Citation Nr: 1802550 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 09-22 092 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for right and left knee disorders, claimed as secondary to service-connected bilateral foot disabilities. 2. Entitlement to service connection for right and left hip disorders, claimed as secondary to service-connected bilateral foot disabilities. 3. Entitlement to service connection for a low back disorder, claimed as secondary to service-connected bilateral foot disabilities. 4. Entitlement to service connection for a neck disorder, claimed as secondary to service-connected bilateral foot disabilities. 5. Entitlement to service connection for right and left shoulder disorders, claimed as secondary to service-connected bilateral foot disabilities. 6. Entitlement to service connection for left ear hearing loss. 7. Entitlement to a compensable initial rating for right ear hearing loss. 8. Entitlement to a compensable rating for paroxysmal atrial fibrillation. 9. Entitlement to a disability rating in excess of 10 percent for residuals of right bunionectomy scar. 10. Entitlement to a disability rating in excess of 10 percent for residuals of left bunionectomy scar. 11. Entitlement to a disability rating in excess of 10 percent for right hallux valgus, status post bunionectomy, excluding periods during which he was in receipt of temporary total evaluations. 12. Entitlement to a disability rating in excess of 10 percent for left hallux valgus, status post bunionectomy, excluding periods during which he was in receipt of temporary total evaluations. 13. Entitlement to a total disability rating based on individual unemployability (TDIU), prior to March 11, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran had active service in the United States Army from August 1979 to August 1982. His awards and decorations included the Army Service Ribbon, the Overseas Service Ribbon, and Marksman (Pistol). This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in August 2007, March 2010, and July 2012 by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. The Veteran was afforded a hearing before the undersigned at the RO in May 2015. A transcript of the proceeding has been associated with the electronic claims file. In March 2016, the Board noted that the Veteran's claims characterized as entitlement to service connection for an acquired psychiatric disorder [adjudicated as a claim for adjustment disorder with mixed anxiety and depressed mood (claimed as a mental condition)] and a neck disability were original claims. The Board reopened claims for service connection for right and left knee disorders and a back disorder. The Board remanded service connection for such disorders, as well as, the above listed claims for additional development. In a December 2016 rating decision, the RO, in pertinent part, granted service connection for depressive disorder, with a 50 percent disability rating, from March 11, 2009 and a TDIU from March 11, 2009. As that decision fully granted those claims, those matters are not before the Board. The TDIU claim for prior to March 11, 2009 remains before the Board. The issues of entitlement to service connection for left ear hearing loss and right and left shoulder disorders, as well as, increased ratings for right ear hearing loss and bilateral hallux valgus and bunion scars are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's statements as to a lack of post-service injuries to his back, neck, and knees are not credible, given the contemporaneous medical evidence and statements he has made to the contrary. 2. Right and left knee disorders are not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 3. Right and left hip disorders are not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 4. A low back disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 5. A neck disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 6. For the entire appeal period, the Veteran's paroxysmal atrial fibrillation is not characterized by episodes paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. CONCLUSIONS OF LAW 1. Right and left knee disorders were not incurred in or aggravated by the Veteran's active duty military service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 3.309, 3.310 (2017). 2. Right and left hip disorders were not incurred in or aggravated by the Veteran's active duty military service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 3.309, 3.310 (2017). 3. A low back disorder was not incurred in or aggravated by the Veteran's active duty military service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 3.309, 3.310 (2017). 4. A neck disorder was not incurred in or aggravated by the Veteran's active duty military service, or caused or aggravated beyond the natural progression by the service-connected bilateral foot disabilities. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 3.309, 3.310 (2017). 5. The criteria for the assignment of compensable disability rating for paroxysmal atrial fibrillation have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. Part 4, including §§ 4.7, 4.104, Diagnostic Code 7010 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Claims The Veteran contends that he currently has right and left knee disorders, right and left hip disorders, a low back disorder, and a neck disorder developed secondary to or were aggravated by his service-connected bilateral foot disorders (which include residuals of bunionectomy scars of each foot; hallux valgus of each foot, status post bunionectomy; and pes planus). A. Applicable Law Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 C.F.R. §§ 3.307, 3.309 (2017). An alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Sensorineural hearing loss and tinnitus are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology for this disease is applicable in the present case. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a), such as psychoses, and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection also may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that effective October 10, 2006, before the Veteran filed his claim, the provisions of 38 C.F.R. § 3.310 were changed to state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). B. Factual Background and Analysis The Veteran's contention is that his service-connected bilateral foot disorders caused him to have an altered gait and that he subsequently developed right and left knee disorders, right and left hip disorders, a low back disorder, and a neck disorder. In a May 2016 VA examination, the VA examiner diagnosed current diagnoses including degenerative arthritis of the spine (both back and neck); right and left hip strain; and knee disorders, including bilateral knee strain, left knee meniscal tear, degenerative joint disease, and chrondromalacia and right knee total knee replacement. As such, the Veteran has current diagnoses and the question before the Board is whether such disorders developed due to service or as secondary to his service-connected bilateral foot disorders. 1. Credibility Determination The Board notes that in the informal hearing presentation, the Veteran's representative argued that the 2016 VA examinations were inadequate because they did not accept the Veteran's lay statements as credible. The Board finds, however, that such acceptance of credibility is not necessary, as his statements are not credible. Specifically, the Board finds that the Veteran's implications of no separate, post-service injuries are not credible. The Veteran reported to Dr. B. Brownwell, DPM, as documented in a March 2015 letter, that "he has never had a back injury." However, a June 2001 Family Medical Group Urgent Care report, sent to the Veteran's former employer's workers compensation division, noted that the Veteran "reports that, on 05/09/01, he was lifting a case of paper, when he twisted and felt a pull in his low back;" he subsequently received a diagnosis of lumbar strain. Additionally, "[h]e reports that he has a history of a prior back strain in 1981, while serving in the military, however, has had no subsequent difficulties and has not seen a doctor or chiropractor for his back in many years." In a June 2001 letter, the Veteran attempted to take action against his former employer, Foster Farms, stating "[o]n May 9, 2001 I injured my back, lifting product" and "[o]n June 4, 2001 I re-injured my back, lifting products. A June 2013 VA DBQ form, provided by the Veteran's private medical provider M.M.C., noted that the Veteran "injured back 2001." In a February 2017 lay statement, the Veteran's former co-worker, D.W. also reported two post-service, work-related back injuries. Also, to the extent that the Veteran may contend to have not had a post-service knee injury, a January 2003 orthopedic consultation, requested by VA, noted that the Veteran "had an accident on the job where his right knee was damaged...surgeries done... claims that in spite of the surgeries the knee is deteriorating and he might have to have a total knee replacement." A May 2001 private medical record, by Dr. A. Ma, noted that the Veteran had lumbar spine disorders following a May 2001 work injury and that he had knee symptoms 12 years previously that had been surgically corrected. In a July 2010 letter, Dr. S. Woolson reported that the Veteran had left knee post-traumatic arthritis, indicating prior trauma to the left knee, though the Veteran claimed to his 2016 VA examiner that he had not had a left knee injury. Furthermore, in a Workers' Compensation Appeals Board application filled out by the Veteran, he reported that from May 2000 to May 2001, he had sustained injury at his employer's premises to his "BACK, NECK, KNEES, FEET, BOTH UPPER EXTREMITIES." He further noted a prior claim for industrial injuries to the right knee and back in 1991. In a July 2001 letter to the Workers' Compensation Appeals Board, he indicated that while working for his employer he only had feet and right knee problems, but after his work-related injuries to his feet, knees, back, and neck, he had problems in those areas. In a March 2008 comprehensive internal medicine evaluation, by MDSI Physician Services, the Veteran only reported knee and foot pain; after complete physical evaluation, including of the neck, back, shoulders, hips, and knees, the provider only diagnosed bilateral degenerative joint disease of the knees and surgery of the feet for hallux valgus. Such reports are indicative of a lack of continuity of symptoms for decades following service. 2. Direct Service Connection To the extent that the Veteran contends that his disorders are directly due to service, the probative evidence of record does not support such claims. Following service, in 1982, the Veteran claimed to have a low back disorder due to service. However, during the June 1983 VA examination, he reported only a history of transient spasms and no current complaint. The examiner found no current sign of pain. Subsequently, in a June 2001 Family Medical Group Urgent Care report, the Veteran noted "a history of a prior back strain in 1981, while serving in the military, however, has had no subsequent difficulties and has not seen a doctor or chiropractor for his back in many years." Furthermore, during his VA examinations, he reported that his back, neck, and bilateral hip problems began in approximately 2001. During his May 2016 VA examination, he claimed his knee problems began in the 1980s; however, he has not reported that such disorders began during service. Indeed, as fully discussed in the credibility determination above, the Board finds that the most probative evidence shows that the Veteran is not credible as to claims that he did not have post-service injuries. Additionally, none of the medical evidence of record is supportive of finding direct service connection. Service treatment records are silent as to any complaints of, or treatment for, the claimed disorders, as is the other evidence of record for over a decade following his separation from service. For example, in a March 2008 comprehensive internal medicine evaluation, by MDSI Physician Services, the Veteran reported 'knee pain as a result of "repetitive heavy lifting" for many years.' After complete physical evaluation, including of the neck, back, shoulders, hips, and knees, the provider only diagnosed bilateral degenerative joint disease of the knees and surgery of the feet for hallux valgus. Moreover, there are no medical opinions of record purporting a direct service connection basis for any of the claimed disorders. Indeed, the VA examiners from May 2016 found no such connection between the claimed back, neck, bilateral hips, or bilateral knees and service, noting consideration of the claims file, peer reviewed medical literature, medical records, and physical examination of the Veteran. None of the private medical opinions addressed direct service connection. Additionally, there is no indication of record that any arthritis developed within a year of separation of service; there is no medical evidence supportive of such finding, and the Veteran himself has indicated that his disorders developed years after separation from service. As noted in the credibility section above, the Veteran appears to have had several post-service injuries after which he developed right and left knee disorders and a low back disorder, as well as, reported right and left shoulder disorders. As such, service connection on a direct or presumptive basis for right and left knee disorders, right and left hip disorders, a low back disorder, and a neck disorder is denied. 3. Secondary Service Connection As to the Veteran's contention of service connection on a secondary basis, there are multiple medical opinions of record. As established above, the claimed disorders developed years after service. As such, the question before the Board is whether such disorders were caused or aggravated beyond the natural progression by the service-connected bilateral foot disorders. None of the competent medical opinion evidence of record has found that any of the claimed disorders were caused by the service-connected bilateral foot disabilities. Indeed, the Board notes that in his June 2010 letter, Dr. Brownell reported that: This abnormal pronation can also result in tibial torsion which would have a direct effect on his knees. His orthopedic surgeon will have to comment further on this since I do not evaluate on knee conditions or more promixal joint abnormalities that were likely aggravated by his abnormal pronation. Dr. Brownell appears to indicate that he is not qualified to evaluate a knee condition or other proximal joint abnormalities. At most, he provided a speculative opinion that is not sufficient to establish a nexus to the service-connected foot disabilities. In a March 2015 letter, Dr. B. Brownell, DPM reported: I have written many letters of support of his claim for his bilateral foot pain and how his foot pain and deformity has caused increased problems in his knees, hips, and back. He has presented me today with a MRI report dated 8/11/14 that states that he has significant degenerative disc disease in both the cervical and lumbar regions. He relates that he has never had a back injury [emphasis added]... In the absence of physical back injury [emphasis added], it more likely that his knee and back pain is directed related to his service connected foot deformity. As clear in the March 2015 letter, Dr. Brownwell based his medical opinion as to back and knee pain being related to the feet based on the Veteran's contention that he never had a back injury, which the Board has found to not be credible. In Coburn v. Nicholson, 19 Vet. App. 427 (2006), the United States Court of Appeals for Veterans Claims (Court) pointed out that reliance on a veteran's statements renders a medical report incredible only if the Board rejects the statements of the veteran. As such, the Board does not find this medical opinion to be probative. In an October 2014 letter, as in a September 2009 letter, Dr. M. Ollada reported diagnoses of bilateral knee osteoarthritis, degenerative joint disease, and cervical discogenic disease and primary symptoms of feet, knees, neck, and back pain. He noted that "[o]ver many years...feet condition has aggravated his knees, hips, back and neck as secondary to his service connected disability." Also, in a February 2015 VA DBQ form, Dr. Brownell noted that the Veteran had a history of bilateral flat feet since service, which "caused painful bunions and significant knee and lower back pain." No explanations were provided on how the conclusions were reached in these medical opinions. The Court has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As such, these opinions are of only limited probative value. The most supportive medical opinion evidence of record is a June 2013 letter, wherein Dr. Brownell reported that: abnormal pronation in his foot are felt proximally in his ankles, knees, hip, and back. With abnormal pronation, there is a collapse of the medial longitudinal arch...resulting in tibial torsion...also internal rotation of-the- femur which can cause pain in the knees...[and] pelvic tilt resulting in hip and lower back pain." He opined that "it is more likely than not that his back, hip, knee, and ankle pain is related to his pes planus condition. However, as demonstrated in the March 2015 letter from Dr. Brownell above, he does not appear to consider, or to indeed have knowledge of, the Veteran's post-service injuries in forming his opinions. As such, the opinion is of only limited probative value. Moreover, the above opinions only associate pain with the service-connected foot disorders. Such findings are not fully supportive of the Veteran's claim. Although Dr. Brownell appears to find that the Veteran's pain is related to his foot disorders, he does not opine that the Veteran's actually diagnosed disorders such as arthritis, meniscal tear, or strains have been aggravated by the foot disorders. Pain is not a disability for which service connection can be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). For example, the Veteran has had a total knee replacement of the right knee (following a post-service, work-related knee injury). There has been no progression of a nonservice-conncected disease associated with the completely replaced knee. Furthermore, the private opinions do not address the claimed cervical spine disorder. In a July 2010 letter, Dr. S. Woolson reported that the Veteran was under his care and had undergone a right total knee replacement and had left knee post-traumatic arthritis. He opined "[h]is abnormal gait from [nonservice-conncected] knee arthritis may aggravate low back pain." Here Dr. Woolson associated the Veteran's abnormal gait to his nonservice-conncected bilateral knee disorders, not his service-connected bilateral foot disorders. As such, this opinion is not supportive of the Veteran's claim. The Veteran has also provided medical treatise information, which may be regarded as competent evidence where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509, 513 (1998). However, the Court has held that generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish the nexus element. See Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Here, as explained above, there are many aspects to the Veteran's claims, such as post-service injuries and possible aggravation beyond the natural progression of the disorders that cannot be addressed by such broad medical treatise evidence. As such, the Board does not find such evidence to be competent to establish service connection. In contrast, the May 2016 VA examiner, in June 2016 addendum opinions, has provided the only opinions that have fully addressed the Veteran's claims. As to the low back disorder and right and left hip disorders the examiner determined that there was insufficient evidence to support finding that such disorders aggravated beyond the natural progression by service-connected foot disabilities. He explained that in addition to a painful foot condition disturbing weight bearing, leading to the claimed conditions, the Veteran also had multiple nonservice-conncected medical conditions of the lower extremities, including the knees and ankles that could also cause stress. Such a finding is consistent with Dr. Woolson's finding that the Veteran had an abnormal gait due to his nonservice-conncected bilateral knee disorders. The VA examiner further found that the evidence of record showed that the Veteran's had post-service bilateral knee injuries that led to surgeries and that there was no evidence that the knee disorders were caused by and/or aggravated beyond the natural progression by the service-connected foot disabilities. The VA examiner additionally determined that the evidence of record did not confirm a neck condition caused by or aggravated by the service-connected foot disabilities. In forming opinions, the VA examiner has noted consideration of the claims file, peer reviewed medical literature, medical records, consideration of the Veteran's reports regarding believed aggravation and injuries (as shown in the VA examination reports of history) and physical examination of the Veteran. Moreover, in addition to the VA examiner being unable to find evidence supportive of aggravation, the Board finds that to the extent that any medical opinions may have found aggravation or the possibility, no pre-aggravation baseline level of disability that was compared to the current level of disability was ever established to establish aggravation. 38 C.F.R. § 3.310(b). The Veteran has also provided an opinion through his claim that he developed the claimed disorders as secondary to his service-connected foot disabilities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, i.e., whether the Veteran has a medically diagnosed disability etiologically caused or aggravated by his service-connected foot disabilities, such question falls outside the realm of common knowledge of a lay person as it involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Indeed, the Board notes that although the Veteran has alleged to have an altered gait due to his feet, doctors have found it to be due to his nonservice-connected knees. Additionally, the Veteran appears to imply there is a causal relationship from the service-connected feet, despite the evidence of clear post-service injuries, without addressing such injuries. In contrast, the 2016 VA examination opinions are the only competent and probative medical opinions of record. That VA examiner considered the Veteran's claims file and medical history in the report. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Additionally, the VA examiner provided an etiological opinion, complete with the rationales described above. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Consequently, the Board assigns great probative value to that negative opinion. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1991). The Veteran's claims for service connection for right and left knee disorders, a right and left hip disorders, a low back disorder, and a neck disorder are denied. II. Increased Rating Claim The Veteran contends that his service-connected paroxysmal atrial fibrillation warrants a compensable rating. During his May 2015 Board hearing, the Veteran reported that he took medication for it and had been hospitalized, including an overnight stay at an emergency room. The Veteran was previously rated at a noncompensable rating under 38 C.F.R. § 4.104, Diagnostic Code 7010. A 10 percent rating is warranted for permanent atrial fibrillation (lone atrial fibrillation), or: one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. A maximum 30 percent rating is warranted where there is paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor. During the appeal period, the evidence shows no episodes of atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. The January 2011 VA examiner noted that June 2009 VA echocardiograms reported an overall normal impression; there were several electrocardiograms (ECGs) all of which showed normal sinus rhythm. The VA examiner opined that the Veteran's in-service atrial fibrillation has since resolved and did not impact his quality of life. The March 2014VA examiner similarly found that since 1997, the Veteran has not had an episode of atrial fibrillation. He noted a January 2014 VA emergency room visit for chest discomfort, but that the ECG had been normal, and that the Veteran has had 18 ECGs done to date and all show normal sinus rhythm. He found no atrial fibrillation in the last year. He found no documented evidence of paroxysmal supraventricular arrhythmias since 1997 and noted that findings of atrial fibrillation in a young man (such as the Veteran had been in service) were likely the result of an episode of "Holiday heart" from taking part in a special occasion such as a holiday or celebration. Private medical records, including from emergency room visits noted by the Veteran during his hearing, similarly reported normal ECGs, such as in Mercy Medical records from September 2012 and January 2014. Indeed, the most recent August 2017 report showed normal sinus rhythm on ECG. Diagnoses made at such times were generally for angina or anxiety, but not atrial fibrillation. Thus, the criteria for a compensable rating under Diagnostic Code 7010 are not met, and an increased rating under this code for the Veteran's cardiac disability is not warranted for this appeal period. Neither the Veteran nor his/her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert, supra. The Veteran's claim for a compensable disability rating for paroxysmal atrial fibrillation is denied. (CONTINUED ON NEXT PAGE) ORDER Service connection for right and left knee disorders is denied. Service connection for right and left hip disorders is denied. Service connection for a low back disorder is denied. Service connection for a neck disorder is denied. A compensable rating for paroxysmal atrial fibrillation is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. As to the claim for service connection for the right and left shoulder disorders, no VA medical opinion on secondary service connection has been obtained, as had been previously ordered by the Board. An addendum medical opinion is necessary to address the claim. In regards to the left ear hearing loss service connection claim and right ear hearing loss increased rating claim, both the Veteran and the May 2016 VA examiner have indicated that the examination was inadequate, for multiple reasons, including that the Veteran was falling asleep during examination. Also, in a March 2017 letter, the Veteran claimed that his hearing has worsened. A new VA examination should be obtained. In a March 2017 statement and other reports, the Veteran has claimed that his service-connected residuals of bunionectomy scars of each foot and hallux valgus, status post bunionectomy of each foot has worsened since the last VA examination, to include having more recently undergone foot surgery and the development of 3rd degree burns, scarring, and nerve damage. A new VA examination should be obtained to address the current severity of these disabilities. The claim for a TDIU, prior to March 11, 2009, is inextricably intertwined with the other remanded claims and cannot be decided. While on remand, any unassociated VA medical records should be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following actions: 1. The AOJ should obtain all unassociated VA treatment records. All reasonable attempts should be made to obtain such records. 2. Obtain a VA medical opinion as to the Veteran's current bilateral shoulder situation. The opinion provider should note in the examination report that the claims folder and the Remand have been reviewed. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of file, which includes VA treatment records, the VA medical opinion provider should offer an opinion on the following: a) Does the Veteran currently have a (i) RIGHT and/or (ii) LEFT shoulder disorder? b) Is it at least as likely as not that any (i) RIGHT and/or (ii) LEFT shoulder disorder is the result of a disease or injury in active service? c) Is it at least as likely as not that the Veteran's service-connected bilateral foot disabilities caused any (i) RIGHT and/or (ii) LEFT shoulder disorder? d) Is it at least as likely as not that any (i) RIGHT and/or (ii) LEFT shoulder disorder was aggravated (i.e., permanently worsened beyond the natural progression) by the Veteran's service-connected bilateral foot disabilities? The examiner should note that VA will not concede aggravation of the non-service-connected disability by a service connected disability unless the baseline level of the non-service-connected disability is established by medical evidence created before the onset of aggravation or by the earliest evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of non-service connected disease or disability. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 3. Schedule the Veteran for a VA examination of the service-connected (i) right and left foot residuals of bunionectomy scars and (ii) right and left foot hallux valgus, status post bunionectomy. The entire claims file and a full copy of this REMAND must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented history and assertions. All indicated tests and studies (to include laboratory tests, if necessary) should be accomplished (with all results made available to the requesting physician prior to the completion of his or her report), and all clinical findings should be reported in detail. The AOJ should ensure that the examiner provides all information required for rating purposes, for both (i) right and left foot residuals of bunionectomy scars and (ii) right and left foot hallux valgus, status post bunionectomy. The VA examiner should address the Veteran's contentions regarding his disabilities also encompassing additional, new foot scars (to include burned skin) and nerve damage, to include caused by surgeries, that are a part of the service-connected disabilities. In addition, the examiner should provide information concerning the functional impact of the Veteran service-connected disabilities. Where necessary, the examiner should attempt to distinguish any impairment related to his service-connected foot disabilities from any other nonservice-connected disabilities. 4. Schedule the Veteran for an appropriate VA examination for his right and left ear hearing loss claims. As to the right ear, determine the current severity of the disability. As to the left ear, determine whether the Veteran meets the criteria for a hearing loss disability for VA purposes and if it is caused by or started during service. The electronic claims file must be provided to the examiner for review in conjunction with the examination, and the examiner should note that it has been reviewed. 5. When the development requested has been completed, the case should again be reviewed by the AOJ on the basis of the additional evidence. If the benefit sought is not granted, the AOJ should furnish the Veteran a supplemental statement of the case and a reasonable opportunity to respond before returning the record to the Board for further review. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs