Citation Nr: 18142676 Decision Date: 10/16/18 Archive Date: 10/16/18 DOCKET NO. 15-35 297A DATE: October 16, 2018 ORDER The application to reopen a claim for entitlement to service connection for a left foot sprain is granted. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a right knee disability is denied. REMANDED Entitlement to service connection for left hand arthritis is remanded. Entitlement to service connection for right hand arthritis is remanded. Entitlement to service connection for polymyositis is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to an increased disability rating in excess of 10 percent for impingement syndrome, left shoulder (herein left shoulder disability) is remanded. Entitlement to an increased disability rating in excess of 10 percent for impingement syndrome, right shoulder (herein right shoulder disability) is remanded. Entitlement to an increased disability rating in excess of 10 percent for chronic neck pain (herein neck disability) is remanded. Entitlement to an increased disability rating in excess of 10 percent for degenerative arthritis, lumbar spine (herein lumbar disability) is remanded. Entitlement to an increased disability rating in excess of 10 percent for degenerative joint disease of the left knee (herein left knee disability) is remanded. Entitlement to an increased disability rating in excess of 10 percent for osteoarthritis of the left ankle (herein left ankle disability) is remanded. Entitlement to an increased disability rating in excess of 10 percent for osteoarthritis of the right ankle (herein right ankle disability) is remanded. Entitlement to an increased disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. A November 1998 rating decision denied entitlement to service connection for a left foot sprain and is final; new and material evidence was received after this decision. 2. Sleep apnea was not incurred in the Veteran’s active service. 3. Erectile dysfunction was not incurred in the Veteran’s active service. 4. A right knee disability was not incurred in the Veteran’s active service and may not be presumed to have been incurred therein. CONCLUSIONS OF LAW 1. The claim for entitlement to service connection for a left foot disability is reopened. U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2018). 2. The criteria for entitlement to service connection for sleep apnea have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). 3. The criteria for entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). 4. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1112 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1980 to August 1983 and from March 1985 to April 1998. 1. New and Material Evidence – Left Foot Sprain Legal Criteria Generally, in order to establish direct service connection, three elements must be established: a current disability, an in-service event and a nexus between the current disability and the in-service event. An unappealed RO denial is generally final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. If new and material evidence is presented or secured with respect to a claim that has been disallowed, however, VA must reopen the claim and review the former disposition. See 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to VA. See 38 C.F.R. § 3.156(a). Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. See id. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. See id. The United States Court of Appeals for Veterans Claims interpreted the language of 38 C.F.R. § 3.156(a) “as creating a low threshold.” See Shade v. Shinseki, 24 Vet. App. 110 (2010). Analysis A November 1998 rating decision denied entitlement to service connection for a left foot sprain. The rating decision stated that “[a]lthough the records indicated that the [V]eteran sprained his Left foot in 1986[,] X-ray findings were within normal limits. At the time of discharge, clinical evaluation noted the left foot to be within normal limits.” As such, at least one reason that the Agency of Original Jurisdiction (AOJ) denied the Veteran’s claim was based on the lack of a current disability. The Veteran was notified of the November 1998 rating decision and of his appellate rights, but did not appeal the decision, or submit new and material evidence within one year of the denial; therefore, it became final. 38 U.S.C. § 7105(c) (1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1998). New and material evidence received after this decision included, but was not necessarily limited to, an October 2014 private medical record that referenced x-rays of the bilateral foot and noted an assessment of “Arthritis Osteoarthritis Foot” (other evidence also referenced osteoarthritis and degenerative changes in the left foot and big toe). This evidence indicated a current left foot disability, which as referenced, the lack of such was a reason for the prior November 1998 rating decision denial (i.e., a current disability was an unestablished fact necessary to substantiate the claim). As new and material evidence has been received, the Board concludes that the claim for entitlement to service connection for a left foot disability is reopened and, in this regard, the Veteran’s claim is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 2. Service Connection – Sleep Apnea 3. Service Connection – Erectile Dysfunction 4. Service Connection – Right Knee Disability These three disabilities are being denied on a similar basis and as such they will be discussed together. As noted above, generally, in order to establish direct service connection three elements must be established: a current disability, an in-service event and a nexus between the current disability and the in-service event. Upon review, the Veteran and/or his representative have not identified, and the service treatment records (STRs) do not otherwise identify, any in-service event to which the Veteran’s claimed sleep apnea, erectile dysfunction or right knee disability could be related. As such, entitlement to service connection is not warranted on a direct basis. With respect to sleep apnea and erectile dysfunction, the Veteran and/or his representative have not raised, and the record does not otherwise indicate entitlement based on, other theories of service connection beyond direct service connection. With respect to the right knee disability, the Veteran has been diagnosed with a chronic disease of arthritis and as such the presumption related to chronic disease is potentially applicable and will be discussed further below. With respect to sleep apnea, the Veteran filed a December 2013 claim and listed “Sleep disorder [service connection].” While various evidence of record noted a diagnosis of sleep apnea, STRs, and the remaining evidence of record, did not identify an in-service event to which sleep apnea could be related. The January 1998 retirement examination report noted upon clinical evaluation that the Veteran’s sinuses and mouth and throat were normal and noted no relevant defects. On the accompanying Report of Medical History form, the Veteran reported that he was in good health and denied having now or ever having frequent trouble sleeping. He also denied on this form having any illness or injury other than those already noted. Upon review, lacking an in-service event, entitlement to service connection is not warranted on a direct basis. As noted, no other theory of service connection has been raised by the Veteran and/or his representative or by the record. As such, the Board finds that sleep apnea was not incurred in the Veteran’s active service. The Board accordingly concludes that the criteria for entitlement to service connection for sleep apnea have not been met and, to this extent, the Veteran’s claim is therefore denied. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. With respect to erectile dysfunction, the Veteran filed a December 2013 claim and listed “Erectile dysfunction [service connection].” While various evidence of record noted a diagnosis of erectile dysfunction, STRs, and the remaining evidence of record, did not identify an in-service event to which that erectile dysfunction could be related. The January 1998 retirement examination report noted upon clinical evaluation that the Veteran’s genitourinary system was normal and noted no relevant defects. On the accompanying Report of Medical History form, the Veteran reported that he was in good health. He also denied on this form having any illness or injury other than those already noted. Upon review, lacking an in-service event, entitlement to service connection is not warranted on a direct basis. As noted, no other theory of service connection has been raised by the Veteran and/or his representative or by the record. As such, the Board finds that erectile dysfunction was not incurred in the Veteran’s active service. The Board accordingly concludes that the criteria for entitlement to service connection for erectile dysfunction have not been met and, to this extent, the Veteran’s claim is therefore denied. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. With respect to the right knee disability, the Veteran filed a claim in September 2014 and listed “Bilateral Knees.” While various evidence of record noted a diagnosis of right knee disability, to include arthritis, STRs, and the remaining evidence of record, did not identify an in-service event to which a right knee disability could be related. The January 1998 retirement examination report noted upon clinical evaluation that the Veteran’s lower extremities were normal and noted no relevant defects. On the accompanying Report of Medical History form, the Veteran reported that he was in good health and denied having now or ever having trick or locked knee; arthritis; or bone, joint or other deformity. He also denied on this form having any illness or injury other than those already noted. Upon review, lacking an in-service event, entitlement to service connection is not warranted on a direct basis. With respect to the potentially applicable presumption related to chronic disease, the evidence did not show manifestations sufficient to identify the disease entity during the Veteran’s active service. See 38 C.F.R. § 3.303(b), 3.309(a). In addition, the earliest diagnosis of record of right knee arthritis (a chronic disease) appears to be in a March 2014 private medical record, which is more than one year from the Veteran’s April 1998 separation from active service. See 38 C.F.R. § 3.307(a)(3). Overall, entitlement to service connection is not warranted based on the presumption related to chronic disease. In sum, the Board finds that a right knee disability was not incurred in the Veteran’s active service and may not be presumed to have been incurred therein. The Board accordingly concludes that the criteria for entitlement to service connection for a right knee disability have not been met and, to this extent, the Veteran’s claim is therefore denied. 38 U.S.C. § 1110, 1112; 38 C.F.R. § 3.303, 3.307, 3.309. REASONS FOR REMAND I. Service Connection Claims With respect to all service connection claims addressed below, the Veteran was not afforded a VA examination. Under 38 U.S.C. § 5103A(d), VA must provide a medical examination and/or obtain a medical opinion when there is: (1) competent evidence that the veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that an event, injury or disease occurred in service; (3) an indication that the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding the third element, the United States Court of Appeals for Veterans Claims stated in McLendon that “[t]his is a low threshold.” 1. Service Connection – Left Hand Arthritis 2. Service Connection – Right Hand Arthritis Evidence of record indicated a current bilateral hand disability. In this regard, a November 2014 VA rheumatology note included an assessment of “[g]eneralized (early) osteoarthritis with Heberden nodes at most of the finger [distal interphalangeal (DIP)] joints” and a November 2015 VA rheumatology included an assessment of “[o]steoarthritis multiple joints of the hands.” STRs referenced in-service treatment related to the Veteran’s hands. With respect to the left hand, a June 1987 STR noted a chief complaint of the left first DIP joint. It was noted that the Veteran complained of an injury one day ago and that he “stated he traumatized it by his thumb hanging on the net.” It was noted that there was decreased range of motion, that the left DIP was “slightly edemic” and that there was metacarpals tenderness. An assessment was noted of contused left first metacarpal versus questionable soft tissue and a plan referenced a splint. A June 1987 STR from the same date, a radiologic consultation request for the left thumb, noted that the Veteran caught his thumb in a net playing basketball. The radiologic report noted no significant abnormalities. An additional June 1987 STR noted decreased range of motion of the metacarpophalangeal (MP) joint of the left thumb with tenderness and no edema. Negative x-rays were referenced. An assessment of left thumb sprain was noted and a plan referenced motrin. Also, an August 1987 STR, a radiologic consultation request for the left hand third finger, noted that the Veteran jammed and extended the finger during football practice and referenced the proximal interphalangeal (PIP) joint. The radiologic report stated that “[t]here is a smooth ossicle ventral to the PIP joint consistent with either an accessory ossicle or an old avulsion injury. The rest of the exam is unremarkable.” With respect to the right hand, an October 1986 STR noted “follow-up for his [right] hand injury. He was told to [return to clinic] today.” It was noted that the Veteran “did not respond to name called.” While unclear, this STR referenced some sort of right hand injury. Also, a July 1993 STR referenced that the Veteran was in a car accident in June 1993 and noted that the Veteran “[complained of] limited use of [right] hand. [Veteran] state[s] inability at certain times to close [right] hand into a fist.” In review, the Board finds that a VA examination is warranted in this case and remand is therefore required for a VA examination and opinion addressing direct service connection, as outlined further in the remand directives below. 3. Service Connection – Polymyositis The Veteran filed a claim in December 2013 for entitlement to service connection for polymyositis. The evidence of record is in conflict as to whether the Veteran has polymyositis. Essentially, private medical records noted a diagnosis of polymyositis and VA treatment records did not. For example, a January 2012 private medical record noted a diagnosis of polymyositis, which appears to be the earliest diagnosis of such. VA treatment records included a May 2012 note that stated “[n]o evidence of polymyositis” and a November 2014 note from a doctor that “I see no signs of polymyositis.” On the other hand, also of record is a June 2013 letter from Dr. F.C. which stated that the Veteran “was in the military and possibly could of been [] exposed to certain fuels, oils, or lubricants that could possibly have caused his polymyositis.” An April 2015 Family and Medical Leave Act (FMLA) form completed by Dr. F.C. referenced polymyositis. A VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance) dated in September 2017 completed by a private doctor noted a diagnosis of polymyositis in the legs. In review, the Board finds that a VA examination is warranted in this case and remand is therefore required for a VA examination and opinion addressing whether the Veteran has had polymyositis during the appeal period and, if so, an opinion addressing direct service connection, as outlined further in the remand directives below. 4. Service Connection – Right Foot Disability 5. Service Connection – Left Foot Disability The Veteran filed a claim in September 2014 for entitlement to service connection and listed a disability of “Bilateral Feet.” The Veteran is service-connected for neck and lumbar disabilities. The evidence of record reasonably raised the issue of secondary service connection with respect to the neck and/or lumbar disabilities. In this regard, the September 2017 VA Form 21-2680 noted a diagnosis of neuropathy of the left and right feet. A November 2017 private medical record noted a chief complaint of bilateral foot pain. It was noted that the Veteran “stated that he injured his neck and back in the military.” An impression was noted of “G60.9,” which internet research indicates is an ICD-10-CM (the International Classification of Diseases, Tenth Revision, Clinical Modification) code for hereditary and idiopathic neuropathy, unspecified. The November 2017 medical record also stated that the Veteran “was informed that neck and back injuries can cause neuropathic symptoms in his lower extremities.” In review, the Board finds that remand is required for a VA examination and opinion addressing secondary service connection, as outlined further in the remand directives below. In addition, with respect to the left foot, an opinion addressing direct service connection is also warranted because STRs noted treatment for the Veteran’s left foot and, as noted above in the new and material section, evidence indicated arthritis of the left foot. In this regard, a January 1983 STR noted an assessment of a left foot sprain; a May 1985 STR noted a chief complaint of a left big toe injury and noted an assessment of possible sprain (a separate STR included a negative x-ray report); an August 1987 STR noted a chief complaint of foot injury and noted an assessment of contusion left foot; a September 1987 STR noted a chief complaint of left foot with a two week duration and noted an assessment of foot strain (a separate STR included an x-ray report stating “[t]he foot itself is normal in appearance”). 6. Service Connection – Acquired Psychiatric Disorder The Veteran filed a claim in December 2013 and listed a disability of “General anxiety disorder.” Evidence of record noted diagnoses of various acquired psychiatric disabilities, to include generalized anxiety disorder, depressive disorder and adjustment disorder. As such, the Board will characterize the Veteran’s claim broadly as one for entitlement to service connection for an acquired psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Initially, the evidence of record reasonably raised the issue of secondary service connection. In this regard, a January 2015 VA psychology note stated that the Veteran “[r]eports his status has deteriorated with increased anxiety and irritability…Notes that he believes the trigger for the increase in anxiety and irritability is increasing pain levels, particularly in his ankles and knees.” It was also noted that the Veteran “notes an observation that historically, when pain levels have increased, so too have irritability and anxiety” and also noted was “[d]iscussed the empirical relation between chronic pain and depression/anxiety issues, and provided education about the gate control theory of pain, as [the Veteran] does describe potential relevant pain/mood interactions and an increased cognitive focus on his pain.” A May 2018 VA psychiatry note referenced the Veteran as having upcoming shoulder surgery and stated that “[o]verall he is feeling down/sad/negative, primarily due to pain level” and an impression was noted that the Veteran was “with increased anxiety due to health issues and ongoing and increased [signs and symptoms] depression.” The Veteran is service-connected for various musculoskeletal disabilities, to include the bilateral ankles and shoulders and the left knee. In review, the Board finds that remand is required for a VA examination and opinion addressing secondary service connection, as outlined further in the remand directives below. In addition, while on remand, an opinion addressing direct service connection is also warranted. In this regard, the Veteran has provided numerous contentions regarding, essentially, how an acquired psychiatric disability could be related to his active service. First, the Veteran stated that during his active service he witnessed the fetal death of two children. In this regard, in a January 2018 statement he stated that “I have un-ending sadness of this [t]rauma everyday…This sadness is with me and stays with me in my nightmares and lon[e]some days, [e]ven up today. Not a day goes by where I do not think [of the children who died]. I cry about my los[s] every night.” Second, the Veteran referenced suffering a head injury during his active service. In this regard, in a June 2017 statement the Veteran stated “[a] blow to the back of the head around 1981 or 82 in Germany…[Doctor] said he tried to kill you; this has led to failed relationships.” In a January 2018 statement, the Veteran referenced “a hit to the back of my head around 1981 or 82 in Germany…The doctor said that the attacker wanted to kill you with that type of blow.” STRs included an October 1981 x-ray report of the skull (the results noted no significant abnormality) that stated “[s]truck in occipital region [with] wine bottle[,] [complain of] pain[,] large hematoma” and a separate October 1981 STR, with a location noted in Germany, stated that the Veteran “was hit on his head…[with] a bottle.” Third, the Veteran referenced an in-service incident that involved a fellow soldier dying and the Veteran having to perform certain duties afterwards. In this regard, the Veteran submitted detailed statements in February 2017 and January 2018 (dated by the Veteran in October 2016) describing this incident. He referenced that following the death of the fellow soldier abroad, he was required to escort the body back to the United States and talk with the deceased soldier’s family, a task for which he was not trained. He described experiencing depression about this incident. In the February 2017 statement, the Veteran stated that “I believe that I have never gotten over the grief of losing my friend, the grief of accompanying him back home and the grief of talking to the family.” The Veteran also stated that “I have constant nightmares of this event and his family encounter. It leaves me angry and in deep depression. Waking in a bed of sweat and flashbacks of this event. When I wake from the nightmares I get angry and often cannot go back to sleep,” that “[i]t feels like I live this event over and over in my nightmares and waking and still having the horror of seeing his parents in devastating grief. I am often upset about the entire experience and felt that my life was ruined by this experience” and that “I try to talk to my counselors but I will never get rid of this anger and grief.” In addition, a January 2018 (dated June 2016) statement from C.P., noted to be a fellow soldier stationed and deployed with the Veteran, essentially corroborated the Veteran’s report of this incident. C.P. stated that following the fellow soldier’s death, his and the Veteran’s “talks were very sorrowful” and that upon the Veteran’s return from his duties in the United States “[i]t was evident in his demeanor when speaking to him…how painfully stressful this tasking was to him.” Fourth, the Veteran, essentially, referenced experiencing in-service mental health symptoms. In this regard, he stated in a June 2017 statement that he “was sent to anger management while in service” and evidence of record included a June 1993 certificate for completion of anger management class. In addition, STRs included an August 1996 STR that stated that the Veteran “describes feeling jittery at night [with] muscle twitching [and] sometimes hyperventilating” and noted “insomnia thinking about cousin who died of stomach problems [and] feeling of panic especially when home alone.” An assessment was noted of anxiety and a psychiatry consult was referenced, but it is not clear if this was completed as no such records related to this appear to be of record. Also, a February 1997 STR referenced the Veteran having an “‘anxiety attack’” and being given something (the writing was illegible) “to ‘calm him down.’” Additionally, the Veteran has contended, essentially, that in-service complaints and treatment related to chest pain were symptoms related to later diagnosed panic attacks. In this regard, in a June 2017 statement he stated “[e]mergency room, history on while in service think heart attack,” he referenced being kept overnight in two hospitals and he also stated “[m]any emergency room visits with [c]hest discomfort until diagnosis.” In a January 2018 statement, the Veteran stated that “I went to the emergency room twice during service for chest pain. I had repeated episodes of chest pain until I was diagnosed with Panic Attacks by the VA doctor.” Various STRs referenced chest pain, to include the January 1998 retirement Report of Medical History form, on which the Veteran reported ever having or having now shortness of breath; pain or pressure in chest; and palpation or pounding heart. In addition, a June 2015 VA psychiatry note stated that the Veteran “admitted to 11 [emergency room] visits over the past several years due to feeling he was having a heart attack, only to find out he is having anxiety. He did not realize he was having a panic attack” and an assessment was noted of “ongoing anxiety along with depression, with intermittent panic attacks.” Also of record is a June 2017 statement from L.W., who described being “very close” with the Veteran during his active service and that they “dated for about a year and a half.” She essentially corroborated various in-service events reported by the Veteran and provided her own observations of the Veteran. She described being told about by the Veteran about “the loss of two children” and “the loss of a subordinate” solider. She described, essentially, witnessing the Veteran experience a nightmare episode “the first night I stayed to his house” and also that that nightmare episodes “continued throughout our relationship.” She also stated that “I made several trips to the hospital with [the Veteran] due to him having chest pains that lead us to believe he was having a heart attack.” She also described the Veteran having outburst of anger and mood swings. She referenced obtaining a master’s degree in counseling and stated that “[b]eing trained as a mental health professional, I knew that [the Veteran] was experiencing negative consequences due to the missions and duties he performed” in the military and that “I thought he may have been experiencing posttraumatic stress disorder [PTSD]. Regardless of the label, the fact remains that [the Veteran] lost several relationships (his marriage, family members and me) due to his inability to display his emotions in a healthy manner.” L.W. referenced later obtaining a doctorate in counseling psychology and to reconnecting with the Veteran. She stated that the Veteran “informed me that he was finally given a diagnoses of anxiety disorder. Having witnessed his symptoms firsthand and hearing about the trauma he experienced while on active duty, I disagree with that diagnosis. I continue to believe that he in fact has [PTSD].” Also of record is a November 2014 statement from a church Bishop who reported being the Veteran’s pastor “for several years” and referenced “my Graduate Studies in Counseling.” It was stated that “[i]n Premarital Counseling with [the Veteran] during our one on one sessions [the Veteran] has always exhibit some sort of Emotional/Physical/Anxiety and even Anger pertaining to his past military experience.” In review, the Board finds that an opinion addressing direct service connection is warranted in this case, as outlined further in the remand directives below. II. Increased Rating Claims 7. Increased Rating – Left Shoulder Disability 8. Increased Rating – Right Shoulder Disability 9. Increased Rating – Neck Disability 10. Increased Rating – Lumbar Disability 11. Increased Rating – Left Knee Disability 12. Increased Rating – Left Ankle Disability 13. Increased Rating – Right Ankle Disability Upon review, remand is required for new VA examinations for the various musculoskeletal increased rating claims on appeal. The United States Court of Appeals for Veterans Claims (Court) has held that “to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of” 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). The referenced portion of 38 C.F.R. § 4.59 states that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” The Veteran was afforded VA examinations for the musculoskeletal disabilities on appeal in 2014 and 2015 and the prior VA examinations did not comply with Correia and as such, remand is required so that the Veteran may be afforded new VA examinations that contains adequate information pursuant to Correia. In addition, the Court stated in Sharp v. Shulkin, 29 Vet. App. 26 (2017) that “[b]ecause the VA examiner did not...estimate the [V]eteran’s functional loss due to flares based on all the evidence of record-including the [V]eteran’s lay information-or explain why she could not do so, the...examination was inadequate.” The ¬¬¬May 2014 VA back examination report (and May 2014 addendum) did not comply with Sharp in that while flare-ups were noted, the examiner did not adequately explain why the Veteran’s functional loss could not be estimated in terms of the degree of additional range-of-motion loss during flare-ups. The May 2014 VA shoulder examination report (with respect to the right shoulder) and the January 2015 VA knee examination report did not comply with Sharp in that while flare-ups were noted, the examiners did not estimate the Veteran’s functional loss due to flares in terms of the degree of additional range-of-motion loss during flare-ups or explain why such could not be done. As such, while on remand, the VA examination report must also contain adequate information pursuant to Sharp. Also, with respect to the back and neck disabilities, evidence indicated that such may have increased in severity since the last VA examination in May 2014. See October 2016 VA Treatment Note (referencing worsening neck and lower back pain). The current severity of these disabilities will be documented by the new VA examinations on remand. In addition, with respect to the right shoulder disability, evidence indicated that such may have increased in severity since the last VA examination in May 2014 and that the Veteran was scheduled for right shoulder surgery in May 2018. See April 2018 VA Treatment Note (stating that the Veteran “hurt his right shoulder in February”); May 2018 VA Treatment Note (referencing scheduled shoulder surgery). The current severity of this disability will be documented by the new VA examination on remand. 14. Increased Rating – GERD An October 2015 statement of the case (SOC) addressed the issue an increased rating for GERD. Subsequent to this SOC, evidence was associated with the Veteran’s claims file by VA that related to the Veteran’s GERD and at least some of this evidence was received in February 2016, prior to transfer of the case to the Board in June 2016. See April 2015 and October 2015 VA Treatment Notes (containing a review of systems that included gastrointestinal). As such, remand is required for the issuance of a supplemental statement of the case (SSOC) pursuant to 38 C.F.R. § 19.31(b)(1) and 19.37(a). III. Outstanding Records While on remand, outstanding VA treatment records must be obtained (the most recent VA treatment records of record are dated in May 2018). In addition, evidence of record indicated that the Veteran received private (non-VA) medical care. For example, a February 2017 VA treatment note referenced multiple non-VA providers, to include Dr. S.K. (pain management), Dr. O. (primary care physician) and Dr. S. (neurologist). As such, while on remand, the Veteran must be given the opportunity to either provide any outstanding relevant private treatment records or complete a release for such providers; if any releases are returned, VA must attempt to obtain the identified records. The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records from May 2018. 2. Contact the Veteran and request that he either provides any outstanding relevant private treatment records, to include from Dr. S.K. (pain management), Dr. O. (primary care physician) and Dr. S. (neurologist), or completes a release for such providers; if any releases are returned, attempt to obtain the identified records. 3. Afford the Veteran an appropriate VA examination to determine the current severity of the following musculoskeletal disabilities: (a.) Left should disability (b.) Right shoulder disability (c.) Neck disability (d.) Lumbar disability (e.) Left knee disability (f.) Left ankle disability (g.) Right ankle disability With respect to range of motion testing, this must be conducted on active and passive motion and in weight-bearing and nonweight-bearing conditions (pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016)). If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. Further, the examiner must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the Veteran. The examiner must either estimate the Veteran’s functional loss due to flares based on all the evidence of record, including the Veteran’s lay information, or explain why he or she cannot do so. The examiner’s determination in this regard should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). 4. Afford the Veteran a VA examination with respect to his claimed left and right hand disabilities. The examiner must provide an opinion addressing the following: Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any left or right hand disability had its onset during active service or is caused or aggravated by any in-service disease, event, or injury. While review of the entire claims folder is required, attention is invited to the STRs discussed in the body of the remand that referenced in-service treatment related to the Veteran’s hands. For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. 5. Afford the Veteran a VA examination with respect to his claimed polymyositis. The examiner must provide an opinion addressing the following: (a.) During the appeal period (dating to approximately December 2013), has the Veteran had polymyositis? While review of the entire claims folder is required, attention is invited to private medical records, including those referenced in the body of the remand, that noted a diagnosis of polymyositis. (b.) If the Veteran has had polymyositis during the appeal period, whether it is at least as likely as not (i.e., probability of 50 percent or greater) that polymyositis had its onset during active service or is caused or aggravated by any in-service disease, event, or injury. While review of the entire claims folder is required, attention is invited to a June 2013 letter from Dr. F.C., which stated that the Veteran “was in the military and possibly could of been [] exposed to certain fuels, oils, or lubricants that could possibly have caused his polymyositis.” For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. 6. Afford the Veteran a VA examination with respect to his claimed left and right feet disabilities. The examiner must provide an opinion addressing the following: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that left or right foot neuropathy is due to or caused by the Veteran’s service-connected neck and/or lumbar disabilities. (b.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that left or right foot neuropathy has been aggravated (i.e., increased in severity) by the Veteran’s service-connected neck and/or lumbar disabilities. With respect to items “a” and “b”, while review of the entire claims folder is required, attention is invited to November 2017 private medical record that referenced a diagnosis of neuropathy and stated that “neck and back injuries can cause neuropathic symptoms in his lower extremities.” (c.) With respect to the left foot, whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any left foot disability had its onset during active service or is caused or aggravated by any in-service disease, event, or injury. While review of the entire claims folder is required, attention is invited to the diagnosed foot osteoarthritis and to the STRs discussed in the body of the remand that referenced in-service treatment related to the Veteran’s foot. For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. 7. Afford the Veteran a VA examination with respect to his claimed acquired psychiatric disability. The examiner must provide an opinion addressing the following: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any acquired psychiatric disability is due to or caused by the Veteran’s service-connected disabilities. (b.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any acquired psychiatric disability has been aggravated (i.e., increased in severity) by the Veteran’s service-connected disabilities. With respect to items “a” and “b”, while review of the entire claims folder is required, attention is invited to a January 2015 VA psychology note and a May 2018 VA psychiatry note, both discussed in the body of the remand, which reasonably raised the issue of secondary service connection. (c.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any acquired psychiatric disability had its onset during active service or is caused or aggravated by any in-service disease, event, or injury. While review of the entire claims folder is required, attention is invited to the Veteran’s numerous contentions regarding, essentially, how an acquired psychiatric disability could be related to his active service. Such contentions, as well as supporting evidence, were discussed in detail in the body of the remand and generally included: a. The in-service fetal death of two children. b. An in-service head injury. c. An in-service incident that involved a fellow soldier dying and the Veteran having to perform certain duties afterwards. d. Experiencing in-service mental health symptoms. For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Hoopengardner, Counsel