Citation Nr: 1803026 Decision Date: 01/16/18 Archive Date: 01/29/18 DOCKET NO. 07-37 917A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for a foot disability, to include plantar fasciitis and/or heel spurs. 2. Entitlement to service connection for rheumatoid arthritis (RA). 3. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected psychiatric and/or orthopedic disabilities. 4. Entitlement to service connection for a respiratory disorder, to include as due to an undiagnosed illness or secondary to RA. 5. Entitlement to service connection for diabetes mellitus (DM), type II, to include as secondary to RA. 6. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the left knee. 7. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the right knee. 8. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease and degenerative joint disease of the cervical spine prior to June 11, 2015, and in excess of 20 percent after June 11, 2015. REPRESENTATION Appellant represented by: Karl A. Kazmierczak, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 1985 to November 1985 and from December 2003 to January 2005. She had service in Southwest Asia from January 2004 to December 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in August 2006, November 2006, September 2009, February 2013, and May 2014 by or on behalf of the New York, New York, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that the February 2013 rating decision also granted a 10 percent rating for left knee instability, but that this specific matter is not on appeal. In June 2015, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The Board, in pertinent part, remanded the issues on appeal for additional development in January 2016. The Board notes that an August 2016 rating decision granted an increased 20 percent rating for degenerative disc disease and degenerative joint disease of the cervical spine effective from June 11, 2015. The issue on the title page as to this matter has been accordingly revised. The issue of entitlement to service connection for hypertension was also granted in the August 2016 rating decision and the appeal as to that matter is considered to have been fully resolved. VA records, however, show that the Veteran submitted a notice of disagreement from this determination and that the matters is currently under development. VA records also show that the issues of entitlement to increased ratings for radiculopathy of the left lower extremity; hypertensive retinopathy; tongue lacerations and discoloration; anxiety to include depression and insomnia and symptom of bruxism; degenerative arthritis of the spine with lumbosacral strain, spinal stenosis, and degenerative disc disease; and a total disability rating based on individual unemployability. As these matters have not been developed for appellate review and are being adequately addressed by the Agency of Original Jurisdiction (AOJ), no further Board action is required at this time. The evidence added to the record subsequent to an August 2016 supplemental statement of the case is found to be essentially cumulative of the information previously of record. The issues of entitlement to increased ratings for patellofemoral syndrome of the left and right knees and for degenerative disc disease and degenerative joint disease of the cervical spine are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. A foot disability, to include plantar fasciitis and/or heel spurs, was not manifest during a period of active service from July 1985 to November 1985; arthritis was not manifest within one year of discharge from that period of service; clear and unmistakable evidence demonstrates heel spurs existed prior to a period of active service from December 2003 to January 2005 and underwent no increase in severity during that service; and, the preponderance of the evidence fails to establish that a present disability is etiologically related to service or to a service-connected disability. 2. A rheumatoid arthritis disability was not manifest during a period of active service from July 1985 to November 1985; was not manifest within one year of discharge from that period of service; clear and unmistakable evidence demonstrates that Palindromic rheumatism existed prior to a period of active service from December 2003 to January 2005 and underwent no increase in severity beyond the natural progress of the disorder during that service; and, the preponderance of the evidence fails to establish that a present RA disability is etiologically related to service or to a service-connected disability. 3. Obstructive sleep apnea was not manifest during service; and, the preponderance of the evidence fails to establish that a present disability is etiologically related to service or to a service-connected disability. 4. A respiratory disorder was not manifest during service; and, the preponderance of the evidence fails to establish that a present disability is etiologically related to service or to a service-connected disability. 5. Diabetes mellitus, type II, was not manifest during service; was not manifest within one year of active service discharge; and, the preponderance of the evidence fails to establish that a present disability is etiologically related to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a foot disability, to include plantar fasciitis and/or heel spurs, have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for rheumatoid arthritis have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for service connection for OSA, to include as secondary to service-connected psychiatric and/or orthopedic disabilities, have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 4. The criteria for service connection for a respiratory disorder, to include as due to an undiagnosed illness or secondary to RA, have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 1117 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2017). 5. The criteria for service connection for DM, type II, to include as secondary to RA, have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The matter was Remanded in January 2016 for the purpose of securing updated VA treatment records, affording the Veteran VA examinations, and obtaining medical opinions with respect to those examinations. VA treatment records have been obtained and a VA examination were conducted with corresponding reports. The Board finds that there was substantial compliance with the 2016 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008)); Dyment v. West, 13 Vet. App. 141 (1999). Since the 2016 Remand, neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the 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 Scott to a duty to assist argument). Service Connection Claims Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012). Generally, the evidence must 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, 1166-67 (Fed. Cir. 2004). A Veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence (obvious or manifest) establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b) (2017). Noted means "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during that active service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306 (2017). A lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). Service connection 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) (2017). When aggravation of a nonservice-connected condition is proximately due to or a result of a service-connected disability a 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, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic diseases, including arthritis and diabetes mellitus, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113 (2012); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2017). VA regulations also provide that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses to a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability if that disability became manifest either during active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1) (effective before and after Oct. 24, 2017). The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstrations of laboratory abnormalities. Chronic multisymptom illness of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue, (2) Signs or symptoms involving skin, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurologic signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the respiratory system (upper or lower), (9) Sleep disturbances, (10) Gastrointestinal signs or symptoms, (11) Cardiovascular signs or symptoms, (12) Abnormal weight loss, and (13) Menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 (Aug. 3, 1998). "The very essence of an undiagnosed illness is that there is no diagnosis." Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006); see also Gutierrez v. Principi, 19 Vet. App. 1, 10 (2004) (a Persian Gulf War veteran's symptoms "cannot be related to any known clinical diagnosis for compensation to be awarded under section 1117"). Under 38 C.F.R. § 3.303(b), 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). Arthritis, diabetes mellitus, and hypertension 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 is applicable in the present case. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2017). In statements and testimony in support of her claims the Veteran asserted that she had foot problems and RA that was aggravated during her period of active service from December 2003 to January 2005. She stated there were no records of treatment for foot problems during service, but that she had recurrent pain and swelling to the feet while in Kuwait due to marching, training, and extensive walking in combat boots. She also asserted that her Palindromic rheumatism or RA was aggravated in service, including as a result of a fall in the shower, vaccinations, the stress of deployment, and exposure to chemicals, metals, or bacteria. She contends that her obstructive sleep apnea was onset during this period of service, that she has a respiratory disorder as a result of her service in Southwest Asia, and that her respiratory disorder and diabetes mellitus were aggravated by her RA. VA records show that service connection is established for right and left carpal tunnel syndrome; anxiety including depression, insomnia, and symptoms of bruxism; degenerative disc and joint disease of the cervical spine; degenerative arthritis of the lumbosacral spine with strain, spinal stenosis, and degenerative disc disease; patellofemoral syndrome of the left and right knees; traumatic arthritis of the right hip; partial thickness tear of the left shoulder supraspinatus tendon; surgical scar of the left and right wrists; left knee instability; right shoulder bursitis with osteoarthritis of the acromioclavicular joint and partial supraspinatus tear; left lower extremity radiculopathy; hypertension; hypertensive retinopathy; and tongue lacerations and discoloration. Service treatment records show an August 1989 report of medical history of noted arthritis. An examination revealed normal clinical evaluations of the lungs, endocrine system, upper and lower extremities, spine, and feet. A June 1994 report of medical history noted no pertinent problems. An examination revealed normal clinical evaluation evaluations of the lungs, endocrine system, upper and lower extremities, spine, and feet. A July 1999 report of medical history of swollen or painful joints and arthritis. An examination revealed normal clinical evaluations of the lungs, endocrine system, upper and lower extremities, spine, and feet. An October 2000 private medical statement noted the Veteran had recurrent inflammatory arthritis or even Palindromic rheumatism that could be triggered by cold rain or any change in weather. It was noted that during such episodes she was unable to walk, run, or perform any minor physical activities. An August 2001 service department physical profile included an assignment limitation of no two and a half mile walk due to heel spurs, recurrent inflammatory arthritis, patellofemoral syndrome, and a shoulder disorder. A December 2003 report of medical history noting swollen joints (arthritis inflammation) and Palindromic arthritis that was presently asymptomatic. An examination revealed a normal clinical evaluation of the feet and lungs, but noted a diagnosis of Palindromic arthritis. A December 2003 report noted a prior history of latent tuberculosis in approximately January 1992 with a normal chest X-ray study in September 2003. A February 2004 line of duty determination found injuries to the right elbow, right hip, and left forehead sustained during a slip and fall in the shower in January 2004 were incurred in the line of duty. In an October 2005 statement A.H., identified as a medical surgical nurse, recalled having worked with the Veteran during drill weekends since 1999. It was noted that her complaints of joint pain had increased over the years. An October 2005 statement from the Veteran's mother noted she had complained about arthritis since 1987 and that it was worse when she came back from service overseas. Additional lay statements noted she had problems with joint pain and swelling. A November 2005 treatment report noted the Veteran had a history of rheumatoid arthritis with complaints including foot pain improved by a new custom molded arch support. A diagnosis of bilateral plantar fasciitis likely related to weight gain. A December 2005 reported noted a diagnosis of bilateral heel pain. A January 2006 report noted an acute exacerbation of Palindromic rheumatism involving the right knee. It was noted that her bilateral plantar fasciitis was resolving. VA examination in May 2006 included diagnoses of bilateral pes planus and bilateral calcaneal spurs. It was noted the Veteran reported a history of bilateral foot problems since 2002 with intermittent pain, stiffness, and swelling. No opinion as to etiology was provided. Subsequent VA treatment records noted diagnoses including right foot extensor digitorum longum tendonitis and rule out stress fracture. A December 2006 private medical statement from C.T., M.D., noted the Veteran was seen for a heel spur condition prior to December 7, 2003, and that she had no pain at the end of that treatment. The physician stated that apparently her heel spur condition had been aggravated since then and that it was plausible this could have been due to her time in service. A March 2007 private medical statement from S.A.G., M.D., identified as a hospital chief of rheumatology, noted the Veteran had a history of possible Palindromic rheumatism and was last seen approximately seven years earlier. It was noted she had returned with a diagnosis of RA based upon multiple joint pains and swelling with a positive rheumatoid factor. As to the question of whether the stress of the Veteran's deployment and a fall in the shower in January 2004 exacerbated and triggered her RA, it was noted this could not be stated for certain but that it was a possibility. A March 2014 VA examination conducted by a physician assistant found that it was as likely as not that the Veteran met the criteria for Gulf War syndrome and that her rheumatoid arthritis treatment with a tumor necrosis factor medication had caused lung problems due to decreased resistance to infections. The examiner also found that it was at least as likely as not that her type II DM was brought on by her treatment with prednisone for fluid and nodules in the lungs. In an April 2014 addendum, and following review of the complete record, the examiner found that there was no undiagnosed condition noted, no diagnosed but medically unexplained chronic condition noted, no diagnosable chronic multisymptom illness noted, and no new diagnosis of any disease with clear and specific etiology. It was noted that records clearly showed that all claimed medical problems can be accounted for and/or were already "s/c" individually and as such could not be diagnosed as Gulf War syndrome. It was determined that the Veteran's joint pain was attributable to her degenerative arthritis, rotator cuff tear, and knee condition. Her complaints of fluid and nodules in the lungs, shortness of breath, difficulty breathing, asthma, and pneumonia similarly did not fall under unexplained illness or diagnosed medically unexplained chronic symptoms. Instead, the problems were due to her obesity or her 130-pack-year smoking history with lung presentation. Her chronic sleep disturbance was due to obstructive sleep apnea. The examiner stated that her RA could not be classified as Gulf War syndrome because she had a pre-existing Palindromic rheumatism prior to deployment which had a tendency to progress in to RA and that her diabetes was secondary to medication for RA. In a May 2014 opinion a VA physician found that it was less likely that the diagnosed disabilities, which the Veteran claimed as a disability pattern or cluster of symptoms, were related to a specific exposure event experienced during her service in Southwest Asia. As rationale it was noted that there was no undiagnosed illness, no diagnosed medically unexplained chronic multisymptom illness, and that her diagnosed conditions were not due to any exposures/events during service in Southwest Asia. A January 2015 private medical opinion from D.A., M.D., J.D., found that the Veteran's obstructive sleep apnea was more likely than not directly related to her service-connected anxiety disability. It was asserted that the designation of a 30 percent rating for her anxiety encompasses insomnia. Records provided were noted to show that she was diagnosed with obstructive sleep apnea in March 2011 and that a VA examiner opined that her psychiatric diagnosis and her psychiatric medication were not the cause of or aggravation of her sleep apnea. It was further opined that chronic pain and the use of pain medications were clearly associated with the development of sleep apnea. Medical literature was referenced in support of the provided opinions. A March 2016 VA sleep apnea examination found that it was not likely that the Veteran's sleep apnea was directly incurred in service. The examiner noted there was no evidence of treatment in service and no documented treatment from 2005 to 2011 when her sleep study was performed. A March 2016 VA non-degenerative arthritis disorders examination included a diagnosis of rheumatoid arthritis (atrophic) and provided a date of diagnosis in July 2000. It was noted the Veteran was diagnosed with Palindromic rheumatism in 2000 and that she had a history of seropositive RA since November 2006. She denied any joint pain prior to service and asserted her slip/fall injury in service had aggravated her RA. The examiner found that it was less likely that RA was incurred in or caused by a claimed in-service injury, event, or disease, noting that her Palindromic rheumatism pre-existed her second period of active service, and RA clearly and unmistakably existed prior to service and was not aggravated beyond the natural progression by an in-service event, injury, or illness. It was noted that she was diagnosed with Palindromic rheumatism in 2000, that the expected natural progression was that it can progress to RA in 30 to 67 percent of patients, and that a diagnosis of RA was provided in November 2006. The examiner stated a review of service treatment records revealed she was asymptomatic in December 2003, that there was no evidence that rheumatology laboratory tests were conducted during that period of service, that an abnormal rheumatoid factor was shown seven months after service, and that there was no evidence to support that her RA may have been exacerbated by an in-service fall. The examiner provided medical literature references in support of the opinion. A March 2016 VA foot conditions examination included a diagnosis of bilateral plantar fasciitis and noted X-ray studies revealed mild hypertrophic changes to the right foot and a prominent plantar calcaneus spur. The examiner found that it was less likely that the Veteran's bilateral plantar fasciitis was less likely caused by service and less likely that her heel spurs increased in severity during service. As rationale it was noted that there were no medical records of plantar fasciitis or heel spurs during active service. An August 2016 VA medical opinion based upon a review of the record, specifically noting review of the private opinion of Dr. D.A., found that it was less likely that sleep apnea was incurred in or caused by a claimed in-service injury, event, or illness. The examiner explained there was no documentation of continuity of complaints since service and that the Veteran's sleep apnea was initially diagnosed by a sleep study in March 2011, six years after her separation from service. Her sleep apnea was found to be most likely due to her chronic morbid obesity with a large tongue, wide neck, and Mallampati IV. The examiner also found that it was less likely her sleep apnea was proximately due to or the result of her psychiatric disabilities or orthopedic pain. As rationale it was noted that a review of evidence-based medical literature did not support the contentions of OSA being caused by psychiatric disabilities or orthopedic pain, noting that associations did not indicate causality. The examiner also stated that the Veteran had numerous well-established evidence-based clinically significant risk factors for developing sleep apnea including, but not limited to, her age, chronic severe morbid obesity, upper airway abnormalities, and smoking. Her most significant contributing risk factor was her severe morbid obesity. Medical literature references were provided in support of the opinions. Based on the foregoing, the Board finds that a foot disability, to include plantar fasciitis and/or heel spurs, was not manifest during a period of active service from July 1985 to November 1985, and that arthritis was not manifest within one year of discharge from that period of service. There is also clear and unmistakable evidence that her heel spurs existed prior to a period of active service from December 2003 to January 2005 and underwent no increase in severity during that service. The preponderance of the evidence fails to establish that a present disability is etiologically related to service or to a service-connected disability. Although a December 2006 private medical statement noted it was plausible that a heel spur condition was aggravated by service, the Board finds the opinion to be too inconclusive to be of any probative weight. The overall evidence of record, including the March 2016 VA opinion, is persuasive and based upon adequate rationale. The Board notes that there is no evidence of plantar fasciitis prior to November 2005 nor any specific evidence of heel spur symptoms prior to December 2005. It is also significant that the November 2005 examiner related the Veteran's plantar fasciitis to her weight rather than any earlier injury or symptom manifestation. There is also no evidence that a rheumatoid arthritis disability manifested during a period of active service from July 1985 to November 1985 or within one year of discharge from that period of service. Instead, clear and unmistakable evidence demonstrates that Palindromic rheumatism developed sometime between 1987 and when the Veteran reentered service in December 2003. Further, to the extent that her Palindromic rheumatism existed prior to a period of active service from December 2003 to January 2005, there is no evidence that the disability increased in severity beyond the natural progress of the disorder during that service. The preponderance of the evidence fails to establish that a present RA disability is etiologically related to service, to include as a result of service in Southwest Asia, or to a service-connected disability. The opinion of the March 2016 VA examiner as to this matter is found to be persuasive. The examiner specifically found that the Veteran's Palindromic rheumatism pre-existed her second period of active service and that RA clearly and unmistakably existed prior to service and was not aggravated beyond the natural progression by an in-service event, injury, or illness. The examiner is shown to have reviewed the evidence of record, and to have adequately considered the credible lay statements and reported symptom manifestation history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Consideration has been given to the March 2007 private medical statement from Dr. S.A.G., a hospital chief of rheumatology, who indicated that it was possible that the stress of the Veteran's deployment and a fall in the shower in January 2004 exacerbated and triggered her RA. However, the opinion to be too inconclusive to be of any probative weight. The October 2005 statement from A.H., a medical surgical nurse, is found to lack sufficient specificity as to observations during an applicable period of service to be of any probative weight as to the claim. Consideration has also been given to the assertions of the Veteran and her mother that arthritis increased in severity during her second period of active service. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disability at issue is not a condition that is readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board acknowledges that the Veteran is competent to report observable symptoms, but there is no indication that she is competent to etiologically link any such symptoms to a current diagnosis. She is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that she received any special training or acquired any medical expertise as to such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. The Board finds that obstructive sleep apnea was not manifest during service and that the preponderance of the evidence fails to establish that a present disability is etiologically related to service or to a service-connected disability. The March 2016 and August 2016 VA medical opinions are found to be persuasive and based upon adequate consideration of the lay and medical evidence of record. The examiner found that the evidence did not demonstrate a continuity of complaints between her separation from active service and her initial diagnosis in March 2011, and that her sleep apnea was most likely due to her age, chronic severe morbid obesity, upper airway abnormalities, and smoking. The examiner also found that it was less likely her sleep apnea was proximately due to or the result of her psychiatric disabilities or orthopedic pain based upon a review of evidence-based medical literature. The January 2015 private medical opinion from Dr. D.A. has been considered. Notably, Dr. D.A. found that the Veteran's obstructive sleep apnea was more likely than not directly related to her service-connected anxiety disability and that chronic pain and the use of pain medications were clearly associated with the development of sleep apnea. The opinion of Dr. D.A., although supported by medical literature references, did not address the Veteran's nonservice-related clinically significant risk factors. The VA opinion, by contrast, considered the complete record (medical history) and provided an explanation for her findings. As such, the opinion from Dr. D.A. is found to be of less probative weight. The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another, provided an adequate basis is provided. Owens v. Brown, 7 Vet. App. 429 (1995). The Board finds that a respiratory disorder was not manifest during service and the preponderance of the evidence fails to establish that a present disability is etiologically related to service, to include as a result of service in Southwest Asia, or to a service-connected disability. The Board notes that a December 2003 examination revealed a normal clinical evaluation of the lungs, but that an associated report noted a prior history of latent tuberculosis in approximately January 1992 with a normal chest X-ray study in September 2003. A March 2014 VA examiner found that it was as likely as not that the Veteran's lung problems due to decreased resistance to infections were caused by her RA treatment with a tumor necrosis factor medication. Further, as discussed, the April 2014 addendum explained that fluid and nodules in the lungs, shortness of breath, difficulty breathing, asthma, and pneumonia did not fall under unexplained illness or diagnosed medically unexplained chronic symptoms or that they were due to her obesity or her 130-pack-year smoking history with lung presentation. A similar finding was made in May 2014 with supporting rationale. These VA opinions are found to be persuasive and based upon adequate consideration of the lay and medical evidence of record. The lay evidence as to this matter does not constitute competent medical evidence and lacks probative value. The Veteran's diabetes mellitus, type II, was not manifest during service or within one year of active service discharge. The preponderance of the evidence also fails to establish that a present disability is etiologically related to service or to a service-connected disability. As an initial matter, diabetes it is noted will not be considered medically unexplained for presumptive service connection purposes as a result of service in Southwest Asia. See 38 C.F.R. § 3.317(a)(2)(ii). A March 2014 VA examiner found that it was as likely as not that the Veteran's type II DM was caused by her treatment with prednisone for fluid and nodules in the lungs, a nonservice-connected disability. In conclusion, the Board finds that service connection for a foot disability, RA, OSA, a respiratory disorder, and type II DM is not warranted. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against these claims. ORDER Entitlement to service connection for a foot disability, to include plantar fasciitis and/or heel spurs, is denied. Entitlement to service connection for RA is denied. Entitlement to service connection for OSA, to include as secondary to service-connected psychiatric and/or orthopedic disabilities, is denied. Entitlement to service connection for a respiratory disorder, to include as due to an undiagnosed illness or secondary to RA, is denied. Entitlement to service connection for DM, type II, to include as secondary to RA, is denied. REMAND A review of the appellate records includes an October 2017 VA report noting that examinations had been ordered to evaluate the Veteran's service-connected left and right knee and cervical spine disabilities. There is no evidence, however, that these examinations have been performed. The Board also notes that subsequent to the January 2016 remand order concerning these disabilities and VA examinations in March 2016 pertinent VA case law addressed the requirements for an adequate examination as to such matters. An adequate orthopedic examination of the knees, it was noted, should record the range of motion for pain on active motion and passive motion and in weight-bearing and nonweight-bearing information, address the necessary findings to evaluate functional loss during flare-ups, or clearly explain why the required testing cannot be completed or is not necessary. See Correia v. McDonald, 28 Vet. App. 158 (2016). Range of motion testing, including for cervical spine disabilities, under 38 C.F.R. § 4.59 require that affected joints be tested for pain on both active and passive motion and in weight-bearing and nonweight-bearing. Additional development is required prior to appellate review. VA's duty to assist the Veteran includes obtaining a thorough and contemporaneous examination where necessary to reach a decision on a claim. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). Here, the Board finds the Veteran must be provided adequate VA examinations, unless such examinations have been obtained as a result of the October 2017 VA request. Prior to the examination, up-to-date VA treatment records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain all VA medical records, including any VA examination reports generated as a result of examination requests in October 2017, pertinent to the issues on appeal not yet associated with the appellate record. 2. If, and only if, adequate VA examinations have not been performed, schedule the Veteran for an examination for opinions as to the current nature and extent of his service-connected patellofemoral syndrome of the left and right knee disabilities. The examiner must record the range of motion for pain on active motion and passive motion and in weight-bearing and nonweight-bearing information, must address the necessary findings to evaluate functional loss during flare-ups, or must clearly explain why the required testing cannot be completed or is not necessary. The examiner should summarize the pertinent evidence of record and reconcile any opinions provided with the other evidence of record. All manifest symptoms involving the knees should be identified with an assessment as to the degree of severity. All examinations, tests, and studies must be conducted. The medical reasons for the opinions provided should be set forth in detail. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, he/she should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record (i.e. additional facts are required), or by the examiner himself/herself (because he/she does not have the needed knowledge or training). Merely saying he/she cannot comment will not suffice. 3. If, and only if, adequate VA examinations have not been performed, schedule the Veteran for an examination for opinions as to the current nature and extent of his service-connected degenerative disc disease and degenerative joint disease of the cervical spine disability. The examiner must record the range of motion for pain on active motion and passive motion and in weight-bearing and nonweight-bearing information, must address the necessary findings to evaluate functional loss during flare-ups, or must clearly explain why the required testing cannot be completed or is not necessary. The examiner should summarize the pertinent evidence of record and reconcile any opinions provided with the other evidence of record. All manifest symptoms should be identified. All examinations, tests, and studies must be conducted. The medical reasons for the opinions provided should be set forth in detail. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, he/she should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record (i.e. additional facts are required), or by the examiner himself/herself (because he/she does not have the needed knowledge or training). Merely saying he/she cannot comment will not suffice. 4. Thereafter, the AOJ should address the issues remaining on appeal. If the benefits sought are not granted to the Veteran's satisfaction, the Veteran and his attorney should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant 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. §§ 5109B, 7112 (2012). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs