is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed, of his in-service and post-service right knee, left knee, and back symptoms, to specifically include addressing whether the Veteran has had recurrent right knee, left knee, and back problems during and since service. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 2. Afford the Veteran an appropriate VA examination to address the onset and etiology of the Veteran's low back and bilateral knee disabilities. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, and an additional examination if indicated, the examiner should state whether it is at least as likely as not that the Veteran's low back disability, right knee disability and left knee disability had their onsets in service or is otherwise etiologically related to service. In providing this opinion, the examiner must address the competent statements submitted by the Veteran to the effect that he suffered from back pain in service due to having to jump in and out of trucks, as well as from lifting objects, to include a specific injury where his back "went out" while lifting a trailer side-panel, in addition to his statements that his low back pain stayed with him since that time and has persisted to the present day. As to the Veteran's right knee and left knee disability claims, in providing this opinion, the examiner must address the competent statements submitted by the Veteran and a fellow service member, A.J., to the effect that the Veteran suffered bilateral knee pain in service related to many hours spent jumping in and out of trucks, but did not report it for fear of falling behind in training, and that his bilateral knee pain has persisted since service to the present day. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017). Department of Veterans Affairs