Citation Nr: 1800294 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 16-01 201 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for depression. 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for hematuria. 4. Entitlement to service connection for a left arm disability. 5. Entitlement to service connection for a right arm disability. 6. Entitlement to service connection for a left shoulder disability. 7. Entitlement to service connection for a right shoulder disability. 8. Entitlement to service connection for erectile dysfunction. 9. Entitlement to service connection for sleep apnea. 10. Entitlement to service connection for a bilateral foot disability. 11. Whether new and material evidence has been received to reopen a claim for service connection for a bunion of the right foot. 12. Whether new and material evidence has been received to reopen a claim for service connection for a back disability. 13. Entitlement to service connection for a back disability on a de novo basis. REPRESENTATION Veteran represented by: Joseph A. Whitcomb, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from November 1989 to November 1993. He had service in Southwest Asia in the Persian Gulf. This matter comes before the Board of Veterans' Appeals (Board) on appeal of October 2013 and August 2014 rating decisions. The Veteran provided testimony at a hearing before the undersigned Veterans Law Judge in November 2016. A transcript is in the record. The issue of entitlement to service connection for depression was not among those that were certified to the Board. However, the record shows that after the receipt of a notice of disagreement, the January 2016 statement of the case included this issue, and a substantive appeal stating that the Veteran wished to appeal all issues in the statement of the case was received that same month. Therefore, this appeal has been completed, and the issue of service connection for depression is before the Board. See 38 C.F.R. § 20.200 (2017). Additional VA treatment records were added to the claims file subsequent to the issuance of the most recent supplemental statement of the case. The Veteran waived his right to initial Regional Office (RO) consideration of this evidence in September 2017. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for erectile dysfunction, a bilateral foot disability, sleep apnea, and a back disability on a de novo basis, and whether or not new and material evidence has been received to reopen a claim for service connection for bunion of the right foot are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran experiences depression as a result of his service connected post-traumatic stress disorder (PTSD). 2. It is as likely as not that the Veteran's chronic headaches are proximately due to or the result of his service connected cervical spine disability. 3. There is no diagnosis of hematuria or an underlying disability that can result in hematuria for any portion of the appeal period. 4. Entitlement to service connection for radiculopathy of the left upper extremity associated with the Veteran's service connected cervical spine disability has previously been established. 5. The Veteran denied having a right shoulder disability on VA examination, and there is no diagnosis of a current disability of the right arm, left arm, right shoulder, or left shoulder for any portion of the appeal period. 6. The Veteran's initial claim of service connection for a back disability was denied in a February 1994 rating decision; he did not submit a notice of disagreement within the one year appeal period, nor was new and material evidence received. 7. Evidence received since February 1994 purports to show an injury in service as well as a current chronic back disability, with signs of an association between the two but with insufficient evidence to reach a decision. CONCLUSIONS OF LAW 1. The criteria for service connection for depression as a component of PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5017(b) (2012); 38 C.F.R. §§ 3.303(a), 3.310(a), 4.14 (2017). 2. The criteria for service connection for chronic headaches as secondary to the Veteran's service connected cervical spine disability have been met. 38 U.S.C. §§ 1110, 1131, 5017(b) (2012); 38 C.F.R. §§ 3.303(a), 3.310(a) (2017). 3. The criteria for service connection for hematuria have not been met. 38 U.S.C. §§ 1110, 1131, 5017(b) (2012); 38 C.F.R. § 3.303(a) (2017). 4. The criteria for service connection for left arm disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5017(b) (2012); 38 C.F.R. §§ 3.303(a), 3.307, 3.309, 3.317 (2017). 5. The criteria for service connection for right arm disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5017(b) (2012); 38 C.F.R. §§ 3.303(a), 3.307, 3.309, 3.317 (2017). 6. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5017(b) (2012); 38 C.F.R. §§ 3.303(a), 3.307, 3.309, 3.317 (2017). 7. The criteria for service connection for right shoulder disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5017(b) (2012); 38 C.F.R. §§ 3.303(a), 3.307, 3.309, 3.317 (2017). 8. The February 1994 rating decision that denied entitlement to service connection for a back disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.105(a), 3.156(b) (2017). 9. New and material evidence has been received, and the claim for service connection for a back disability is reopened. 38 C.F.R. § 3.156(a) (2017). 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. §§ 5102, 5103, 5103A, 5107, 5126 (West 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran was provided with complete VCAA notification in a March 2013 letter prior to the initial adjudication of his claim. The duty to notify has been met. The Board also finds that the duty to assist has been met. In this regard, the Veteran has been afforded VA examinations of his claimed disabilities, and medical opinions have been obtained where needed. The Veteran's service treatment records, VA treatment records, and all private records that have been identified have also been obtained. He was afforded a hearing in this matter. 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 The Veteran contends that he has developed many different disabilities as a result of active service, to include his service in Southwest Asia. 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. Such evidence of continuity of symptomatology alone may establish service connection but 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. For a Persian Gulf Veteran, service connection may also be established for a qualifying chronic disability, including an undiagnosed illness, or a medically unexplained chronic multisymptom illness, defined by a cluster of certain signs and symptoms including chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, provided the illness became manifest during active service or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(2)(i)(B). 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). 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). Depression The Veteran contends that he has chronic depression as a result of his service in Southwest Asia. The record shows that entitlement to service connection for PTSD was previously granted in a May 2016 rating decision. Post service records include an August 2004 primary care note. A screen for depression was positive. 1/4/2016 VBMS, Capri, p. 234. An April 2014 mental health hotline call shows that the Veteran reported bouts of depression, and he sought a formal assessment to determine a treatment course. 1/4/2016 VBMS, Capri, p. 225. A February 2016 VA PTSD examination shows that the Veteran endorsed having depression. 2/16/2016 VBMS, C&P Exam, p. 1. An August 2016 VA treatment record states that the Veteran was followed for several current problems, including "Depression/PTSD". 2/9/2017 VBMS, Capri, p. 19. Depression was included on the Veteran's problem list through 2016, and his assessments through 2017 often included the designation "Depression/PTSD". A June 2017 mental health triage note says that the Veteran was upset about an incident at his work place. His risk factors included depression and PTSD. On examination, his mood was depressed. The diagnoses included major depressive disorder, and PTSD. Based on the above, the Board finds that entitlement to service connection for depression is warranted. The evidence documents that the Veteran has experienced bouts of depression since at least 2004. Moreover, his treatment providers have associated this depression with his PTSD since 2016. The Board concludes that it is as likely as not that the Veteran's depression is a component of his service connected PTSD, and that it should be included with this disability. In reaching this decision, the Board observes that by regulation, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2017). Therefore, a separate evaluation for the depression cannot be awarded; rather, the diagnosis of depression will be made part of the service-connected diagnosis of PTSD. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303(a), 3.310(a). Headaches The Veteran's service treatment records are negative for complaints, treatment, or diagnoses relating to headaches. Post service treatment records include a private treatment record dated April 2009 which shows the Veteran presented with headache. The assessment was a sinus headache. 11/12/2013 VBMS, Medical Treatment Record - Non-Government Facility, p. 52. August 2012 private medical records show that the Veteran was experiencing an increase in the severity and frequency of his headaches following a motor vehicle accident. The diagnosis was a concussion. 11/12/2013, VBMS, Medical Treatment Record - Non-Government Facility, p. 14. The Veteran was afforded a VA examination of his claimed headache disability in August 2013. The claims file was reviewed by the examiner. The Veteran reported severe frontal headaches that occurred about three times per month and lasted for up to two hours. He reported using prescription pain medications, plus energy drinks plus alcohol with his headaches. The Veteran currently experienced headaches about twice per month. He was unaware of precipitating factors, although he acknowledges regular heavy alcohol consumption. The examiner opined that the Veteran's headaches were most likely due to using alcohol with energy drinks. 1/4/2016 VBMS, Capri, pp. 183, 202. A December 2015 VA treatment note shows that the Veteran was seen for complaints of chronic headaches for the past three years. He denied vision changes, nausea, fever, neck pain, stiffness, weakness, and other symptoms. The usual trigger was stress or weather changes. On examination, he was noted to have frequent neck spasms and a history of neck pain. 1/4/2016 VBMS, Capri, p. 17. January 2016 VA treatment records notes that the Veteran had been seen in December for a particularly intense headache. He reported continued headaches over the past several weeks. An addendum states that the Veteran was to have been provided a magnetic resonance imaging (MRI) of the brain, but after a more thorough chart review it was determined that more information was needed. The examiner opined that the Veteran's headaches were likely due to neck pain. 1/12/2016 VBMS, Capri, p. 1. The Board finds that entitlement to service connection for headaches is supported by the evidence. The service treatment records are negative for headaches, and they were first documented years after discharge from service. However, entitlement to service connection for cervical joint and disc disease has previously been established. Service connection for left upper extremity radiculopathy associated with the cervical spine disability has also been established. The Board notes that private and VA examiners have attributed the Veteran's headaches to various causes, including sinusitis, stress, and mixing alcohol with other drinks and medications. However, in January 2016 a VA nurse practitioner opined that the Veteran's headaches were most likely due to neck pain. It is noted that this opinion was provided after a review of the Veteran's medical records. It is at least as probative as the other opinions that attribute the headaches to other causes. Resolving all doubt in favor of the Veteran, the Board finds that his headaches are proximately due to or the result of his service connected cervical spine disability. It follows that service connection for the headaches is also warranted. 38 C.F.R. § 3.310(a). Hematuria The Veteran's service treatment records confirm that he was seen for hematuria from September 1992 to October 1992. The assessment was hematuria, painless. 11/24/1993 VBMS, STR - Medical, pp. 2, 18. An October 1992 X-ray study of the kidneys using contrast material was normal. 11/24/1993 VBMS, STR - Medical, p. 1. Post service treatment records include an August 2004 VA treatment note that states the Veteran has had hematuria, although not recently. 1/4/2016 VBMS, Capri, p. 235. The Veteran was provided a VA examination of the urinary tract in August 2013. He reported that his last episode of hematuria was in November 2004. The diagnosis was hematuria, resolved. The examiner opined that there was no subjective or objective evidence of a chronic urinary condition of hematuria. This had resolved in 2004 without recurrence, as reported by the Veteran. 1/4/2016 VBMS, Capri, pp. 190, 214. A July 2016 VA urology note shows that the Veteran reported having blood in his urine in the past. He said the cause of this was never identified. Per his report, he continued to have frank hematuria infrequently, with the last episode about a year ago. The examiner noted that a review of all urinary analyses conducted at the Veteran's VA medical clinic were negative for hematuria. The Veteran was scheduled for a cystoscopy, but he cancelled after realizing what this involved. 2/9/2017 VBMS, Capri, pp. 22, 28. An April 2017 VA treatment note reports a history of idiopathic hematuria that had not occurred in over a year. 7/18/2017 VBMS, Capri, p. 44. In this case, the Board finds that entitlement to service connection for hematuria is not established. The service treatment records clearly show that the Veteran was treated for this problem. However, treatment in service by itself is not sufficient to establish service connection. 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) (holding that Secretary's and Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Caluza v. Brown, 7 Vet. App. 498, 505 (1995); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v Derwinski, 2 Vet. App. 141, 143 (1992). The Board further notes that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain v. Nicholson, 21 Vet. App. 319 (2007). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1. See also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that a symptom, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). In this Veteran's claim, it does not appear that he continues to experience hematuria. At the August 2013 VA examination, he reported that the last time he had experienced hematuria was in 2004, which is well before he filed his current claim. The July 2016 treatment note says that the Veteran reported his last hematuria had been about a year ago, but adds that every urinalysis in his record was negative for hematuria. The Board observes that while a change in the color of one's urine is observable by a layman, the absence of blood in the urinalyses indicates that there was no hematuria. In any event, without a showing of chronic disability, as opposed to an isolated symptom, service connection would not be warranted. Indeed, the Veteran's hematuria, even if it were to currently exist, has not been linked to a chronic disability, and he cancelled testing that would have been useful in determining whether or not there is a chronic disability. In sum, in the absence of a showing of a chronic disability manifested by hematuria for any portion of the appeal period, service connection is not warranted. Arm and Shoulder Pain The Veteran contends that he has disabilities manifested by pain of the right arm, left arm, right shoulder, and left shoulder. Initially, the Board observes that entitlement to service connection for left upper extremity radiculopathy associated with the Veteran's service connected cervical spine disease has been established. As noted, the evaluation of the same disability under various diagnoses is to be avoided. Therefore, any disability of the left arm and/or left shoulder must be separate and distinct from the radiculopathy of the left upper extremity before service connection can be established. 38 C.F.R. § 4.14. The Veteran's service treatment records are negative for complaints, treatment, or diagnoses relating to arms and shoulders. Post service private medical records show that the Veteran presented with right elbow pain in December 2007. It was noted that he had been doing a lot of work with his right forearm. The assessment was lateral epicondylitis. 11/12/2013 VBMS, Medical Treatment Record - Non-Government Facility, p. 1. In August 2012, the Veteran experienced shoulder pain following a motor vehicle accident. It seemed to be resolving with physical therapy. However, he presented with left shoulder pain again in June 2013. 11/12/2013, VBMS, Medical Treatment Record - Non-Government Facility, pp. 2, 12. The Veteran underwent a series of VA examinations for his claimed disabilities in August 2013. At the examination of the shoulders and arms, the Veteran denied a separate arm condition, and he also denied a problem with the right shoulder. He reported anterior left shoulder paresthesia and pain. An X-ray study of the left shoulder was normal. As the right shoulder was asymptomatic with a normal examination, no X-ray was obtained. The arms were reported to be normal. 1/4/2016 VBMS, Capri, p. 205. A Gulf War examination conducted at this time reported that the Veteran did not have any undiagnosed illnesses for which no etiology was established, and he did not have any additional signs or symptoms that might represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. The examiner found that for the Veteran's claimed arm pain, the diagnosis was normal bilateral arms. For the claimed condition of shoulder pain, the diagnosis was normal bilateral shoulders, and cervical spine disability with left upper extremity radiculopathy. It was not related to service in Southwest Asia, but was a biomechanical condition. 1/4/2016 VBMS, Capri, p. 183. An August 2013 letter from a VA medical center to the Veteran addressed the results of his recent VA examinations. An X-ray study of the left shoulder was reportedly unremarkable. Evidence of a degenerative neck condition was noted, which was said to explain the symptoms he experienced in his left shoulder region. 1/4/2016 VBMS, Capri, p. 180. VA treatment records dating September 2014 and July 2015 continue to report radiculopathy of the left arm. The Veteran reported pain into the shoulder and arm down to the wrist. The July 2015 diagnosis was chronic neck pain that causes radiculopathic pain through the left shoulder. 1/4/2016 VBMS, Capri pp. 22, 102. After review of the evidence, the Board finds that entitlement to service connection for left arm pain, right arm pain, left shoulder pain, or right shoulder pain is not warranted. The service treatment records are negative for evidence relating to a disability of the right arm, left arm, right shoulder, or left shoulder. The only post service evidence of a right arm disability is the epicondylitis that was treated in 2007. This appears to have resolved, as there is no further mention of it in the record, and the August 2013 VA examination found both arms to be normal. The Veteran denied having a separate arm disability and a right shoulder disability at the August 2013 examination. There is also no evidence of a left shoulder disability other than the radiculopathy for which service connection has already been established. As previously noted, a diagnosis of a current disability is the first criterion in the process of establishing service connection. See Degmetich. "Pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted." Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). In the absence of a diagnosis of a disability of the right or left arm, or of the right or left shoulder except for the left arm radiculopathy for which service connection has already been established, entitlement to service connection is not warranted for any of the disabilities of the upper extremity claimed by the Veteran. In reaching this decision, the Board has considered entitlement to service connection on a presumptive basis for a disability of the right or left arm, or of the right or left shoulder. However, there is no X-ray evidence or diagnosis of arthritis for any of these joints, and in fact the only X-ray that was obtained shows the left shoulder to be normal. This also precludes consideration of continuity of symptomatology for these four issues. Finally, entitlement to service connection on the basis of service in Southwest Asia has also been considered, but the August 2013 VA examiner found that the Veteran did not have any undiagnosed illnesses for which no etiology was established, and he did not have any additional signs or symptoms that might represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. These theories of entitlement do not establish service connection for any of the four claimed disabilities. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309, 3.317. New and Material Evidence The record indicates that entitlement to service connection for a back disability was previously denied in a February 1994 rating decision. The Veteran was notified of this decision and provided with his appellate rights in a February 1994 letter. He did not submit a Notice of Disagreement with this decision within one year of receipt of the letter. Furthermore, new and material evidence was not received during that period. Therefore, the February 1994 decision is final, and is not subject to revision on the same factual basis. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.105(a), 3.156(b). 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). 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 evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (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. The evidence considered by the February 1994 rating decision consisted of service treatment records. The decision noted the Veteran's contention that he had a back disability that comes and goes. However, the decision further noted that the service treatment records were negative for any complaints or treatment pertaining to the back, and concluded that the evidence failed to show a chronic disability of the back being incurred or aggravated by active service. The evidence received since February 1994 includes an August 2004 VA treatment record in which he reports intermittent low back pain for the past 10 years. No specific trauma was noted. 1/4/2016 VBMS, Capri, p. 235. Records dating from 2004 to the present have continued to show ongoing treatment for low back pain with few objective findings on examination other than spasms. However, a July 2016 VA X-ray study of the low back revealed mild degenerative disc disease at L2-L3. 2/9/2017 VBMS, Capri, p. 34. At the November 2016 hearing, the Veteran testified that he believed his arm, shoulder, and back problems were the result of having to lift and use a sledge hammer to "bust" the tracks from tracked vehicles during service. The Board observes that this activity was the basis for a positive opinion in the August 2013 VA examination linking the Veteran's cervical spine disability to active service. He also reported that his back disability began after he was struck by a tank skirt in service, although the examiner noted that the back disability was not on appeal and did not provide an opinion addressing its etiology. 1/4/2016 VBMS, Capri, pp. 187, 189. The Board concludes that new and material evidence has been received to reopen the low back claim. Indeed, the Veteran's testimony, as well as all post service medical records, constitute new evidence, in that none of the information in this evidence was previously considered. It is also material, in that the testimony purports to show the source of a back injury in service, and the records now establish the existence of a current chronic back disability. This evidence meets the McLendon standard that obliges VA to provide the Veteran an examination. It follows that his claim is reopened. See Shade. The matter of entitlement to service connection for a back disability on a de novo basis will be addressed in the remand section at the end of this decision. ORDER Entitlement to service connection for depression as a component of his service connected PTSD is granted. Entitlement to service connection for headaches is granted. Entitlement to service connection for hematuria is denied. Entitlement to service connection for left arm pain is denied. Entitlement to service connection for right arm pain is denied. Entitlement to service connection for left shoulder pain is denied. Entitlement to service connection for right shoulder pain is denied. New and material evidence having been received, the petition to reopen a claim for service connection for a back disability is granted. REMAND The initial evidence of erectile dysfunction is found in private treatment dated October 2008. The examiner opined that this was most likely secondary to stress, as the Veteran was working two jobs. 11/12/2013 VBMS, Medical Treatment Record - Non-Government Facility, pp. 59-60. Similarly, a January 2016 VA treatment note says that the Veteran recognized that the problem may be related to psychological issues. 4/15/2016 VBMS, Capri, p. 28. The Board observes that entitlement to service connection for PTSD has previously been established, and service connection for depression has now been included in that award. Anxiety is a symptom that can be associated with PTSD. This raises the question as to whether or not the Veteran's erectile dysfunction is related to his service connected PTSD. The August 2013 VA examination did not address secondary service connection. The Board finds that the Veteran should be scheduled for a new examination of the male reproductive system to address this theory of entitlement. Regarding the Veteran's claims of service connection for obstructive sleep apnea and for a bilateral foot disorder, both were addressed in VA examinations conducted in July 2014. The examiner opined that the Veteran's sleep apnea was a condition with a clear and specific etiology, and the diagnosis was less likely than not related to a specific exposure event during service in Southwest Asia. Similarly, the examiner opined that Veteran's painful arches were clearly related to weight-bearing, and were less likely than not related to an exposure event in Southwest Asia. 7/31/2014 VBMS, C&P Exam, pp. 3, 10. The Board finds that both of these medical opinions are inadequate. Although the examiner provided an opinion as to whether or not the sleep apnea or aching arches were part of an undiagnosed illness due to exposure to environmental hazards in Southwest Asia, he did not provide an opinion regarding direct service connection. The Veteran is not precluded from establishing service connection of a direct basis merely because he believes his disabilities may be part of an undiagnosed illness. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran should be scheduled for new examinations that address the possibility of direct service connection. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran's claim of service connection for a right foot bunion was previously denied in an August 1998 rating decision. This decision was not appealed and is final. Therefore, VA was under no obligation to afford the Veteran an examination for this disability in conjunction with his claim to reopen. 38 C.F.R. § 3.159(c)(4)(iii) (2017). However, the July 2014 examination also addressed the Veteran's claim of service connection for a right bunion when it noted in the opinion section that the Veteran has a congenital condition of the right 4th and 5th bradymetatarsia that was diagnosed at the time of enlistment. It was currently asymptomatic and required no specific treatment. 7/31/2014 VBMS, C&P Exam, p. 10. The service treatment records confirm that a congenital right foot deformity was noted on the Veteran's entrance examination. 11/24/1993 VBMS, STR - Medical, p. 11. The Board observes that the July 2014 opinion is inadequate, in that it suggests that service connection for a congenital disability may not be awarded. In fact, service connection for a congenital disease may be awarded if it is aggravated during service. VAOPGCPREC 82-90 (O.G.C. Prec. 82-90). As VA provided the Veteran an examination, it must be adequate. Therefore, an addendum opinion as to whether or not the Veteran has a congenital disease that was aggravated in service or a congenital defect with a superimposed disability should be obtained. See Barr. Finally, as previously discussed, the McLendon standard has been met for the Veteran's claimed back disability. He should be scheduled for a VA examination to determine the etiology of this disability. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination of the male reproductive system. The claims file must be made available to the examiner, and the examination report should note that it has been reviewed. All indicated tests and studies should be conducted. At the conclusion of the examination and record review, the examiner should provide the following opinions: a) Is it at least as likely as not that the Veteran's erectile dysfunction was incurred during or due to active service? b) If the answer to (a) is negative, is it as likely as not that the Veteran's erectile dysfunction was incurred due to his service connected PTSD and depression, to include secondary to anxiety related to the PTSD? c) If the answers to (a) and (b) are both negative, is it as likely as not that the Veteran's erectile dysfunction was aggravated (increased in severity beyond natural progression) by his service connected PTSD? If yes, can a baseline severity of the erectile dysfunction prior to aggravation be established? 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. 2. Schedule the Veteran for a VA examination of his sleep apnea. The claims file must be made available to the examiner, and the examination report should note that it has been reviewed. All indicated tests and studies should be conducted. At the conclusion of the examination and record review, the examiner should provide the following opinions: a) Is it at least as likely as not that the Veteran's sleep apnea was incurred during or due to active 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. 3. Schedule the Veteran for a VA examination of his back disability. The claims file must be made available to the examiner, and the examination report should note that it has been reviewed. All indicated tests and studies should be conducted. At the conclusion of the examination and record review, the examiner should provide the following opinions: a) Is it at least as likely as not that the Veteran's back disability was incurred during or due to active service? The reasons for all opinions should be provided. The examiner should address the Veteran's contentions regarding his performing heavy labor to repair tracked vehicles and being struck by a tank skirt in service. 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. Schedule the Veteran for a VA examination of his claimed bilateral foot disability and congenital right foot disorder. The claims file must be made available to the examiner, and the examination report should note that it has been reviewed. All indicated tests and studies should be conducted. At the conclusion of the examination and record review, the examiner should provide the following opinions: a) Is it at least as likely as not any chronic bilateral foot disability (exclusive of the congenital defect) was incurred during or due to active service, to include weight bearing during active service? b) With regard to the congenital right 4th and 5th bradymetatarsia, is this abnormality considered a disease (capable of getting better or worse) or a defect (a static condition)? c) If considered a disease, it is as likely as not that the congenital right 4th and 5th bradymetatarsia was aggravated (increased in severity beyond natural progression) by active service? Is so, did this aggravation include a chronic bunion? Please estimate the baseline level of disability prior to such aggravation. d) If considered a defect, does the Veteran have any superimposed disabilities due to the congenital right 4th and 5th bradymetatarsia, to include but not limited to a bunion? If so, is it as likely as not that any superimposed disability was due to an event or illness during active service? Note to the examiner(s): "Defects" are usually static in nature, so not generally subject to episodic improvement or worsening, whereas "diseases" are. 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