Citation Nr: 1805511 Decision Date: 01/29/18 Archive Date: 02/07/18 DOCKET NO. 11-34 379 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Whether new and material evidence has been submitted to reopen a previously denied claim of service connection for depression. 2. Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for right shoulder disability. 4. Entitlement to service connection, to include on a secondary basis, for hypertension (HTN). 5. Entitlement to service connection, to include on a secondary basis, for obstructive sleep apnea (OSA). 6. Entitlement to service connection for pes planus. 7. Entitlement to service connection for right ankle disability. 8. Entitlement to service connection for left ankle disability. 9. Entitlement to service connection for a back disability (claimed as scoliosis). 10. Entitlement to service connection for alcohol dependence as due to PTSD. 11. Entitlement to an initial increased rating in excess of 10 percent disabling prior to January 7, 2014, and in excess of 50 percent therefrom for PTSD. 12. Entitlement to an initial increased rating in excess of 10 percent disabling for gastroesophageal reflux disease (GERD) with cough. REPRESENTATION Veteran represented by: John S. Berry, Esq. ATTORNEY FOR THE BOARD S. Kalolwala, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1965 to September 1968, including service in the Republic of Vietnam ("Vietnam"). This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2011 and May 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. A February 2014 rating decision granted an increased 50 percent disability rating for Veteran's service connected PTSD. As this is not the maximum disability rating possible, the appeal remains in appellate status and is properly before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to service connection for OSA, HTN, alcohol dependence, low back, right shoulder, and right and left ankle, respectively, and increased rating for PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. An April 2003 rating decision denied, in pertinent part, the claim of entitlement to service connection for depression; the Veteran did not perfect an appeal with respect to this issue. 2. The evidence received since the April 2003 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the underlying claim of entitlement to service connection for depression. 3. The dysphoric symptomatology the Veteran experiences is a manifestation of the Veteran's PTSD rather than a separately diagnosed disability. 4. The Veteran does not have a bilateral foot disability, including pes planus. 5. For the entirety of the appeal, the Veteran's GERD manifested by, at worst, pyrosis, regurgitation, and reflux not accompanied substernal arm or shoulder pain, productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The April 2003 rating decision denying, in pertinent part, service connection for depression is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2017). 2. New and material evidence sufficient to reopen the claim of service connection for depression has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 3. The criteria for service connection for an acquired psychiatric disorder (other than PTSD) have not been met. 38 U.S.C. § 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for a foot disability have not been met. 38 U.S.C. § 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for an increased disability rating in excess of 10 percent for the Veteran's service-connected GERD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.20, 4.130, Diagnostic Code 7346 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA's duty to notify was satisfied by letters dated in June 2011, October 2011, December 2011, and January 2012. See 38 U.S.C. § 5103 (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records are in the claims file. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of the claims in this Board decision. II. New and Material Evidence In any case involving a finally denied claim, the Board must address whether new and material evidence has been received to reopen before addressing the merits of the claim. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Wakeford v. Brown, 8 Vet. App. 237, 239-40 (1995). VA must reopen a previously and finally disallowed claim when "new and material evidence" is presented or secured. 38 U.S.C. §§ 5108, 7104(b); 38 C.F.R. § 3.156(a). In order to satisfy these requirements, the evidence "must be both new and material." Smith v. West, 12 Vet. App. 312, 314 (1999). "New and material evidence" is defined as follows: New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In making the determination of materiality, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. The Board has considered whether the evidence submitted since the April 2003 rating decision constitutes new and material evidence sufficient to reopen the claim of service connection for depression, and finds that it does. The evidence was not of record at the time of the prior denial and relates to an unestablished fact, by itself or when considered with other evidence, necessary to substantiate the claim. Moreover, the evidence, at the very least, triggered VA's duty to assist. Accordingly, the Board finds that new and material evidence has been submitted and the petition to reopen the claim for service connection for depression must be granted. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). III. Service connection Legal Principles Establishing service connection generally requires (1) evidence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 281 F.3d 1163, 1167 (Fed. Cir. 2004). Because "Congress specifically limit[ed] entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," service connection cannot be granted "[i]n the absence of proof of a present disability." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement is satisfied when a veteran "has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim," McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), or "when the record contains a recent diagnosis of disability prior to . . . filing a claim for benefits based on that disability," Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). "In the absence of proof of a present disability there can be no valid claim." Brammer, supra. Alternatively, service connection may be proven on a secondary basis. In this instance, the evidence must demonstrate an etiological relationship between a service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. 38 C.F.R. § 3.310(a); Wallin v. West, 11 Vet. App. 509 (1998). While the applicable laws and regulations do not provide a definition of "proximate cause," generally it is defined as "[t]hat which, in a natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred." BLACK'S LAW DICTIONARY 1103 (5th ed. 1979); Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002), rev'd on other grounds by Morgan v. Principi, 327 F.3d 1357 (Fed. Cir. 2003). Otherwise, evidence must demonstrate that a non-service-connected disability is aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). There is a large amount of evidence in this case, consisting of both lay and medical evidence. The Board notes that it has reviewed the evidence in its entirety, but will not be discussing all of it with specificity. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (the Board is presumed to have considered all evidence presented in the record; it is not required to specifically discuss every piece of evidence). Discussion(s) Acquired Psychiatric Disorder Based on a review of the record, the Board finds that service connection is not warranted for the Veteran's claimed depression. In making this finding, the Board recognizes the inconsistent diagnoses of an acquired psychiatric disorder (other than PTSD) in the record. On one hand, the primary records in support of the presence of an acquired psychiatric disorder are a statement dated in May 2013 by Dr. P.F., wherein the physician noted the Veteran carried a diagnosis of dysthymic disorder by history and treatment records dated in April 2014 noting a diagnosis of depressive disorder by history. On the other hand, clinical treatment records and opinions on file overwhelmingly and persuasively indicate that any dysphoric symptomatology the Veteran experiences, e.g., depression and anxiety, is a manifestation of the Veteran's PTSD rather than a separately diagnosed disability. For instance, report of the June 2011 VA examination reflects the examiner's opinion that the Veteran's reports of psychiatric symptoms such as anxiety and depression are natural symptomatology of his PTSD. This is echoed by the report of the January 2014 VA examination wherein the examiner opined that although the Veteran exhibited dysphoric symptoms, the Veteran did not meet the criteria for a separate diagnosis of depressive disorder. Rather, the Veteran's symptoms of depression were appropriately attributed to his PTSD diagnosis. In May 2014, an addendum opinion was obtained to reconcile the seemingly inconsistent diagnoses. At that time, the examiner explained there is insufficient evidence that the Veteran's meets the full criteria for a diagnosis of an acquired psychiatric disorder other than service-connected PTSD. The Board finds that the May 2013 physician's statement and April 2014 treatment record are less probative than the subsequent VA examination, particularly as the VA examiner's opinion is supported by the clinical treatment records on file which are deliberately indicative of depression as a symptom of the Veteran's service-connected PTSD, rather than its own distinct diagnosis. Next, the Board does not dispute the Veteran's previous contentions that he experiences symptoms such as depression. The Veteran is clearly competent to make these statements as they relate to observable symptomatology. However, the disability at issue and the attribution of manifest symptoms to specific medical diagnoses are not matters that are 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). In this case, the cause of the Veteran's depression is a matter suited to the realm of medical expertise. As such, to the extent the Veteran is diagnosing an acquired psychiatric disability other than service-connected PTSD, the Board finds his statements are not competent lay evidence. Lastly, the Board observes that the Veteran's service-connected PTSD incorporates all such psychiatric symptomatology reported by the Veteran, including his depression. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Based on a review of the foregoing evidence, and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for an acquired psychiatric disability other than PTSD. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the appeal is denied. Pes Planus The relevant evidence of record consists of the Veteran's service treatment records (STRs), post-service medical treatment records, and lay statements from the Veteran and other sources. STRs dated in September 1965 reflect the Veteran checked the box on his report of medical history at enlistment indicating "yes" to prior foot trouble. However, the Veteran's clinical evaluation at enlistment indicated his feet were "normal." Otherwise, STRs are negative for any complaints of and/or treatment for or diagnosis of a foot disability during service. In particular, the Veteran's August 1968 report of medical examination at separation indicated his feet were "normal." Post-service medical treatment records dated between November 1991 and April 2015 reflect sporadic complaints of foot pain. For instance, records dated in September 2009 reflect the Veteran presented after a slip and fall with forced eversion of his left foot. At that time, imaging studies were performed and revealed "normal feet." Treatment records dated in October 2009 reflect the Veteran presented for, in pertinent part, a podiatrist consult after continued left foot pain. At that time, the Veteran was temporarily prescribed orthopedic shoes and advised to return to regular shoes once the pinpoint pain of the left foot subsides. Records are otherwise negative for a diagnosis of a foot disability. In a statement dated in April 2012, the Veteran reported, in pertinent part, that he sustained numerous injuries to his feet due to repetitive jumps from helicopters in service while performing his duties as a "dust-off" medic. He further reported requiring special arch-support in his shoes since service. After a thorough review of the record, the Board finds that service connection is not warranted for the Veteran's claimed foot disability, to include pes planus. The medical evidence simply does not show the condition is present. To that extent, the Board notes that Congress has specifically limited service connection to instances where there is current disability that has resulted from disease or injury in service. See 38 U.S.C. § 1131. In the absence of a current disability, the analysis ends, and the claim for service connection for a foot disability cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board does not dispute the Veteran's previous contentions that he experiences pain in his bilateral feet. The Veteran is clearly competent to make these statements as they relate to observable symptomatology. However, a symptom or a finding, such as pain without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Additionally, to the extent the Veteran is self-diagnosing a current foot disability manifesting with pain, the Board finds his statements are not competent lay evidence. Based on a review of the foregoing evidence, and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a foot disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the Veteran's claims for service connection, that doctrine is not helpful to the Veteran. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). IV. Increased Rating Legal Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred in or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the factual circumstances) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran is currently assigned a 10 percent disability rating for GERD under 38 C.F.R. § 4.114, Diagnostic Code 7346. Where, as here, an unlisted condition is encountered, e.g., GERD, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2017). Under Diagnostic Code 7346 (which concerns hiatal hernia), a 10 percent rating is assigned when the disease exhibits two or more of the symptoms for the 30 percent rating of less severity. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346 (2017). The criteria for the higher disability ratings are conjunctive, meaning that the Veteran must demonstrate all of the listed symptoms to be entitled to the rating. Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (holding instead that only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). Discussion Based on a review of the evidence, the Board finds that an increased disability rating in excess of 10 percent for the Veteran's service-connected GERD is not warranted because the Veteran does not satisfy the criteria for a higher rating under the applicable diagnostic code at any during the appeal period. In making this finding, the Board accords significant probative weight to the VA examination provided in January 2012. The record reflects the examiner reviewed the Veteran's pertinent medical history, documented his current complaints, and rendered findings and diagnoses consistent with the remainder of the evidence of record, and therefore, the examination is adequate for adjudication purposes. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). In particular, the report of the January 2012 VA esophageal examination reflects, in pertinent part, a diagnosis of GERD. At that time, the Veteran's reported experiencing persistent symptoms of pyrosis, reflux, and regurgitation without medication. The Veteran indicated he used conservative treatment, i.e., Roloids, since service to alleviate his symptoms, and his now prescribed medication, i.e., Omeprazole. He denied experiencing any dysphagia or other symptomatology. While post-service medical treatment records dated between November 1991 and April 2015 reflect ongoing treatment and a history of prescribed medication for GERD; the record does not reflect (nor does the Veteran contend) that he experienced dysphagia at any point. Moreover, the record does not reflect (nor does the Veteran contend) that his symptomatology was accompanied by substernal arm or shoulder pain, productive of considerable impairment of health. As previously indicated, a next-higher 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, productive of considerable impairment of health. Importantly, the Board notes that the ameliorative effects of the Veteran's medication were not considered in denying a higher rating. Rather, the January 2012 VA examiner specifically indicated that the symptoms reported by the Veteran were the symptoms experienced prior to medication. The Board has also considered the various lay statements of record. However, to the extent the Veteran is addressing questions of the medical nature and severity of his GERD, the Board finds his statements are not competent lay evidence. Notwithstanding, the probative medical evidence outweighs any lay evidence of record. Based on a review of the foregoing evidence, and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent. The preponderance of the evidence is against the Veteran's claim for a rating higher than 10 percent. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the appeal is denied. ORDER The petition to reopen the claim of entitlement to service connection for depression based on the submission of new and material evidence is granted. Entitlement to service connection for an acquired psychiatric disorder other than PTSD is denied. Entitlement to service connection for pes planus is denied. Entitlement to an initial increased rating in excess of 10 percent disabling for GERD with cough is denied. REMAND A review of the record reflects that the remaining claims must be remanded for additional development prior to appellate consideration. First, the Board turns to the claim of entitlement to service connection, to include on a secondary basis, for OSA. In January 2012, the Veteran was provided a VA sleep disorder examination. Report of the January 2012 VA examination reflects, in pertinent part, a diagnosis of OSA. At that time, the Veteran reported experiencing symptoms of snoring, daytime somnolence, and restless sleep. The examiner noted the Veteran currently uses a continuous positive airway pressure (CPAP) machine to help alleviate his symptoms. The examiner opined that the Veteran's OSA is less likely than not caused by, a result of, or aggravated by his service-connected PTSD. In that regard, the Board notes that the Veteran's STRs dated in May 1967 reflect he presented with complaints of excessive fatigue and tiredness. Additionally, in a statement dated in January 2012, the Veteran reported a history of loud snoring and cessation of breathing since service. He indicated that although he experienced such symptoms, his lack of knowledge regarding OSA is what prevented him from seeking appropriate treatment earlier. Rather, he explained that he treated his symptoms with "home-remedies." It was not until in or around 2009 when a family member encouraged the Veteran to obtain a sleep study that he was diagnosed with OSA. Developmental actions on a direct theory of entitlement have not yet been taken. As such, a remand is appropriate to address this theory of entitlement. Next, the Board turns to the claim of entitlement to service connection, to include on a secondary basis, for HTN. In January 2012, the Veteran was provided with a VA examination. Report of the January 2012 VA examination reflects, in pertinent part, a diagnosis of HTN. The examiner opined that the Veteran's HTN is less likely than not caused by, a result of, or aggravated by his service-connected PTSD. In doing so, the examiner explained, in pertinent part, the distinction between essential HTN and secondary HTN. Secondary HTN is the result of another underlying disability resulting in persistently elevated blood pressure. The examiner indicated that one of the identifiable disorders associated with secondary HTN is OSA. Given the issue of entitlement to service connection for OSA must be remanded for further development, the Board finds developmental actions on this theory of entitlement, if applicable, will promote judicial economy and fairness to the Veteran. Next, the Board turns to entitlement to service connection for alcohol dependence. In that regard, the Board notes that the record is replete with evidence that the Veteran's alcohol dependence may be associated with his PTSD symptoms. For instance, treatment records dated in December 2002 reflect the Veteran began to drink heavily since service in Vietnam. He explained that he drank to "feel normal," and to "shut down [his] thoughts at night so [he] can go to sleep." Treatment records dated in March 2003 reflect that his psychiatric symptoms would go away when he drank. Treatment records dated in December 2010 reflect a clinician's note that the Veteran would binge-drink to suppress his daily anxiety. Lastly, treatment records dated in October 2011 reflect the Veteran's "PTSD likely a trigger for [the Veteran's] alcohol abuse." Conversely, report of the June 2011 PTSD examination reflects, in pertinent part, that the Veteran's alcohol dependence is not caused by his PTSD. In light of the foregoing, the Board finds that clarification of the evidence is necessary in this case prior to appellate consideration. See Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (emphasizing the Board's duty to remand an issue "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). In light of the above determination, the Board finds that it must remand the issue of entitlement to an increased rating for PTSD as inextricably intertwined with that issue, as the adjudication of the issue of alcohol dependence may impact the Veteran's rating for PTSD. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (stating two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). In particular, the record reflects the Veteran's legal history includes three convictions/charges for driving under the influence (DUIs), which undoubtedly would have some occupational impact. Next, the Board turns to entitlement to service connection for a back disability, to include congenital scoliosis. Although the Veteran indicated a history of back trouble prior to service, no abnormalities of the back were noted at his September 1965 enlistment medical examination and no diagnosis of any back disability was made. Thereafter, STRs dated in August 1968 reflect a chest x-ray was performed and revealed a "slight scoliosis" of the spine. No abnormalities of the back were noted at his September 1968 separation medical examination, and no diagnosis of any back disability was made. Parenthetically, the Board notes that post-service treatment records dated between November 1991 and April 2015 reflect the Veteran sustained multiple back injuries. For instance, records dated in June 1999 reflect the Veteran presented with pain in his lower back following a recent slip and fall injury. At that time, he reported a history of back injury (approximately 10-12 years prior) wherein he "snapped his back" playing basketball and had experienced intermittent spasms since then. He was diagnosed with chronic right sacroiliac strain syndrome. Treatment records dated in September 2014 reflect imaging studies were performed and revealed moderate to severe scoliosis of the spine. The Board lacks the medical expertise to determine whether the Veteran's scoliosis existed prior to service, and if so, whether or not it was aggravated beyond its natural progression by service. In light of the foregoing, the Board finds that a remand is necessary in order to obtain a medical examination and opinion commenting on the evidence of record. Lastly, the Board turns to entitlement to service connection for a right shoulder disability, and right and left ankle disability, respectively. As a preliminary matter, the Board notes that the Veteran was not provided with a VA examination as to these disabilities. STRs are negative for any complaints of and/or treatment for a right shoulder disability in service. Similarly, STRs are negative for any complaints of and/or treatment for right and/or left ankle disability. However, in a statement dated in January 2012, the Veteran explained that in performance of his duties as a medic, he injured his right shoulder and ankles on multiple occasions, albeit he never sought treatment. He indicated that his injuries were never of such severity that he could not treat himself with conservative methods such as wraps and medication, i.e., Aspirin. But, he noted the repeated trauma has left him with chronic shoulder and ankle pain since service. Parenthetically, the Board notes that post-service treatment records dated between November 1991 and April 2015 reflect the Veteran sustained multiple shoulder injuries. For instance, treatment records dated in December 1997 reflect the Veteran presented with right shoulder pain following an injury sustained while weight-lifting. The Veteran was diagnosed with right rotator cuff strain with tendinitis and impingement. Thereafter, in January 1998, the Veteran underwent a surgical procedure, i.e., acromioplasty, and has had residual pain in the biceps since. Treatment records dated in May 2011 reflect the Veteran presented with pain in his right shoulder following an injury sustained earlier in March while weight-lifting. At that time, x-rays were performed and revealed slight glenohumeral arthritis in the right shoulder. With respect to the Veteran's claimed ankle disabilities, treatment records dated in September 2009 reflect diagnoses of left ankle ligamentous strain and chronic right ankle Achilles tendonitis. Given the current diagnoses of a right shoulder disability and right and left ankle disabilities, the Veteran's statements regarding injuries sustained in service, and ongoing pain since service, the Board finds that a remand is appropriate to obtain a medical examination and opinion addressing the nature and etiology of such conditions. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding post-service medical treatment records from VA treatment facilities. 2. Thereafter, arrange for the examiner who prepared the January 2012 VA medical opinion, if available, to prepare an addendum opinion as to the nature and etiology of the Veteran's diagnosed OSA, and if deemed necessary, conduct new examination of the Veteran. The electronic claims file must be made accessible to the examiner for review, and such review should be noted in the examination report. Following a review of the claims file and medical history, the VA examiner must offer an opinion as to the following: a. Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's OSA is caused by, or otherwise etiologically related to active military service? In rendering any opinion, the examiner should consider the lay statements of record regarding ongoing symptomatology since service, and STRs dated in May 1967 which reflects complaints of excessive fatigue and tiredness in service. b. If, and only if, the requested development establishes a positive nexus for OSA, opine whether it is as likely as not (i.e., a 50 percent or better probability) that the Veteran's HTN is proximately due to, or aggravated by the Veteran's OSA. c. Whether it is as likely as not (i.e., a 50 percent or better probability) that the Veteran's HTN is aggravated by the Veteran's OSA. (Aggravation is defined as a worsening of the underlying condition as compared to an increase in symptoms.) The examiner must provide a rationale for all opinions provided. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Arrange for an appropriate medical professional to prepare a medical opinion as to the nature and etiology of the Veteran's claimed alcohol dependence, and if deemed necessary, conduct new examination of the Veteran. The electronic claims file must be made accessible to the examiner for review, and such review should be noted in the examination report. Following a review of the claims file and medical history, the VA examiner must offer an opinion as to the following: a. Does the Veteran have alcohol abuse disorder? If so, whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is proximately due to or the result of the Veteran's service-connected PTSD. In rendering any opinion, the examiner should consider the Veteran's lay statements regarding self-medicating with alcohol since service in Vietnam, and an October 2011 clinician's note indicating the Veteran's PTSD is likely a trigger for his alcohol abuse. The examiner must provide a rationale for all opinions provided. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. Schedule the Veteran for VA examination by an appropriate medical professional to prepare an opinion with respect to the nature and etiology of any claimed back disability, including scoliosis. The electronic claims file must be made available to the examiner for review, and such review should be noted in the examination report. Following a review of the claims file and medical history, the VA examiner should offer an opinion as to the following: a. Does the Veteran have a back disability? If so, the examiner should identify the specific disorder and whether it is medically considered a congenital defect or disease. b. If congenital, the examiner should opine whether it is at least as likely as not (i.e., a 50 percent or better probability) that there was a superimposed injury or disease in service that resulted in additional back disability. c. If a disease, the examiner should opine whether there is clear and unmistakable evidence that such disease pre-existed service. (Clear and unmistakable evidence is defined as obvious, manifest, and undebatable evidence). d. If pre-existing, the examiner should opine whether there is clear and unmistakable evidence that the disability was not aggravated by military service and that the increase in severity was due to the natural progress of the disability. (Aggravation is defined as a worsening of the underlying condition as compared to an increase in symptoms. Intermittent or temporary flare-ups during service of a preexisting injury or disease do not constitute aggravation; rather, the underlying condition must have worsened.) e. If, and only if, the answer to questions (c) or (d) above is "no," the examiner must opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disability is etiologically related to military service. The examiner must provide a rationale for all opinions provided. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 5. Schedule the Veteran for VA examination by an appropriate medical professional to prepare an opinion with respect to the nature and etiology of any claimed right and left ankle disability. The electronic claims file must be made available to the examiner for review, and such review should be noted in the examination report. Following a review of the claims file and medical history, the VA examiner should offer an opinion as to the following: a. Does the Veteran currently have a right ankle disability? If so, the examiner should identify the specific disability and whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disability is etiologically related to military service. b. Does the Veteran currently have a left ankle disability? If so, the examiner should identify the specific disability and whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disability is etiologically related to military service. The examiner must provide a rationale for all opinions provided. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 6. Schedule the Veteran for VA examination by an appropriate medical professional to prepare an opinion with respect to the nature and etiology of any claimed right shoulder disability. The electronic claims file must be made available to the examiner for review, and such review should be noted in the examination report. Following a review of the claims file and medical history, the VA examiner should offer an opinion as to the following: a. Does the Veteran currently have a right shoulder disability? b. If so, the examiner should identify the specific disability and whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disability is etiologically related to military service. In rendering any opinion, the examiner should consider the Veteran's statements regarding ongoing symptomatology since service, and discuss the significance, if any, of the numerous right shoulder injuries documented since service. 7. Thereafter, readjudicate the issues remaining on appeal. If the benefits sought on appeal remain denied, issue a supplemental statement of the case and provide the Veteran and his attorney with an opportunity to respond. Then return the case to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs