Citation Nr: 18142277 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 16-19 039 DATE: October 15, 2018 ORDER Entitlement to service connection for a left ankle disability is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a left ankle disability. CONCLUSION OF LAW The criteria for service connection for a left ankle disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty as an aviation storekeeper in the U.S. Navy from March 1984 to March 1988 and from September 1990 to July 1997 with service in Southwest Asia. In a December 2016 statement, the Veteran identified his Southwest Asia service as aboard an aircraft carrier operating in the Persian Gulf and Arabian Sea. Service Connection A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran 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” - the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For the showing of 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.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. 3.303 (b). Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. Entitlement to service connection for left ankle disability. The Veteran contends that service connection is warranted for a left ankle disability. The Veteran contends he injured his left ankle in-service and his left ankle disability has continued since service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a left ankle disability and has not had a left ankle disability at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s service treatment records (STRs) have been associated with the claims file. The Board notes that the Veteran’s representative vaguely contends in September 2017 correspondence that VA was unable to obtain the Veteran’s service treatment records and a heightened duty to explain its findings and conclusions is warranted. This contention is included in a lengthy recitation of generalized contentions and legal citations void of specific errors or omissions in this Veteran’s case. The Veteran’s STRs for both periods of service have been associated with the claims file, and such have been considered. The Veteran as a result of a motor vehicle accident had a left tibia-fibular fracture in December 1985 and his left leg was immobilized for 10 months. During recovery he underwent physical therapy to work on left ankle range of motion. November 1986 STRs noted ankle pain. December 1986 physical therapy notes reported left ankle swelling and overall improved range of motion. At separation on the report of medical examination in March 1997 the examiner noted a normal clinical evaluation of the lower extremities and musculoskeletal system. On the report of medical history at separation the Veteran denied swollen or painful joints, or any bone or joint deformity. The Veteran was afforded a VA examination in June 2017. The June 2017 VA examiner evaluated the Veteran and determined that, while he has experienced prior subjective symptoms of left ankle pain, he did not report current symptoms related to his left ankle and did not have a diagnosis of a left ankle disability. The examiner noted no pain on examination, normal range of motion testing and normal muscle strength testing. The examiner found that it was less likely than not that the Veteran incurred a left ankle disability as a result of his in-service motor vehicle accident in 1985. Further, the examiner noted despite consistent treatment encounters, VA treatment records do not contain reports of a left ankle disability. The Veteran does not have a current left ankle disability. The Board notes the Veteran’s reports of ongoing manifestations of pain; however, there is no evidence that the Veteran’s reported pain interferes with his functioning as evidenced by VA treatment records and examinations noting normal range of motion. Under 38 U.S.C. § 1110 there must be a disability due to an identified personal injury suffered or disease or injury, contracted in-service. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Here there is no functional limitation. Further, not all pain results in a disability, as in here, or rises to the level of impairment of working ability. Under 38 C.F.R. § 3.317, the Board notes that service connection can be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, 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 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). However, the Veteran has not contended that his reported ankle disability is generally a result of exposure in Southwest Asia, rather he has reported his ankle pain is attributable to his in-service motor vehicle accident in 1985. As with all claims for service connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board notes the Veteran’s reports regarding his symptoms in-service and ongoing manifestations which he is competent to report. However, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for a left ankle disability. The Board notes that the medical evidence is more probative and more credible than the lay opinions of record. The June 2017 VA examination did not find any indication of a current left ankle disability, and on examination the Veteran denied left ankle pain or symptomology. Further, VA treatment records are absent indications of a left ankle disability. Thus, the more probative evidence of record indicates the Veteran does not have a current left ankle disability and service connection is not warranted. As such, the Board finds that service connection for a left ankle disability is not warranted. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. REMANDED Entitlement to an increased rating in excess of 20 percent for degenerative disc disease (DDD) of the lumbar spine associated with residuals of a left tibia-fibular fracture is remanded. Entitlement to an increased rating in excess of 20 percent for left lower extremity radiculopathy is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to an increased rating in excess of 30 percent for unspecified alcohol related disorder with alcohol use disorder, from March 31, 2016 and a noncompensable rating from June 5, 2017 forward is remanded. Entitlement to an effective date prior to March 31, 2016 for the award of service connection for unspecified alcohol related disorder with alcohol use disorder is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a compensable rating for residuals of a bilateral inguinal hernia repair is remanded. Entitlement to an increased rating in excess of 30 percent for irritable bowel syndrome (IBS) with gastroesophageal reflux disease (GERD) is remanded. Entitlement to an effective date prior to March 31, 2016, for the award of service connection for irritable bowel syndrome (IBS) with gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service connected disabilities is remanded. Entitlement to service connection for urinary frequency, to include as secondary to service connected disabilities is remanded. Entitlement to service connection for hypertension, to in include as secondary to service connected disabilities is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for fatigue is remanded. Entitlement to service connection for a left knee disability, to include as secondary to a service connected disability is remanded. Entitlement to service connection for a right knee disability, to include as secondary to a service connected disability is remanded. Entitlement to service connection for left elbow tingling and numbness, to include as secondary to DDD and left lower extremity radiculopathy is remanded. Entitlement to service connection for right elbow tingling and numbness is remanded. Entitlement to service connection for a neck disability, to include as secondary to a service connected disability is remanded. Entitlement to service connection for sleep apnea, to include as secondary to a service connected disability is remanded. Entitlement to a total disability rating based upon individual unemployability due to service connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty as an aviation storekeeper in the U.S. Navy from March 1984 to March 1988 and from September 1990 to July 1997 with service in Southwest Asia aboard an aircraft carrier. As discussed below, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to TDIU will be considered to have been raised by the record as “part and parcel” of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447, 453–54 (2009). The Veteran in September 2017 correspondence indicated that his service-connected disabilities have contributed to his current unemployment and ability to seek employment. The title page has been updated accordingly. 1. Entitlement to an increased rating in excess of 20 percent for DDD of lumbar spine is remanded. In an April 2016 statement, the Veteran contended that his low back disability has increased in severity since he was last examined by VA. Specifically, the Veteran reports increased difficulty sitting, standing and getting out of bed due to his low back disabilty. The Veteran should be provided an opportunity for a VA examination to ascertain the current severity and manifestations of his low back disability. As such a remand is warranted. 2. Entitlement to increased rating in excess of 20 percent for left lower extremity radiculopathy is remanded In an April 2016 statement, the Veteran asserted that his left lower extremity radiculopathy has increased in severity since he was last examined by VA. Specifically, the Veteran reports difficulty walking and limping in his left leg. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his left lower extremity radiculopathy. As such a remand is warranted. 3. Entitlement to service connection for a hearing loss disability is remanded. The Veteran contends service connection is warranted for a bilateral hearing loss disability as a result of his in-service noise exposure. In an April 2016 statement the Veteran provided medical literature suggesting that noise exposure may result in delayed onset hearing loss. The Board cannot make a fully-informed decision on the issue of service connection for bilateral hearing loss because no VA examiner has opined whether the Veteran’s current hearing loss is the result of in-service noise exposure and delayed onset. As such remand is warranted. 4. Entitlement to service connection for tinnitus is remanded. The Veteran contends service connection is warranted for tinnitus and provided medical literature suggesting delayed onset of tinnitus as a result of significant noise exposure. The Board cannot make a fully-informed decision on the issue of service connection for tinnitus because no VA examiner has opined whether the Veteran’s tinnitus is the result of in-service noise exposure and delayed onset. As such remand is warranted. 5. Entitlement to an increased rating in excess of 30 percent for unspecified alcohol related disorder with alcohol use disorder, from March 31, 2016 and as noncompensable from June 5, 2017 forward is remanded. In September 2017 correspondence the Veteran through his representative asserted that his unspecified alcohol related disorder with alcohol use disorder has increased in severity since he was last examined by VA. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his service connected acquired psychiatric disorder. 6. Entitlement to an effective date prior to March 31, 2016 for the award of service connection for unspecified alcohol related disorder with alcohol use disorder is remanded. Next, because a decision on the remanded issue of entitlement to an increased rating in excess of 30 percent for unspecified alcohol related disorder with alcohol use disorder could significantly impact a decision on the issue of entitlement to an effective date prior to March 31, 2016 for the award of service connection for unspecified alcohol related disorder with alcohol use disorder, these issues are inextricably intertwined. A remand of the claim for an earlier effective date for award of service connection for unspecified alcohol related disorder is warranted. 7. Entitlement to service connection for posttraumatic stress disorder (PTSD). Finally, because a decision on the remanded issue of an increased rating for unspecified alcohol related disorder with alcohol use disorder could significantly impact a decision on the issue of service connection for PTSD, these issues are inextricably intertwined. A remand of the claim for service connection for PTSD is warranted. 8. Entitlement to a compensable rating for residuals of a bilateral inguinal hernia repair is remanded. In a September 2017 statement, the Veteran asserted that the residuals of his bilateral inguinal hernia repair have increased in severity since the Veteran was last examined by VA. Specifically, the Veteran contends his scars from his hernia repair result in ongoing pain and should be separately rated. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his residuals of a bilateral inguinal hernia repair. 9. Entitlement to an increased rating in excess of 30 percent for irritable bowel syndrome with gastroesophageal reflux disease is remanded. In a September 2017 statement, the Veteran asserted that his IBS with GERD has increased in severity since the Veteran was last examined by VA. Specifically, the Veteran contends a worsening of his disability. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his IBS with GERD. As such a remand is warranted. 10. Entitlement to an effective date prior to March 31, 2016, for the award of service connection for irritable bowel syndrome with gastroesophageal reflux disease is remanded. Further, because a decision on the remanded issue of an increased rating for IBS with GERD could significantly impact a decision on the issue of entitlement to an effective date prior to March 31, 2016 for IBS with GERD, these issues are inextricably intertwined. A remand of the claim for an earlier effective date for IBS with GERD is required. 11. Entitlement to service connection for erectile dysfunction to include as secondary to service connected disabilities. The Board cannot make a fully-informed decision on the issue of service connection for erectile dysfunction to include as secondary to service connected disabilities because no VA examiner has fully opined whether direct and/or secondary service connection is warranted. Specifically, the October 2017 VA examiner failed to fully address secondary service connection and aggravation relating to medication prescribed for the Veteran’s service connected low back disability, left tibia-fibular fracture, and residuals of a hernia repair, and aggravation as to the Veteran’s service connected unspecified alcohol use disorder. As such a remand is warranted. 12. Entitlement to service connection for urinary frequency, to include as secondary to service connected disabilities. The Board cannot make a fully-informed decision on the issue of service connection for urinary frequency to include as secondary to service connected disabilities because no VA examiner has fully opined as to direct and/or secondary service connection. The Veteran contends his increased urinary frequency is due to his service connected low back disability. The Veteran submitted medical literature in September 2017 suggesting that spinal injuries causing nerve compression may cause bladder dysfunction. In a November 2017 VA opinion the examiner noted that alcohol use could play into the Veteran’s previous urinary tract complaints and the examiner noted urinary frequency can have numerous etiologies. However, secondary service connection, specifically as to service connected alcohol use disorder has not been fully addressed. As such a remand is warranted 13. Entitlement to service connection for hypertension, to in include as secondary to service connected disabilities. The Board cannot make a fully-informed decision on the issue of service connection for hypertension, to include as secondary to service connected unspecified alcohol related disorder and a low back disability because no VA examiner has fully opined whether direct and/or secondary service connection is warranted. A June 2017 VA examination failed to fully address secondary service connection and specifically aggravation. Specifically, the Veteran contends that his hypertension has been worsened by medications prescribed for his service connected left lower extremity radiculopathy, low back disability, left tibia fibular fracture and or residuals of his hernia repair. In addition, the Veteran contends his hypertension has worsened as a result of his service connected unspecified alcohol related disorder. As such a remand is warranted. 14. Entitlement to service connection for headaches. The Veteran contends service connection is warranted for headaches which began while he was serving in Saudi Arabia. In September 2017 correspondence the Veteran’s representative contends that his headaches are a result of his service in the Gulf War and that compensation is warranted under the provisions of 38 C.F.R. § 3.317. The Veteran served in Southwest Asia during the applicable time period. The Veteran contends several of his symptoms and current disabilities are a result of his service in Southwest Asia. However, the Veteran has not been provided with the appropriate notice regarding establishing a service connection claim pursuant to the provisions under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. Since this claim has not been fully considered under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, the RO should provide the Veteran with appropriate evidence needed to establish service connection pursuant to these provisions. In addition, the Board cannot make a fully-informed decision on the issue of service connection for headaches because no VA examiner has opined whether direct service connection is warranted to include as due to the Veteran’s service in Southwest Asia during the applicable period. As such a remand is warranted. 15. Entitlement to service connection for fatigue. In September 2017 correspondence the Veteran’s representative contends that his fatigue is a result of his service in the Gulf War and that compensation is warranted under the provisions of 38 C.F.R. § 3.317. The Veteran served in Southwest Asia during the applicable time period. Since this claim has not been fully considered under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, the RO should provide the Veteran with appropriate evidence needed to establish service connection pursuant to these provisions. In addition, the Board cannot make a fully-informed decision on the issue of service connection for fatigue because no VA examiner has opined whether direct service connection is warranted to include as due to the Veteran’s service in Southwest Asia during the applicable period. As such a remand is warranted. 16. Entitlement to service connection for a left knee disability, to include as secondary to a service connected disability. The Board cannot make a fully-informed decision on the issue of service connection for a left knee disability to include as secondary to service connected disabilities because no VA examiner has opined whether secondary service connection is warranted. Specifically, secondary service connection and aggravation due to the Veteran’s service connected DDD, left lower extremity radiculopathy and left tibia-fibular fracture should be addressed. In addition, the Veteran contends his knee pain is a related of his service in Southwest Asia. As such a remand is warranted. 17. Entitlement to service connection for right knee disability, to include as secondary to a service connected disability. The Board cannot make a fully-informed decision on the issue of service connection for a right knee disability to include as secondary to service connected disabilities because no VA examiner has opined whether direct and/or secondary service connection is warranted to include as due to service in Southwest Asia. The June 2017 VA examiner failed to fully address the Veteran’s right knee and whether direct and/or secondary service connection is warranted to include service in Southwest Asia. A such remand is warranted. 18. Entitlement to service connection for left elbow tingling and numbness, to include as secondary DDD and to left lower extremity radiculopathy. The Board cannot make a fully-informed decision on the issue of service connection because no VA examiner has opined whether secondary service connection and service connection as due to exposure in Southwest Asia is warranted. The Veteran contends secondary service connection is warranted due to his service connected low back disability and his left lower extremity radiculopathy. An August 2017 supplemental opinion noted left elbow pain and likely hyperflexion of the left elbow which is not an injury typical for a fall. In addition, the Veteran contends these symptoms of tingling and numbness are a result of his service in the Gulf War and that compensation is warranted under the provisions of 38 C.F.R. § 3.317. However, no VA examiner has fully addressed secondary service connection and service connection due to service in Southwest Asia. As such a remand is warranted. 19. Entitlement to service connection for right elbow tingling and numbness. The Veteran contends these symptoms are a result of his service in Southwest Asia and that compensation is warranted under the provisions of 38 C.F.R. § 3.317. The Veteran served in Southwest Asia during the applicable time period. As noted above, appropriate notice shoulder be provided. In addition, no VA examiner has fully addressed direct service connection and service connection due to service in Southwest Asia. A remand of the claim for service connection for right elbow tingling and numbness is warranted. 20. Entitlement to service connection for a neck disability, to include as secondary to service connected disability. The Board cannot make a fully-informed decision on the issue of service connection for a neck disability to include as secondary to a service connected disability because no VA examiner has fully opined whether direct service connection is warranted. An August 2016 VA examiner noted that the Veteran’s neck disability was less likely than not proximately due to or the result of his service connected low back disability. In an October 2017 VA supplemental opinion, the examiner noted that neck conditions are not directly caused by or due to DDD of the lumbar spine, as the lower spine does not affect another distant area of the spinal column and found that the Veteran’s neck condition was not aggravated beyond its natural progression by his service connected degenerative disc disease. As such a remand is warranted. 21. Entitlement to service connection for sleep apnea, to include as secondary to a service connected disability is remanded. The Veteran contends service connection for sleep apnea is warranted to include as secondary to his service connected GERD and/or alcohol use disorder. In addition, the Veteran contends his sleep apnea developed as a result of his service in Southwest Asia during the applicable time period. As noted above, the Veteran has not been provided notice as to the criteria required to substantiate a claim based on Persian Gulf War service under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. As such a remand is warranted. 22. Entitlement to a total disability rating based upon individual unemployability due to service connected disabilities (TDIU) is remanded. 23. As noted above the Veteran contends through the record that he is unemployable due to his service connected disabilities and as such the Board finds the issue of entitlement to TDIU has been raised by the record. As a result, since it has just been determined that a claim for TDIU is part of the pending increased rating claim, the Veteran has not been sent a notification letter in compliance with 38 U.S.C. § 5103 (a) and 38 C.F.R. § 3.159. On remand, the Veteran should be provided with proper notice of the evidence necessary to substantiate a claim of entitlement to TDIU. Then finally, because a decision on the remanded issues of service connection and increased ratings could significantly impact a decision on the issue of entitlement to a total disability rating due to service connected disabilities, these issues are inextricably intertwined. As such a remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Provide notice as to the criteria required to substantiate a claim based on Persian Gulf War service under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 as to the claims for service connection for headaches, fatigue, joint pain, tingling and numbness in the elbows, knees and sleep apnea. In addition, the Veteran should be properly notified of how to substantiate a claim for entitlement to TDIU. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected degenerative disc disease (DDD) and left lower extremity radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to his DDD and left lower extremity radiculopathy alone and discuss the effect of the Veteran’s DDD and left lower extremity radiculopathy on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran’s representative’s April 2016 statements noting increased difficulty sitting, standing and getting out of bed due to his low back. In addition, the Veteran has reported a limp as a result of his left lower extremity radiculopathy. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral hearing loss and tinnitus. The examiner must opine whether: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral hearing loss is caused by service? (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s tinnitus is caused by service? (c.) Is it at least as likely as not that the Veteran’s bilateral hearing loss (1) began during active service, (2) manifested within the applicable presumptive period after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? (d.) Is it at least as likely as not that the Veteran’s tinnitus (1) began during active service, (2) manifested within the applicable presumptive period after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran’s September 2017 correspondence and submitted medical literature suggesting that his current bilateral hearing loss and tinnitus had delayed onset and is related to his in-service noise exposure. In addition, attention is invited to the April 2016 VA examination noting that it was less likely than not that the Veteran’s hearing loss and tinnitus was caused by in-service noise exposure. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected acquired psychiatric disability, to include unspecified alcohol related disorder with alcohol use disorder. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner should identify all disorders based on the DSM-V and any symptoms and functional impairments due to the Veteran’s unspecified alcohol related disorder alone and discuss the effect of the Veteran’s psychiatric disorder on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service connected residuals of his bilateral inguinal hernia repair. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to residuals of bilateral inguinal hernia repair alone and discuss the effect of the Veteran’s residuals of hernia repair on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran’s statements noting ongoing pain related to scars associated with residuals of his bilateral inguinal hernia repair. Additionally, the Veteran has reported intermittent pain and discomfort with a noticeable bulge present. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected irritable bowel syndrome with gastroesophageal reflux. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to IBS with GERD alone and discuss the effect of the Veteran’s IBS with GERD on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any erectile dysfunction. The examiner must opine whether: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s current erectile dysfunction is caused by service? (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s erectile dysfunction was caused by his service connected unspecified alcohol use disorder and/or medications taken for his service connected left lower extremity radiculopathy, low back disability, GERD, and left tibia-fibular fracture? (c.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s erectile dysfunction was aggravated (permanently worsened beyond its natural progression) by his service connected unspecified alcohol use disorder and/or medications taken for his service connected left lower extremity radiculopathy, low back disability, GERD, and left tibia-fibular fracture? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the June 2017 VA examination noting it was less likely than not that the Veteran’s erectile dysfunction was proximately due to or the result of medication taken for his service connected left lower extremity radiculopathy, low back disability, left tibia-fibular fracture and/or residuals of his hernia repair. Additionally, the examiner noted it was less likely than not that the Veteran’s erectile dysfunction was proximately due to the Veteran’s unspecified alcohol related disorder, noting such is not a cause of erectile dysfunction. If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation of his erectile dysfunction by the service connected disabilities. 8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any genitourinary disorder, to include urinary frequency. The examiner must opine whether: (a.) Identify any genitourinary disorders. (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s genitourinary disorder is caused by service? (c.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s genitourinary disorder was caused by his service connected low back disability and/or left lower extremity radiculopathy? (d.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s genitourinary disorder was aggravated (permanently worsened beyond its natural progression) by his service connected low back disability and/or left lower extremity radiculopathy? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to medical literature submitted by the Veteran in September 2017 suggesting that spinal disorders or injuries may cause nerve compression or damage resulting in bladder dysfunction. In a November 2017 VA opinion the examiner noted that alcohol use could play into the Veteran’s previous urinary tract complaints and the examiner noted urinary frequency can have numerous etiologies. If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation of his urinary dysfunction by the service connected disability. 9. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s current hypertension is caused by service? (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension was caused by his service connected unspecified alcohol use disorder, low back disability, and/or medications taken for his service connected left lower extremity radiculopathy, low back disability, GERD, and left tibia-fibular fracture? (c.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension was aggravated (permanently worsened beyond its natural progression) by his service connected unspecified alcohol use disorder/and or medications taken for his service connected left lower extremity radiculopathy, low back disability, and/or left tibia-fibular fracture? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. A June 2017 VA examination noted that it was less likely than not that the Veteran’s hypertension was proximately due to his unspecified alcohol use disorder, as an unspecified alcohol related disorder is not a known cause of hypertension. In addition, the examiner found that it was less likely than not that the Veteran’s hypertension was proximately due to medications taken for his service connected left lower extremity radiculopathy, low back disability, left tibia-fibular fracture, and/or residuals of a hernia repair. 10. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any headaches. The examiner must opine whether: (a.) Identify all headache disorders. (b.) Are the Veteran’s symptoms of headaches a sign of an undiagnosed illness? If any symptoms have not been determined to be associated with a known clinical diagnosis, are these a sign of an undiagnosed illness or a chronic multi-symptom illness? As established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. (c.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s headaches are related to active service, to include environmental hazards exposed to in Southwest Asia? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran’s representative’s contentions that his headaches are related to his service in the Persian Gulf War. The Veteran served in Southwest Asia during the applicable presumptive period. A VA examination in June 2017 noted migraine headaches and found that it was less likely than not that the Veteran’s current migraine headaches were incurred in or caused by the claimed in-service injury, event or illness. The examiner noted no complaints of headaches in-service, and found his current migraine headaches were not related to service. 11. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any chronic fatigue to include an undiagnosed illness or medically unexplained chronic multi-symptom illness. The examiner must opine whether: (a.) Are the Veteran’s symptoms of fatigue attributable to a known clinical diagnosis? (b.) If any symptoms have not been determined to be associated with a known clinical diagnosis, are these a sign of an undiagnosed illness or a chronic multi-symptom illness? As established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. (c.) If not, does the Veteran have a diagnosis of chronic fatigue disorder? (d.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s known clinical diagnoses to include chronic fatigue are related to active service, to include environmental hazards exposed to in Southwest Asia? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner should note the Veteran had service in Southwest Asia aboard an aircraft carrier. In a Gulf War VA examination in April 2017 the examiner noted that the Veteran’s reports of symptoms could be related to a myriad of diagnoses and it is not possible to separate these generalized complaints and symptoms with all his other medical and social/mental health comorbidities. The examiner noted it was unknown if these symptoms have any specific relationship to serving in Southwest Asia. 12. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right and left knee disabilities. The examiner must opine whether: (a.) Identify all right and left knee disabilities. (b.) Are the Veteran’s symptoms of knee pain a sign of an undiagnosed illness? If any symptoms have not been determined to be associated with a known clinical diagnosis, are these a sign of an undiagnosed illness or a chronic multi-symptom illness? As established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. (c.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s right and left knee disabilities are caused by service, to include any environmental hazards exposed to in Southwest Asia aboard an aircraft carrier? (d.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s left knee strain was caused by his service connected low back disability, left lower extremity and/or tibia-fibular fractures? (e.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s left knee strain was aggravated (permanently worsened beyond its natural progression) by his service connected low back disability? (f.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s right knee disability was caused by his service connected low back disability, left lower extremity and/or tibia-fibular fractures? (g.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s right knee disability was aggravated (permanently worsened beyond its natural progression) by his service connected low back disability, left lower extremity and/or tibia-fibular fractures? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran’s representative’s contentions that his knee pain is related to his service in the Persian Gulf War. The Veteran served in Southwest Asia at sea during the applicable presumptive period. Additionally, the Veteran contends that his left knee disability has been aggravated by his service connected DDD and left lower extremity radiculopathy. In addition, a June 2017 VA examination found that it was less likely than not that the Veteran has a diagnosis of a left knee strain which was incurred in his 1985 in-service motor vehicle accident. A July 2017 supplemental VA opinion noted that while the Veteran reported several instances of knee pain in-service after his tibia fracture there was no evidence of a chronic knee condition. The examiner noted that the Veteran’s complaints of left knee pain in May 1983 was diagnosis as a chronic knee strain which is a self-limiting condition. If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation of his knees by the service connected disability or disabilities. 13. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s left and right upper extremities, to include tingling in numbness in the elbows: (a.) Identify any left upper extremity disabilities. (b.) Identify any right upper extremity disabilities. (c.) If any symptoms have not been determined to be associated with a known clinical diagnosis, are these a sign of an undiagnosed illness or a chronic multi-symptom illness? As established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. (d.) Is it at least as likely as (a 50 percent probability or greater) that the Veteran’s left upper extremity disability is related to service, to include environmental hazards exposed to in Southwest Asia? (e.) Is it at least as likely as (a 50 percent probability or greater) that the Veteran’s right upper extremity disability is related to service to include environmental hazards exposed to in Southwest Asia aboard an aircraft carrier? (f.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s left upper extremity disability was caused by his service connected low back disability, and/or left lower extremity radiculopathy? (g.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s left upper extremity disability was aggravated (permanently worsened beyond its natural progression) by his service connected low back disability? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran’s representative’s contentions that his tingling and numbness in his upper extremities are caused by his service in the Persian Gulf War. The Veteran served in Southwest Asia during the applicable presumptive period. In addition, the Veteran’s representative’s in September 2017 contends that his left upper extremity disability is secondary to his service connected low back disability and/or left lower extremity radiculopathy. 14. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any neck disorder. The examiner must opine whether: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s current cervical strain is related to service? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the August 2016 VA examiner noted that the Veteran’s neck disability is less likely than not proximately due to or the result of his service connected low back disability, however such was incomplete. An October 2017 VA supplemental opinion the examiner noted that neck conditions are not directly caused by or due to degenerative disc disease of the lumbar spine, as the lower spine does not affect another distinct area of the spinal column and that the Veteran’s neck condition was not aggravation beyond its natural progression by his service connection degenerative disc disease. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kardian