Citation Nr: 1756879 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 15-09 441 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an increased rating in excess of 30 percent for left knee degenerative joint disease and calcified tendonitis with limited extension (left knee disability). 2. Entitlement to an effective date earlier than August 31, 2011, for the award of a 30 percent rating for the Veteran's left knee disability. 3. Whether new and material evidence has been received to reopen a previously-denied claim of entitlement to service connection for hypertension. 4. Entitlement to service connection for a right knee disability, to include as secondary to service-connected disability. 5. Entitlement to service connection for a low back disability, to include as secondary to service-connected disability. 6. Entitlement to service connection for a left big toe disability, claimed as loss of big toe, to include as secondary to service-connected disability. 7. Entitlement to service connection for a left hip condition, to include as secondary to service-connected disability. 8. Entitlement to service connection for left leg numbness, to include as secondary to the claimed low back disability. 9. Entitlement to service connection for a renal disorder, claimed as renal failure. 10. Entitlement to service connection for sleep apnea, to include as secondary to the claimed hypertension disability. 11. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD B. Garcia, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1971 to June 1973. He had subsequent service in the United States Army Reserves. These matters come before the Board of Veterans' Appeals (Board) from November 2012 (earlier effective date), and November 2015 (service connection and increased rating claims) rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The matter of entitlement to earlier effective date was previously before the Board in December 2014, when it was remanded for issuance of a statement of the case. Notably, the Board denied the claim in a September 2015 decision, and the Veteran appealed the Board's September 2015 decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2017 memorandum decision, the Court set aside the Board's determination of an effective date and remanded the matter to the Board for proceedings consistent with the memorandum decision. With respect to the claim for service connection for sleep apnea, the Board observes that in the November 2015 rating decision, the RO noted that the claim was considered reopened and therefore suggested that issue was whether new and material evidence had been received to reopen a previously-denied claim. However, based on a review of the claims file, there is no indication that the Veteran filed a previous claim for sleep apnea. As such, the RO appears to have been in error, and the matter on appeal is properly characterized as entitlement to service connection for sleep apnea. In light of an addendum to an October 2015 VA knee examination report, which indicates that the Veteran was seeking service connection for "loss of movement of left toe" as opposed to "loss of big toe," the Board has re-characterized the toe-related claim on appeal as entitlement to service connection for a left big toe disability. See Clemons v. Shinseki, 23 Vet. App. 1, 5-8 (2009). A claim for a TDIU is part and parcel of an increased rating claim where, as here, a claimant asserts that his service-connected disabilities prevent him from working. See Rice v. Shinseki, 22 Vet. App. 447, 454-55 (2009). In a November 2015 statement from the Veteran, he maintained that he was no longer able to work due to his lack of mobility. As such, the Board has characterized the issues on appeal to include a claim of entitlement to a TDIU. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The claims pertaining to the Veteran's left knee, right knee, low back, left lower extremity numbness, and left big toe, in addition to the issue of entitlement to a 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. In a December 2014 decision, the Board denied the Veteran's claim for service connection for hypertension based on the determination that the evidence of record was against a finding that his hypertension manifested during, or was otherwise etiologically related to, his active military service. 2. The additional evidence associated with the claims file following the December 2014 Board decision does not relate to an unestablished fact necessary to substantiate the Veteran's claim for service connection for hypertension, nor does it otherwise raise a reasonable possibility of substantiating his claim. 3. The preponderance of the evidence is against a finding that the Veteran's hypertensive renal disease initially manifested during, or is otherwise etiologically related to, his active military service. 4. The preponderance of the evidence is against a finding that the Veteran's obstructive sleep apnea initially manifested during, or is otherwise etiologically related to, his active military service. 5. The preponderance of the evidence is against a finding that the Veteran has a current left hip disability. CONCLUSIONS OF LAW 1. The December 2014 Board decision, which denied the Veteran's claim for service connection for hypertension, became final. 38 U.S.C. § 7103, 7104 (2012); 38 C.F.R. § 20.1100 (2017). 2. The additional evidence received since the December 2014 Board decision is not new and material, and the claim for service connection for hypertension is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for service connection for hypertensive renal disease have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.102, 3.303 (2017). 4. The criteria for service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the instant claims, the Veteran's signature on his June 2015 claim, submitted via a VA Form 21-526EZ, indicates that he received VCAA notice. See 38 U.S.C. § 5103; 38 C.F.R. § 3.159(b). The record reflects that the Veteran's separation examination report associated with the conclusion of his period of active duty service in June 1973 is not included in the service treatment records (STRs) contained in the claims file. In this regard, in March 2012, the RO issued a formal finding as to the unavailability of STRs that remained unassociated with the claims file. In a March 2012 letter, the Veteran was informed that his service treatment records were incomplete, as his separation examination was unavailable. The record also indicates that the RO attempted to obtain treatment records from the St. Louis VAMC dated between June 1973 and September 1973 that might have been pertinent to the Veteran's hypertension claim. In June 2013, the RO was informed that the St. Louis VAMC had no records that were responsive to its request. In light of this background, the record reflects that the separation examination report and VA treatment records dated between June and September 1973 are unavailable, and that further attempts to obtain them would be futile. Accordingly, VA has no further duty to assist in obtaining these records. See 38 U.S.C. § 5103A(c); 38 C.F.R. § 3.159(c)(2). Additionally, although the Veteran was not afforded a VA sleep apnea examination, a VA examination is not needed to adjudicate the claim. As explained below, the evidence does not establish that the Veteran suffered a relevant in-service event, injury, or disease, and there is no indication that the disability is associated with the Veteran's active military service or with another service-connected disability. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McClendon v. Nicholson, 20 Vet. App. 79, 86 (2006). The Veteran has not raised, nor does the record otherwise suggest, any other issues with the duties to notify or to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) ("[T]he Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying the Scott to duty to assist argument). II. Claim to Reopen Legal Criteria A decision issued by the Board is final, unless appealed to the Court or another exception to finality applies. See 38 U.S.C. §§ 7103(a), 7104(a); 38 C.F.R. § 20.1100 (stating that a Board decision is final as of the date stamped on the face of the decision). In general, a claim that has been denied by the Board may not thereafter be reopened or allowed. See 38 U.S.C. § 7104(b). An exception to this rule is set forth in 38 U.S.C. § 5108, which pertains to reopening disallowed claims. To reopen a claim that has been denied by a final decision, a claimant must present new and material evidence in support of the claim. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). "New evidence" means existing evidence that was not previously submitted to VA. 38 C.F.R. § 3.156(a). "Material evidence" means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate a claim. Id. 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 it must raise a reasonable possibility of substantiating the claim. Id. There is generally a low threshold for determining that a claimant has presented new and material evidence. See id.; see also Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). For instance, the phrase "raise a reasonable possibility of substantiating the claim" is to be viewed as "enabling rather than precluding reopening." See Shade, 24 Vet. App. at 121. For purposes of reopening a claim, the credibility of newly presented evidence is generally presumed, unless the evidence is inherently incredible or beyond the competence of the witness presenting the evidence. See, e.g., Justus v. Principi, 3 Vet. App. 510, 513 (1992). Additionally, where VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim pursuant to 38 C.F.R. § 3.156(c), provided that such records include service records that are related to the claimed in-service event, injury, or disease. Factual Background and Legal Analysis In an April 2012 rating decision, the RO denied service connection for hypertension on the ground that there was no basis for establishing an etiological connection between the Veteran's hypertension and his active military service. The Veteran's claim was subsequently denied by the Board in December 2014. Despite the Veteran's repeated contention that his hypertension had its initial onset during active duty service in Germany and that he continued to have "uncontrollable" blood pressure since service, the record was against a finding that the Veteran's hypertension manifested during service, as the record established that hypertension became manifest many years after the Veteran's service. As stressed by the Board, the earliest indication of pertinently elevated blood pressure in the record appeared to be no earlier than 1983, approximately ten years after separation from service, and the earliest indication of hypertension was in the 1990s, many years after the Veteran's separation from service in June 1973. The Board's December 2014 decision subsumed the April 2012 rating decision, and it became final on December 12, 2014, the date it was stamped. See 38 C.F.R. § 20.1100; 38 C.F.R. § 20.1104. At the time of the December 2014 Board decision, the evidence, in pertinent part, consisted of STRs dated from June 1971 to May 1995. The Veteran's separation examination report from his period of service ending in June 1973 was unavailable. The evidence also consisted of VA treatment records dated from September 1973 to June 2006 and from May 2011 to January 2012, service personnel records, Social Security Administration records, and lay statements. The Veteran filed the instant request to reopen the claim for service connection for hypertension in June 2015, in which he asserted that his hypertension was secondary to pain from his service-connected left knee disability. Evidence added to the claims file since the Board's December 2014 decision, in pertinent part, includes VA treatment records dated from November 2010 to December 2015, and an October 2015 VA hypertension examination report and medical opinion. The Board concludes that the additional evidence received since the December 2014 Board decision is not new and material because it does not relate to an unestablished fact necessary to substantiate the Veteran's claim, nor does it raise a reasonable possibility of substantiating his claim when considered by itself or in conjunction with the evidence that was previously of record. The additional evidence shows that the Veteran has been continued to be treated for hypertension. However, there is no new competent evidence indicating that the Veteran's hypertension might be related to his active military service. Crucially, the mere offering of an alternative theory of entitlement does not constitute new and material evidence sufficient to reopen a previously-denied claim. See, e.g., Roebuck v. Nicholson, 20 Vet. App. 307 (2006). In this regard, although the Veteran is service-connected for a left knee disability, there is no new evidence of record, other than the Veteran's contention in his June 2015 claim, which suggests that his hypertension is secondary to pain from his left knee disability. While the Veteran has asserted a relationship exists between his hypertension and a service-connected musculoskeletal disability, the question of whether such a relationship exists is a complex medical issue that is far beyond the purview of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Moreover, the October 2015 examiner opined that there was no evidence that the Veteran's hypertension was caused or aggravated by his service-connected left knee disability. There was no indication of any such relationship in the Veteran's medical records. The examiner noted that the Veteran only had minor patellar arthritis of the left knee, his blood pressure was "very well controlled" on a single medication, and there was no indication of renal injury or decrease in function based on laboratory tests showing normal kidney function. Aside from the Veteran's lay contention, he has not submitted any competent evidence, such as medical findings, statements, or opinions, which suggests a possible relationship between his left knee disability and hypertension. See 38 C.F.R. § 3.159(a) (defining competent medical evidence). As there is no competent evidence suggesting that the Veteran's hypertension was caused or aggravated by his left knee disability, his lay contention does not raise a reasonable possibility that VA assistance would help substantiate his claim. Specifically, it does not rise to the level of triggering VA's duty to assist by providing a VA examination or obtaining a medical opinion. See Shade, 24 Vet. App. at 116. Thus, while the Veteran's lay assertion that his hypertension was caused or aggravated by his left knee disability constitutes an alternative theory of entitlement, it does not qualify as new and material evidence sufficient to reopen his previously-denied claim. Specifically, there is no new competent evidence that suggests that the Veteran's hypertension was caused by, or is otherwise related to, his active military service. Thus, the additional evidence submitted since the December 2014 rating decision, when considered by itself and in conjunction with evidence that was previously of record, is not new and material. As new and material evidence has not been received, the claim for service connection for hypertension is not reopened. See 38 C.F.R. § 3.156(a). III. Entitlement to Service Connection Legal Criteria A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered, or disease contracted, in the line of duty, or for aggravation of a preexisting injury or disease incurred in the line of duty during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must generally show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting from disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease that is initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a) (stating that when service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition). Additionally, service connection may be established by the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310(b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Determinations regarding service connection are based on a review of all of the evidence of record, including pertinent medical and lay evidence. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Under certain circumstances, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno, 6 Vet. App. at 469. When considering evidence and determining its probative value, VA considers both the competency and the credibility of the witness. See Layno, 6 Vet. App. at 469. To deny a claim for benefits on its merits, the preponderance of the evidence must be against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) ("A veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' to prevail."). Renal Disorder: Factual Background and Legal Analysis As reflected in his June 2015 claim, the Veteran contends that he is entitled to service connection for renal failure. In his June 1971 report of medical examination on entrance into service, the Veteran was clinically evaluated as normal. The Veteran's service treatment records from his period of service from June 1971 to June 1973, in addition to those from his Reserves service, show no treatment related to the renal system. In reports of medical examination from the Veteran's Reserves service dated in March 1982, March 1986, April 1990, and March 1994, the only defects or diagnoses noted are a vision-related issue (March 1982) and a forearm scar (March 1994). Veteran's VA problem list includes hypertensive renal disease, and in an August 2015 letter, a VA nurse practitioner wrote that one of the medical conditions that the Veteran was currently receiving treatment for was hypertensive renal disease. The first notation of hypertensive renal disease in the Veteran's VA treatment records appears to be from October 2013. However, there do not appear to be any specific notations regarding the nature or etiology of the Veteran's hypertensive renal disease in his VA treatment records. The Veteran was afforded several VA examinations in October 2015, and in a medical opinion, the examiner noted that based on laboratory testing performed, the Veteran's kidney functions were all in the normal range. There was no indication of renal injury or decrease in function. To establish service connection, there must be evidence of a current disability. See Shedden, 381 F.3d at 1167. The Veteran's VA treatment records reflect a diagnosis of hypertensive renal disease. Thus, despite the fact that the October 2015 examiner found no indication of renal injury or failure, the element of a current disability has been met in this case. See id.; see also Clemons, 23 Vet. App. at 5-8. While the Shedden element of a current disability has been met, when considering the pertinent evidence in light of the above-noted legal authority, the Board finds that service connection is not warranted for the Veteran's hypertensive renal disease, as the weight of the evidence is against a finding that his disability was caused by, or is otherwise etiologically related to, his active military service. There is no indication of kidney-related disease or injury during the Veteran's period of active service that ended in June 1973. As such, the requirement of an in-service incurrence of a disease or injury has not been met. See Shedden, 381 F.3d at 1167. Moreover, evidence of a prolonged period between discharge from active service and the medical documentation of a claimed disability may be considered as evidence against a claim of entitlement to service connection. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Here, the Veteran's VA treatment records do not reflect a diagnosis of, or treatment for, hypertensive renal disease prior to October 2013, approximately forty years after the Veteran's separation from active military service in June 1973. Additionally, the Veteran has not asserted, nor does the record otherwise reflect, continuity of relevant symptomatology since service so as to warrant an award of service connection. Thus, given the lack of indication of an in-service incurrence of hypertensive renal disease or any other renal condition, in addition to the length of time between the Veteran's service and documented diagnosis of hypertensive renal disease, the preponderance of the evidence is against a finding that his hypertensive renal disease was caused by, or is otherwise etiologically related to, his period of active military service ending in June 1973. For these reasons, the Board also concludes that an additional VA examination or medical opinion is neither warranted nor required. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McClendon, 20 Vet. App. at 86. The Board observes that the Veteran served in the Army Reserves, and the record indicates periods of active duty for training (ACDUTRA) between 1975 and 1996. However, the evidence does not suggest, nor does the Veteran contend, that his hypertensive renal disease had its initial onset during, or was otherwise caused by an event during a period of ACDUTRA. Nor is there any suggestion or contention that the Veteran's hypertensive renal disease is the result of an injury during inactive duty for training (INACDUTRA). As such, there is no basis for direct service connection related to a period of ACDUTRA or INACDUTRA, and this matter will not be further discussed. See 38 C.F.R. § 3.6(a). To the extent that the Veteran maintains that his hypertensive renal disease is proximately due to, or aggravated by, his non-service connected hypertension, that matter has no bearing where, as here, the Veteran's request to reopen his claim of service connection for hypertension has been denied. In summary, the evidence of record weighs against a finding that a nexus exists between the Veteran's hypertensive renal disease and his active military service. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the Veteran's claim, that doctrine does not apply, and the Veteran's claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Sleep Apnea: Factual Background and Legal Analysis As reflected in his June 2015 claim, the Veteran contends that he is entitled to service connection for sleep apnea as secondary to hypertension. In his June 1971 report of medical examination on entrance into service, the Veteran was clinically evaluated as normal. The only sleep-related issue noted in the Veteran's STRs is from April 1973, when the Veteran reported being unable to sleep. It was noted that his fiancée had a miscarriage and that the Veteran believed this was the reason for his lack of sleep. Following his period of active service ending in June 1973, the Veteran was treated for insomnia in September 1973. It appears that his insomnia was anxiety-related. STRs from the Veteran's Reserves service show no treatment related to sleep issues or apneic symptoms. The Veteran denied sleep-related issues in reports of medical history dated in March 1982, March 1986, April 1990, and March 1994, and in corresponding reports of medical examination, the Veteran was clinically evaluated as normal, with the exception of vision-related issues (March 1982) and a forearm scar (March 1994). According to a May 2013 VA sleep study consult, the Veteran was diagnosed with severe obstructive sleep apnea. Given the Veteran's diagnosis of obstructive sleep apnea, the element of a current disability has been established. See Shedden, 381 F.3d at 1167. However, when considering the pertinent evidence in light of the above-noted legal authority, the Board finds that service connection is not warranted for the Veteran's obstructive sleep apnea, as the weight of the evidence is against a finding that his disability was caused by, or is otherwise etiologically related to, his active military service. The record does not indicate in-service incurrence of sleep apnea. See Shedden, 381 F.3d at 1167. Specifically, while the Veteran was treated for sleep difficulty once during his period of service ending in June 1973, it was noted that he believed that his lack of sleep was attributed to his fiancée miscarrying. Further, there is no indication of apneic symptoms during this period of service. Additionally, aside from a single medical record noting anxiety-related insomnia in September 1973, the record contains no indication of sleep issues until May 2013, when the Veteran underwent a VA sleep study. There is also no indication of apneic symptoms prior to the May 2013 VA sleep study. The period of almost forty years between the Veteran's discharge from active service in June 1973 and the medical documentation of sleep apnea weighs significantly against his claim for service connection, particularly given the fact that the Veteran has not asserted, nor does the record otherwise reflect, continuity of relevant symptomatology since service. See Maxon, 230 F.3d at 1333. Thus, given the lack of indication of sleep apnea or relevant symptoms during service, in addition to the length of time between the Veteran's service and documented diagnosis of obstructive sleep apnea, the preponderance of the evidence is against a finding that his obstructive sleep apnea was caused by, or is otherwise etiologically related to, his period of active military service that ended in June 1973. For these reasons, the Board also concludes that a VA examination or medical opinion is not warranted or required. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McClendon, 20 Vet. App. at 86. Additionally, the evidence does not suggest, nor does the Veteran contend, that his obstructive sleep apnea had its initial onset, or was otherwise caused by an event, during a period of ACDUTRA. Nor is there any suggestion or contention that the Veteran's obstructive sleep apnea is the result of an injury during INACDUTRA. As such, there is no basis for direct service connection related to any period of ACDUTRA or INACDUTRA, and this matter will not be further discussed. See 38 C.F.R. § 3.6(a). Although the Veteran maintains that his obstructive sleep apnea is proximately due to, or aggravated by, his non-service connected hypertension, this assertion has no bearing where, as here, the request to reopen the Veteran's claim of service connection for hypertension has been denied. In summary, the evidence of record weighs against a finding that a nexus exists between the Veteran's obstructive sleep apnea and his active military service. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the Veteran's claim, that doctrine does not apply, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Left Hip: Factual Background and Legal Analysis As reflected in his June 2015 claim, the Veteran contends that he is entitled to service connection for a left hip disability as secondary to his service-connected left knee disability. The Veteran was clinically evaluated as normal in his June 1971 report of medical examination on entrance into service. The Veteran's service treatment records from his period of service from June 1971 to June 1973, in addition to those from his Reserves service, show no treatment treatment for left hip-related symptoms or issues. The Veteran denied a history of musculoskeletal symptoms in reports of medical history dated in March 1982, March 1986, April 1990, and March 1994. In corresponding reports of medical examination, the Veteran was clinically evaluated as normal, with the exception of vision-related issues (March 1982) and a forearm scar (March 1994). The Veteran's post-service medical treatment records contain no documented treatment for, or assessments or diagnoses of, a left hip disorder. The Veteran was afforded a VA hip and lower legs examination in October 2015. The Veteran reported a left hip condition due to his service-connected left knee disability, but no particular symptoms or injury, aside from sometimes feeling pain when he gets out of bed. The examiner noted that there were no VA treatment records documenting any hip condition or complaints related to left hip pain. The Veteran's range of motion was normal on both initial and repeated range of motion testing. The Veteran's muscle strength was normal, and he did not exhibit any muscle atrophy. There was also no malunion or nonunion of the femur or flail hip joint, nor was there any leg length discrepancy. According to the examiner, the Veteran's left hip examination was normal, and there was no evidence of a diagnosed left hip condition. As noted above, to establish service connection for a claimed disorder on either a direct or secondary basis, there must be evidence of a current disability. See Shedden, 381 F.3d at 1167; see also 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). Thus, without competent evidence of a current disability, service connection cannot be granted. See, e.g., Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement for a service-connected disease or injury to cases where such incidents have resulted in a disability," and "[i]n the absence of proof of a present disability[,] there can be no valid claim."). That a condition or injury occurred in service alone is not enough; there must be a disability resulting from that condition or injury. See, e.g., Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Existence of a current disability must be shown by competent medical evidence. See, e.g., McClain v. Nicholson, 21 Vet. App. 319, 320-21 (2007). With respect to the required Shedden element of a current disability, the weight of the evidence of record is against finding that a diagnosed hip disability currently exists or has existed at any time during the appeal period. See 381 F.3d at 1167. Crucially, the October 2015 VA examiner found no basis for rendering a left hip diagnosis. The examiner considered the Veteran's report of having occasional pain when he gets out of bed. However, the Veteran had a normal hip examination with no documented left hip disability. His left hip range of motion and muscle strength testing was normal, and there was no other indication of a current disability based on examination or review of the Veteran's medical records. The examination report reflects that the examiner performed a thorough examination of the Veteran and considered his contentions. The examiner also utilized his medical expertise in finding no current left hip disability. As such, the Board finds the October 2015 examiner's opinion to be fully-informed and reliable. See Nieves-Rodriguez, 22 Vet. App. 295, 301-04 (2008). Moreover, there is no objective evidence of record that tends to suggest that the Veteran has had a diagnosed left hip disability at any time during the course of the appeal. On the contrary, the Veteran's medical records are devoid of any specific complaints related to, or treatment for, a left hip condition, and there are no noted left hip diagnoses or assessments in his medical records. As such, the weight of the evidence is against a finding that the Veteran has a current disability. The Board has considered the Veteran's lay contentions, as reflected in the October 2015 examination report, and acknowledges that he is competent to offer statements regarding observable symptomatology, such as occasional hip pain in the mornings. See Layno, 6 Vet. App. at 469-70. However, the Veteran's contention that he has a current left hip disability is significantly outweighed by the October 2015 examiner's opinion. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). There is also no objective medical evidence of record that otherwise tends to suggest the presence of diagnosed left hip disability at any time during the appeal period. Accordingly, service connection for a left hip disability is not warranted. In summary, the competent medical evidence of record weighs against a finding that the Veteran has had a diagnosed left hip disability at any time during the course of the appeal. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the Veteran's claim, that doctrine does not apply, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER New and material evidence not having been received, the claim of entitlement to service connection for hypertension is not reopened. Entitlement to service connection for a renal disorder, claimed as renal failure, is denied. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for a left hip disability is denied. REMAND Before a decision can be reached on the instant claims, a remand is necessary to ensure that there is a complete record upon which to afford the Veteran every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Left Knee The Veteran contends that he is entitled to a rating in excess of 30 percent for his left knee disability and that he is entitled to an effective date earlier than August 31, 2011, for the award of a 30 percent rating for his left knee disability. As noted above, the Court issued a memorandum decision in February 2017 that set aside the Board's September 2015 determination of an effective date of August 31, 2011, for the Veteran's service-connected left knee disability and remanded the matter to the Board for readjudication. In its memorandum decision, the Court found that the Board's failure to consider and address evidence tending to show that the Veteran might be entitled to an additional rating for instability of the left knee rendered its statement of reasons or bases inadequate. Although the Veteran was last afforded a VA knee examination in October 2015, another medical examination is needed before the Board can adjudicate the Veteran's claims. The Veteran's VA treatment records document multiple reports of the Veteran's left knee giving out on him, such as an April 2011 orthopedic consult, in which the Veteran reported that his knee would give way every other day, and VA physical therapy notes, in which the Veteran reported his left knee giving out frequently. There are also VA treatment records documenting reports of falling on account of the Veteran's purported left knee instability, such as a December 2013 VA physical therapy consult. Despite this history, the October 2015 examiner indicated that there was no history of lateral instability and that left knee joint stability testing was not indicated. In light of this background, a new examination that addresses whether the Veteran has a history of lateral instability, and if applicable, the degree of lateral instability, is needed prior to adjudicating the Veteran's claims. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Right Knee As reflected in his June 2015 claim and the October 2015 VA knee examination report, the Veteran contends that he has a right knee disability that is secondary to his service-connected left knee disability. The Veteran was afforded a VA knee examination in October 2015, and the examiner did not render a right knee diagnosis. It was noted that while the Veteran reported right knee pain, April 2015 X-rays of the right knee were normal. Examination of the Veteran's right knee was also normal. However, an August 2015 VA pain note indicates with the respect to the right knee, an April 2015 X-ray showed irregular calcification at the anterior surface of the patella that was suggestive of quadriceps calcification. The treatment record includes an impression of knee pain, left greater than right, due to calcific tendinitis. Additionally, in a September 2015 VA rheumatology note, the Veteran was given an assessment of degenerative joint disease, "especially in the knees." Given this history, an additional opinion that clarifies whether the Veteran has a current diagnosis and that addresses the etiology of any diagnosed condition is warranted before the Board can adjudicate the Veteran's claim. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Low Back and Left Lower Extremity Numbness As reflected in his June 2015 claim and the October 2015 VA back examination report, the Veteran contends that he has a low back disability that is secondary to his service-connected left knee disability. The Veteran was afforded a VA back examination in October 2015, and the examiner provided that there was no diagnosis associated with the Veteran's claimed low back disability. According to the examination report, the Veteran's back examination was normal, as was a January 2013 X-ray of the Veteran's lumbar spine. As such, there was no evidence of a back condition. However, based on the Veteran's VA treatment records, additional clarification is needed before the Board can adjudicate the Veteran's claim. For instance, an August 2015 VA pain note includes an impression of low back pain, osteoarthritis, and a September 2015 VA rheumatology note includes an assessment of degenerative joint disease affecting the lumbar area. The August 2015 VA pain note also provides that the Veteran reported that knee pain preceded his back pain and that gait abnormality may contribute to his back pain. Accordingly, a medical opinion that clarifies whether the Veteran has any current disability and that addresses the etiology of any diagnosed disability is warranted on remand. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). As the remanded claim might have a bearing on the Veteran's claim for service connection for left lower extremity numbness, the claims are inextricably intertwined, and the Board will defer consideration of his left lower extremity claim until his low back claim is addressed. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (providing that two issues are "inextricably intertwined" when they are so closely related that a final Board decision cannot be rendered until the other issue has been considered). Left Big Toe In his June 2015 application for service connection, the Veteran claimed entitlement to service connection for loss of big toe secondary to his left knee disability. In an October 2015 addendum to an October 2015 VA knee examination report, the examiner wrote that there was no evidence of any left toe abnormality, and that there was no loss of any portion of either big toe. The Veteran stated that he had "loss of movement" of the left toe but nevertheless demonstrated full flexion and extension. It was noted that the Veteran recently saw VA podiatry and was given a diagnosis of bilateral hallux valgus asymptomatic. The examiner noted that this diagnosis should be changed to hallux limitus, which suggests loss of toe movement, and that there was evidence of moderate degenerative arthritis of the metatarsal joints of both great toes. Although the Veteran's STRs do not appear to contain any treatment related to a left toe condition, a September 2015 VA rheumatology note provides that the Veteran reported in-service trauma to his left toe while in the service and constant pain and swelling since that time. In a November 2015 VA podiatry note, which includes an assessment of hallux limitus right, asymptomatic, and hallux limitus left, it was noted that the Veteran related chronic left knee pain, for which he admitted to changing his gait. Given this background, a VA foot examination that addresses the nature and etiology of the Veteran's claimed disability is warranted on remand. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McClendon, 20 Vet. App. at 86. TDIU As stated in the Introduction, the Board has determined that a claim for a TDIU is part of the Veteran's pending increased rating claim. However, the Veteran has not been sent a notification letter in compliance with 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). The Board therefore finds that the issue of entitlement to a TDIU must be remanded for appropriate notice and development. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from VA or private health care providers. Follow the procedures for obtaining the records, as set forth by 38 C.F.R. § 3.159(c), and obtain VA Form 21-4142 releases if necessary. If VA attempts to obtain any outstanding records that are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 2. Ensure that all notification and development action required by 38 U.S.C. §§ 5102, 5103 and 5103A are fully complied with and satisfied with respect to the issue of entitlement to a TDIU pursuant to 38 C.F.R. § 4.16. 3. After completing the development requested in number (1) above, schedule the Veteran for a VA examination with an appropriate medical examiner to address the current severity of his service-connected left knee disability, as well as the nature and etiology of his claimed right knee disability. The claims file, including a copy of this remand, must be made available to the examiner. After reviewing the claims file and examining the Veteran, the examiner should specifically address the following: a) The examiner should clarify whether the Veteran has a current diagnosis that pertains to his claimed right knee disability. If there are no current diagnoses found, the examiner must reconcile such a finding with VA treatment records noted above, which indicate possible calcific tendinitis and/or degenerative joint disease affecting the right knee. b) For each identified right knee disability, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the disability was caused by, or is otherwise etiologically related to, the Veteran's active military service. c) For each identified right knee disability, the examiner should opine as to whether it is at least as likely as not that the disorder was caused OR aggravated by the Veteran's service-connected left knee disability. "Aggravated" for VA purposes means that the condition is permanently worsened beyond its natural progression. If the Veteran's service-connected left knee disability is found to aggravate a right knee disability, the examiner should identify the percentage of disability that is attributable to the aggravation. See 38 C.F.R. § 3.310(a); Allen, 7 Vet. App. at 448. d) Range of motion testing of both knees should be undertaken, to include after repetitive use. The examiner is to report the range of motion measurements in degrees. The examiner should consider whether there is likely to be additional range of motion loss due to any of the following: (1) during flare-ups; (2) after repetitive use over time; (3) in weight bearing; and (4) as a result of pain, weakness, fatigability, or incoordination. The examiner should also address whether there is a difference in active range of motion, versus passive range of motion. If so, the examiner is asked to describe the additional loss, in degrees, if possible. In any event, the examiner should fully describe any associated functional limitations. e) The examiner should specifically offer an opinion as to the impact of any functional loss due to pain during flare-ups, considering all procurable and assembled data, and by obtaining all tests and records that might reasonably illuminate the medical analysis. The examiner must, at a minimum, ask the Veteran to describe the severity, frequency, duration, or functional loss manifestations related to flare-ups. f) The examiner should specifically offer an opinion as to whether there is a history of lateral instability, and if so, should indicate the degree of lateral instability (slight, moderate, or severe). If the examiner finds no history of left lateral instability, he/she should specifically address VA treatment records documenting multiple reports of the Veteran's left knee "giving out" and reports of falls on due to purported left knee instability, as noted above. A complete rationale should be provided for any opinion expressed. If the examiner is unable to reach an opinion without resorting to speculation, he or she should explain the reasons for such inability and comment on whether any further tests, evidence, or information would be useful in rendering the opinion being sought; or, whether the inability to provide the opinion is based on the limits of medical knowledge. 4. After completing the development requested in number (1) above, obtain a supplemental medical opinion from an appropriate examiner regarding the nature and etiology of the Veteran's claimed low back disability. The claims file, including a copy of this remand, must be made available to the examiner. If, and only if, determined necessary by the examiner, the Veteran should be scheduled for another VA examination. The examiner should respond to the following: a) The examiner should clarify whether the Veteran has a current diagnosis that pertains to his claimed low back disability. If no current diagnosis is found, the examiner must reconcile such a finding with VA treatment records noted above, which indicate possible osteoarthritis and/or degenerative joint disease affecting the lumbar spine. b) For each identified disability, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that it was caused by, or is otherwise etiologically related to, the Veteran's active military service. c) For each identified disability, the examiner should opine as to whether it is at least as likely as not that the disability was caused OR aggravated by his service-connected left knee disability. In rendering these opinions, the examiner should, at a minimum, consider and address the August 2015 VA pain note, described above, which indicates that the Veteran's knee pain preceded his back pain and that gait abnormality may contribute to his back pain. "Aggravated" for VA purposes means that the condition is permanently worsened beyond its natural progression. If the Veteran's service-connected left knee disability is found to aggravate a low back disability, the examiner should identify the percentage of disability that is attributable to the aggravation. See 38 C.F.R. § 3.310(a); Allen, 7 Vet. App. at 448. A complete rationale should be provided for any opinion expressed. If the examiner is unable to reach an opinion without resorting to speculation, he or she should explain the reasons for such inability and comment on whether any further tests, evidence, or information would be useful in rendering the opinion being sought; or, whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Afford the Veteran a VA examination with an appropriate medical examiner to determine the nature and etiology of his claimed left big toe disability. The claims file, including a copy of this remand, must be made available to, and reviewed by, the examiner. All tests and studies deemed necessary by the examiner should be performed, and all clinical findings should be reported in detail. After a review of the record and an examination and interview of the Veteran, the examiner should offer his or her opinion as to the following inquiries: a) The examiner should identify, with specificity, all diagnoses pertaining to the Veteran's claimed left big toe disability. If diagnoses of hallux limitus or degenerative arthritis are not found, the examiner must reconcile such a finding with the October 2015 examiner's addendums, in addition to the November 2015 VA podiatry note, which are noted above. b) For each diagnosed disability, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that it was caused by, or is otherwise etiologically related to, the Veteran's active military service. In rendering an opinion, the examiner should consider and address the Veteran's report of in-service trauma to his left toe during service and continued constant pain and swelling since service, as reflected in the September 2015 VA rheumatology note described above. c) For each diagnosed disability, the examiner should opine as to whether it is at least as likely as not that it is caused OR aggravated by the Veteran's service-connected left knee disability. "Aggravated" for VA purposes means that the condition is permanently worsened beyond its natural progression. If the Veteran's service-connected left knee disability is found to aggravate a diagnosed left big toe disability, the examiner should identify the percentage of disability that is attributable to the aggravation. See 38 C.F.R. § 3.310(a); Allen, 7 Vet. App. at 448. A complete rationale should be provided for any opinion expressed. If the examiner is unable to reach an opinion without resorting to speculation, he or she should explain the reasons for such inability and comment on whether any further tests, evidence, or information would be useful in rendering the opinion being sought; or, whether the inability to provide the opinion is based on the limits of medical knowledge. 6. After completing the development requested above, in addition to any other development deemed necessary, readjudicate the Veteran's claims. If any of the benefits sought are not granted in full, the AOJ should furnish the Veteran and his representative an SSOC and afford an opportunity to respond. The claims file should then be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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. §§ 5109B, 7112 (2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs