Citation Nr: 1805427 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 12-00 382 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for a left knee disorder. 3. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Saikh, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1983 to September 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In July 2015, the Veteran testified at a videoconference hearing before a Veterans Law Judge. A transcript of that hearing has been associated with the record. In October 2017, the Veteran was notified that the VLJ who conducted the July 2015 hearing was no longer available to issue a decision. He was offered another hearing before a Veterans Law Judge who would decide his case, but he has elected not to have another hearing. The Board remanded the case for further development in December 2015. That development has been completed, and the case has since been returned to the Board for appellate review. The Board notes that, following the April 2015 Supplemental Statement of the Case (SSOC), the Veteran submitted additional evidence, along with a waiver of initial Agency of Original Jurisdiction (AOJ) consideration. Additional evidence, including VA treatment records, were added to the claims folder after that time. The additional evidence was either duplicative of the evidence considered by the AOJ or not relevant to the issue on appeal. Furthermore, the Veteran's representative submitted an appellate brief following the addition of this evidence. Thus, a remand for AOJ review of this additional evidence is not warranted. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issue of entitlement to service connection for a low back disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction. FINDINGS OF FACT 1. The Veteran's current left knee disorder did not manifest in service or within one year thereafter and is not otherwise causally or etiologically related to his military service. 2. The Veteran's bilateral hearing loss did not manifest in service or within one year thereafter and is not otherwise causally or etiologically related to his military service. CONCLUSIONS OF LAW 1. A left knee disorder was not incurred in active service and may not be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 2. Bilateral hearing loss was not incurred in active service, and sensorineural hearing loss may not be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative 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). Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis and organic diseases of the nervous system such as sensorineural hearing loss, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements of service connection is through a demonstration of continuity of symptomatology. However, 38 C.F.R. § 3.303(b) applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 38 U.S.C. § 1101. With respect to the current appeal, this list includes arthritis and sensorineural hearing loss. See 38 C.F.R. § 3.309(a). For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309(a)). For the purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The absence of in-service evidence of a hearing disability during service (i.e., one meeting the requirements of 38 C.F.R. § 3.385) is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Left Knee Disorder In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a left knee disorder. The Veteran's service treatment records show that in he reported having twisted his knee while playing basketball in January 1985. The treatment provider noted that the left knee could exhibit full range of motion and that here was tenderness on the distinct patellar tendon. He was diagnosed with subpatellar bursitis of the left knee. On subsequent service examinations in November 1987 and in April 1992, there was no record of any knee injuries or disabilities. Rather, his lower extremities were found to be normal. The remainder of his service treatment records are entirely negative for any complaints, treatment, or diagnosis of a left knee disorder. In an August 2008 VA examination, the Veteran reported that his left knee disorder had existed since 1993, which occurred while he was playing basketball. He reported having pain, stiffness, and weakness. The examiner diagnosed him with degenerative arthritis and indicated that his x-ray showed degenerative arthritis changes with loss of motion and grinding. During a July 2011 hearing before a Decision Review Officer, the Veteran reported that his left knee disorder started in 1989 while he was playing football. He reported that he was given anti-inflammatory medication and crutches for treatment and put on a profile. During an August 2011 VA examination, the examiner noted that the Veteran had suprapatellar bursitis and chondromalacia of the patellofemoral compartment. The examiner concluded that it was less likely than not that the Veteran's knee disorder was incurred in or caused by any event, injury, or illness in service. The examiner explained that there was only one complaint for the Veteran's left knee noted during service, which is the January 1985 basketball injury, and that the records were silent for a period of 20 years (from 1985 to 2006) for any record of a knee disability. There was no record of documented continuing complaints or treatments to indicate a chronic disabling condition. The examiner also explained that the recently submitted MRI report only documented the extent of the problem at this time and could not establish a nexus sufficient for service connection. In an August 2015 VA clinical record, the Veteran reported that he had injured his knee while playing basketball and football. In a March 2017 statement, the Veteran reported that that he had not sought treatment for his injuries from service following his separation because he had no insurance coverage. Instead, he treated himself by taking over the counter medications. He sought treatment from the VA in 1998 to1999 when he was unemployed and later sought treatment again when his knee pain worsened. In the March 2017 VA examination, the examiner noted that the Veteran had left knee osteoarthritis and patellofemoral pain syndrome affecting both knees. He reported that he first had left knee pain when he twisted his knee playing basketball in service in 1985. He sustained another injury to his knee in 1989 while playing football, but continued to play league sports in service until 1991. Following service, the Veteran was employed as a logistics worker, which required lifting, pulling, and walking. He denied having any injury to his left knee after service. During the March 2017 VA examination, the Veteran reported having functional impairment due to his left knee. Specifically, he reported that he was unable to run and could only walk about 20 minutes before needing a break. He also reported that he could only sit for limited periods of time. The examiner was unable to report range of motion measurements because the Veteran had marked guarding with complaints of pain during the patella examination. Although the Veteran would not flex his knee greater than 80 degrees, the examiner noted that the Veteran could flex his knee greater than 90 degrees when he crossed his leg to put on his shoe. The examiner also noted that the Veteran was able to walk quickly and apparently painlessly when he departed. Imaging studies of the knee revealed minimal patellofemoral degenerative changes, but were otherwise negative. The March 2017 VA examiner concluded that the Veteran's left knee disorder was less likely than not incurred in or caused by any in-service injury, event, or illness. The examiner addressed the January 1985 injury in service and explained that bursitis is an inflammatory condition which resolves over a short period of time. The Veteran had reported no other knee symptoms following that injury, so it could be assumed that the injury fully resolved. The examiner noted that, although there was no separation examination, an examination taken one year prior to separation showed normal lower extremities. The examiner indicated that there was no record of any knee disorder or symptoms until a 2008 VA examination, and although the Veteran indicated that he had left knee pain for 15 years, there were no medical records documenting that pain until 2008. With regard to a March 2009 MRI which showed chondromalacia of the patella, the March 2017 VA examiner explained that there were no signs or symptoms of it in service and that it was quite common and had multiple causes. The Veteran had multiple jobs after service that required walking and physical work, which would increase stress on his knees. The examiner also noted that the Veteran's left knee disorder developed gradually over the years and was related to his participation in sports, physical work-related activities, weight gain, and increasing age. There was no objective evidence which supported a finding that the left knee disorder was due to the injury in service, which had fully resolved. The examiner could not find any record of a knee injury that occurred in 1989 and thus concluded that all available evidence supported a finding of the left knee disability developing after service. In an April 2017 statement, the Veteran indicated that he had not sought further treatment in service for his injuries because he was self-medicating with ice-packs and pain medication. He explained that he is strong-willed and wanted to continue to play through the pain. He also explained that he did not seek treatment for his knee following service because he was unemployed and did not have medical insurance. In an April 2017 letter, a friend of the Veteran, V.H (initials used to protect privacy) stated that he had played sports in service and suffered back, knee, and ankle injuries. In another April 2017 letter, a friend of the Veteran, B.B., who also served with him, indicated that the Veteran did play sports, but had to play with knee and back supports to help with pain and swelling. As noted above, after reviewing the evidence of record, the Board finds that service connection is not warranted for a left knee disability. In regards to whether arthritis was shown during service or within a year of separation, the Board finds that such a diagnosis was not shown. To determine that a chronic disease was "shown in service," the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1331. There is affirmative evidence that the Veteran did not have arthritis during service, as the Veteran's lower extremities were reported to be normal on clinical examination during an April 1992 examination. The Board acknowledges that a separation examination could not be located, as evidenced by an October 2016 response to a Request for Information. However, as was noted by the examiner conducting the March 2017 examination, bursitis resolves in a short period of time, so if there were any residual injuries, they would have likely manifested at the time of the April 1992 examination. Moreover, arthritis must be objectively confirmed by x-ray. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In this case, there is no objective evidence showing that the Veteran had arthritis within the first year after his separation from service. Thus, the Veteran is not entitled to service connection for left knee arthritis on a presumptive basis, either as a chronic disease during service or within one year of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a); Walker, 708 F.3d 1335 -37. Therefore, chronicity is not established in service or within a year of separation. Moreover, following the Veteran's military service, the evidence of record does not establish continuity of symptomatology. 38 C.F.R. § 3.303(b). To the extent that the Veteran has asserted that there has been a continuity of symptomatology since service, the Board finds such assertions are not reliable or credible. As noted above, the April 1992 examination found his lower extremities to be normal, and he did not report any symptoms with regard to his knee. Thus, there was affirmative evidence showing that he did not have a knee disability near the time he was separating from service. Moreover, despite the Veteran's report that he sought treatment in 1998 or 1999, there is no record of any knee complaints until the August 2008 VA examination where he was diagnosed with degenerative arthritis, which was many years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board also finds it significant that the Veteran sought treatment for a knee injury during service in 1985, yet sought no treatment for his left knee during the remainder of his military service. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (citing FED. R. EVID. 803 (7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded"). In addition to the lack of evidence showing that a left knee disorder manifested during service or within close proximity thereto, the weight of the evidence of record does not otherwise link the Veteran's current left knee disorder to service. The Veteran does have a current left knee disorder, and there is evidence that he had a knee injury in service; however, the evidence does not establish a nexus between any in-service injury or symptomatology and his current knee disability. Rather, the weight of the evidence is against a finding that the Veteran's left knee disorder is related to his military service. In this regard, the March 2017 VA examination is the most probative evidence on the issue of nexus because the opinion is based on an accurate review of the Veteran's medical history and is supported by rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no medical opinion otherwise relating the Veteran's current knee disability to his military service. The Board notes that the Veteran reported sustaining another injury to his knee in 1989 while playing football. A review of the Veteran's service treatment records does not show any record of this injury. While there is a likelihood that the record may be unavailable, as was observed with regard to the Veteran's separation examination, as noted above, the April 1992 service examination does not note any abnormalities with regard to the lower extremities. Thus, even assuming that this injury occurred, the evidence of record does not support a finding that it caused the Veteran's current left knee disability. The Board also acknowledges the Veteran's own statements that his current left knee disability is related to the injuries that he sustained in service. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the diagnosis of a knee disability, to include arthritis, and the etiology of such a disorder, 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 specific question of the etiology of this disorder is a complex medical matter that falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset of his current knee disability. See Jandreau, 492 F.3d at 1377. Moreover, even assuming that the Veteran is competent to opine on this medical matter, the Board finds that the specific, reasoned opinion of the VA examiner is of greater probative weight than the Veteran's more general lay assertions. The examiner reviewed and considered the evidence of record, including the Veteran's statements, provided a medical opinion with supporting rationale, and relied on his own medical training, knowledge, and expertise. Based on the foregoing, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a left knee disorder. Because the preponderance of the evidence is against the Veteran's claims, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for a left knee disorder is not warranted. Bilateral Hearing Loss In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for bilateral hearing loss. The Veteran has asserted that his bilateral hearing loss resulted from noise exposure in service, specifically due to exposure as an air transportation supervisor. He indicated that he was exposed to noises from the flight line, aircrafts, and other heavy equipment. Audiograms performed during his military service do not show any hearing loss or any complaints or treatment related to hearing loss. Indeed, audiograms from June 1982, June 1985, February 1986, November 1987, and April 1992, all exhibit auditory thresholds that do not rise to the level of a hearing loss disability. See 38 C.F.R. § 3.385. Minimal threshold shifts were observed between the June 1982 and April 1992 audiograms at the frequencies of 2000, 4000, and 6000 Hertz; however, these shifts did not result in increases of more than 5 decibels. In an April 2009 statement, the Veteran reported that he was exposed to acoustic trauma from jet engines, material handling equipment, ground power units, air power units, and generators on a daily basis. During an August 2011 VA examination, the Veteran was found to have sensorineural hearing loss in both ears at the frequency range of 500 to 4000 Hertz. The examiner stated that his hearing loss was not at least as likely as not caused by or the result of any event in service. The examiner indicated that his exit audiogram showed no significant decrease in hearing levels during service and that he had normal hearing going into service and normal hearing coming out. Therefore, hearing loss was not related to acoustic trauma in service. During the March 2017 VA examination, the Veteran was found to have sensorineural hearing loss in the right ear and normal hearing in his left ear. The examiner opined that it was not at least as likely as not that the Veteran's right ear hearing loss was caused by or the result of an event in service. The examiner explained that the Veteran's last examination in service on record showed normal hearing and that the mild hearing loss exhibited upon current examination was more likely due to age and civilian occupational noise exposure. The Veteran had reported that he continued to be exposed to aircraft noise after service when working in supply management and while working for British Airways. With regard to the likelihood that the Veteran's noise exposure could have resulted in delayed onset noise exposure, the examiner noted that, when military noise exposure was removed, hearing would not be expected to worsen. In support of this rationale, the examiner cited to separate Institute of Medicine articles. One article noted that the most pronounced effects of noise exposure on pure-tone thresholds are measurable immediately following exposure and that most recovery to stable hearing occurred within 30 days. The other article noted that the understanding of mechanisms and processes involved in recovery from noise exposure suggest that a delay in many years of the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely. As noted above, after reviewing the evidence of record, the Board finds that service connection for bilateral hearing loss is not warranted. The Veteran has alleged that he was exposed to noise from his service, and the Board notes that the Veteran is considered competent to relate a history of noise exposure during service which fulfills the in-service injury component of service connection. The Veteran also currently has hearing loss in his right ear at a level that is considered disabling for VA purposes, but he does not exhibit that level of hearing loss in his left ear. See 38 C.F.R. § 3. 385. The Board does note that, during the August 2011 VA examination, the Veteran did exhibit hearing loss at a level that is considered disabling. However, even assuming that the Veteran did exhibit hearing loss at a level considered disabling in his left ear, the probative medical evidence of record does not show that these conditions manifested in service, within one year of separation, or are otherwise related to service. The Board notes that neither sensorineural hearing loss nor manifestations sufficient to identify this disease entity were shown during service. Rather, the hearing examinations taken throughout active service were essentially normal, and the Veteran denied having any history of ear trouble during that time period. While the Veteran now states that his hearing loss began in service, there is no record of the disorder in his service treatment records. Therefore, while sensorineural hearing loss is recognized as a chronic disease under 38 C.F.R. § 3.309 (a), no notations of the disease or any characteristic manifestations of sensorineural hearing loss were shown in the service records. Thus, service connection under 38 C.F.R. § 3.303 (b) is not warranted, and sensorineural hearing loss may not be presumed to have been incurred in service. 38 U.S.C. § 1101; 38 C.F.R. §§ 3.307, 3.309. The Board does acknowledge the Veteran's statements that his hearing loss began in service. The Veteran is competent to report his experience and symptoms in service and thereafter. While lay persons are generally not competent to offer evidence which requires medical knowledge, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). A veteran can attest to factual matters of which he has or had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). In this case, the Board finds that the Veteran is competent to state that he has had difficulty hearing since his military service. However, his allegations are inconsistent with the contemporaneous record. As previously discussed, there is no evidence of any complaints, treatment, or diagnosis in service, and he repeatedly denied having ear trouble or hearing loss during service. Significantly, the objective findings show that he did not have hearing loss during service. The Board finds that this affirmative evidence outweighs the Veteran's more recent assertions of an onset in service. The Board notes that the absence of in-service evidence of a hearing disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385) is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Nevertheless, the Board finds that the March 2017 VA examiner's opinion is adequate and the most probative evidence of record on this matter. The examiner reviewed and detailed the relevant evidence in the claims file and concluded that the Veteran's current hearing loss was not causally or etiologically related to his military service, including noise exposure therein. Specifically, the March 2017 VA examiner noted that the Veteran did not exhibit any significant threshold shifts on the April 1992 examination, which is the last examination of record in service. As noted earlier, the Board acknowledges that the Veteran's separation examination is unavailable; however, the April 1992 examination did not show any significant threshold shifts. Furthermore, as noted by the examiner in the March 2017 opinion, the most pronounced effects of noise exposure on pure-tone thresholds are measurable immediately following exposure. Thus, any effects of noise exposure would likely have been observed in either the April 1992 or earlier audiograms. The examiner had also noted that the Veteran had a history of post-service occupational noise exposure which may have caused his hearing loss. The Board has considered the Veteran's statements that his current hearing loss is related to his military noise exposure. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of these disorders, falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset and intervening noise exposure. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming that he is competent to provide such an opinion, the Board finds that the VA examiner's opinion is more probative, as it was provided by a medical professional with knowledge, training, and expertise and is supported by a complete rationale based on such knowledge. The examiner also reviewed the claims file and considered the Veteran's reported history and lay statements. Based on the foregoing, the Board finds that the Veteran's bilateral hearing loss is not causally or etiologically related to his military service, to include the noise exposure therein. The preponderance of the evidence is against the Veteran's claim, and as such, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for bilateral hearing loss is not warranted. ORDER Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for bilateral hearing loss is denied. REMAND In the December 2015 remand, the Board directed the AOJ to obtain a medical opinion regarding the etiology of the Veteran's low back disorder. The examiner was requested to address service treatment records from September 1991 and July 1992, which documented reports of and treatment for low back pain. The examiner was also requested to address lay statements from the Veteran and a fellow service member regarding a back injury that the Veteran sustained from falling in the shower. In the January 2017 opinion that was obtained pursuant to the remand, the examiner stated "the active duty records were negative for complaints, diagnosis, treatment, injury and/or events related to a low back condition." This finding contradicts service treatment records from September 1991 and July 1992 which clearly document complaints of low back pain. Furthermore, the examiner did not address the Veteran's reports of an injury he sustained in service when he fell in the shower. Thus, a remand is necessary to obtain an additional medical opinion which accurately addresses the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that where remand instructions are not followed, the Board errs as a matter of law when it fails to ensure compliance). Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his low back. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of the Veteran's low back disorder. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should state whether it is at least as likely as not that the Veteran's low back disorder manifested in service or is causally or etiologically related to his military service, to include any injury or symptomatology therein. In rendering this opinion, the examiner should specifically consider the service treatment records dated in September 1991 and July 1992 which document reports of and treatment for low back pain; statements from the Veteran and a fellow service member which describe an incident during service which occurred between February 1991 and July 1991 where the Veteran sustained a back injury from falling in the shower; and the testimony provided by the Veteran during the July 2015 Board hearing. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]"38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should review the medical opinion to ensure it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 4. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. Thereafter, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs