Citation Nr: 18143601 Decision Date: 10/23/18 Archive Date: 10/19/18 DOCKET NO. 15-18 751A DATE: October 23, 2018 ORDER The application to reopen the claim of entitlement to service connection for obstructive sleep apnea is granted. The application to reopen the claim of entitlement to service connection for right wrist carpal tunnel syndrome (CTS) is granted. The application to reopen the claim of entitlement to service connection for a left knee disorder is granted. The application to reopen the claim of entitlement to service connection for a right hip disorder is granted. The application to reopen the claim of entitlement to service connection for hemorrhoids is denied. The application to reopen the claim of entitlement to service connection for heart myopathy is denied. The application to reopen the claim of entitlement to service connection for colon polyps is denied. The application to reopen the claim of entitlement to service connection for right shoulder arthritis is denied. Service connection for obstructive sleep apnea is granted. Service connection for a right wrist disorder, to include CTS, is granted. Service connection for a left wrist disorder, to include CTS, is granted. Service connection for bilateral hearing loss is denied. Service connection for sinusitis is denied. A rating of 20 percent, but no higher, for right lower extremity radiculopathy is granted. A rating of 20 percent, but no higher, for left lower extremity radiculopathy is granted. REMANDED Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. Entitlement to service connection for a bilateral elbow disorder is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for left upper extremity radiculopathy is remanded. FINDINGS OF FACT 1. In an unappealed July 2012 rating decision, the RO denied service connection for obstructive sleep apnea (OSA), CTS of the right wrist, hemorrhoids, heart myopathy, colon polyps, right shoulder arthritis, left knee arthritis, and right hip arthritis because there was no evidence that these disabilities were related to service. 2. Evidence received since the July 2012 rating decision is new and material and raises a reasonable possibility of substantiating the claims of entitlement to service connection for OSA, right wrist CTS, left knee arthritis, and right hip arthritis. 3. Evidence received since the July 2012 rating decision is not new and material and does not raise a reasonable possibility of substantiating the claims of entitlement to service connection for hemorrhoids, heart myopathy, colon polyps, and right shoulder arthritis. 4. The Veteran’s currently diagnosed OSA was aggravated by his service-connected rhinitis disability. 5. The Veteran’s right and left wrist CTS is related to service. 6. The Veteran does not have a hearing loss disability for VA compensation purposes. 7. The preponderance of the evidence shows that the Veteran does not have a diagnosis of sinusitis; his symptoms have been attributed to the already service-connected rhinitis disability. 8. The Veteran’s right and left lower extremity radiculopathy disability more nearly approximates “moderate” neurological symptoms. CONCLUSIONS OF LAW 1. The July 2012 rating decision denying service connection for OSA, right wrist CTS, hemorrhoids, heart myopathy, colon polyps, right shoulder arthritis, left knee arthritis, and right hip arthritis is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2017). 2. New and material evidence has been received since the last denial of service connection for OSA and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 3. New and material evidence has been received since the last denial of service connection for right wrist CTS and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 4. New and material evidence has been received since the last denial of service connection for left knee arthritis and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 5. New and material evidence has been received since the last denial of service connection for right hip arthritis and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 6. New and material evidence has not been received since the last denial of service connection for hemorrhoids; the application to reopen the claim is denied. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 7. New and material evidence has not been received since the last denial of service connection for heart myopathy; the application to reopen the claim is denied. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 8. New and material evidence has not been received since the last denial of service connection for colon polyps; the application to reopen the claim is denied. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 9. New and material evidence has not been received since the last denial of service connection for right shoulder arthritis; the application to reopen the claim is denied. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 10. The criteria for service connection for OSA as secondary to the service-connected rhinitis disability are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 11. The criteria for service connection for right wrist CTS are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 12. The criteria for service connection for left wrist CTS are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 13. The criteria for service connection for a bilateral hearing loss disability are not met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2017). 14. The criteria for service connection for sinusitis are not met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 15. The criteria for a 20 percent rating, but no higher, for right lower extremity radiculopathy are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8520 (2017). 16. The criteria for a 20 percent rating, but no higher, for left lower extremity radiculopathy are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1981 to August 2001. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a December 2013 and February 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran failed to report to a Board hearing scheduled in September 2018. As the record does not contain explanation as to why he failed to report to the hearing, nor did he request to reschedule the hearing, the Board deems the Veteran’s request for such a hearing to be withdrawn. See 38 C.F.R. § 20.704 (2017). New and Material Evidence—Laws and Analysis The Veteran was initially denied service connection for OSA, right wrist CTS, hemorrhoids, heart myopathy, colon polyps, right shoulder arthritis, left knee arthritis, and right hip arthritis in a July 2012 rating decision because there was no evidence that his disabilities were related to service or that a diagnosis was present. The Veteran was notified of the rating decision, but did not appeal the decision. As such, the July 2012 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A claim will be reopened in the event that new and material evidence is presented. 38 U.S.C. § 5108. Because the July 2012 rating decision was the last final disallowance, the Board must review all of the evidence submitted since that rating decision to determine whether the Veteran’s claims for service connection should be reopened and re-adjudicated on a de novo basis. Evans v. Brown, 9 Vet. App. 273 (1996). If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Board shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. With regard to petitions to reopen previously and finally disallowed claims, the Board must conduct a two-part analysis. First, the Board must determine whether the evidence presented or secured since the prior final disallowance of the claim is “new and material.” Second, if the Board determines that the evidence is “new and material,” it must reopen the claim and evaluate the merits of the claim in view of all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). Section 3.156(a) provides as follows: A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a) (2017). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). As it pertains to the claims to reopen service connection for OSA, right wrist CTS, left knee arthritis, and right hip arthritis, the evidence received subsequent to the July 2012 rating decision includes, in pertinent part, a June 2014 VA private medical examination by Dr. Ellis. The report indicated that the drainage from the Veteran’s sinuses as well as thickening of the mucous membranes in the back of his throat and upper respiratory tract had “contributed to and aggravated his sleep apnea.” Moreover, Dr. Ellis opined that the Veteran’s right wrist CTS was caused by “repetitive typing on a straight keyboard on the AWACS planes for many years.” Dr. Ellis also diagnosed the Veteran with “traumatic arthritis" of the left knee and opined that the left knee disability was related to carrying equipment, standing, squatting, and getting in and out of airplanes during service. A diagnosis of right hip traumatic arthritis was also noted. Dr. Ellis indicated that the tightness in his back and sacroiliac ligaments caused tightness of the buttock muscles “causing increased abnormal stresses from the hip joints causing traumatic arthritis in both hips.” The Board finds that this evidence is new and material within the meaning of applicable law and regulations because the opinion by Dr. Ellis is new, as such evidence was not of record prior to the issuance of the July 2012 rating decision, and it relates to the unestablished element of a relationship between the claimed disorders and a service connected disability or as directly related to service. As such, the claims are reopened. As it pertains to the claims for service connection for hemorrhoids, heart myopathy, colon polyps, right shoulder arthritis, the Board finds that additional evidence received since the July 2012 rating decision is not new and material. In this regard, the June 2014 report from Dr. Ellis does not address the Veteran’s hemorrhoids, colon polyps, right shoulder, or a heart disorder. Further, VA and private treatment records received following the July 2012 rating decision are absent for any indication that the Veteran’s hemorrhoids, colon polyps, right shoulder, and/or heart disorders were incurred in service or were otherwise related to service. For these reasons, the Board concludes that new and material evidence has not been received to reopen the claims for service connection for hemorrhoids, heart myopathy, colon polyps, and right shoulder arthritis. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) (2017) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57(1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382(1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner’s opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. OSA On review of all evidence of record, the Board finds that the weight of the evidence supports a finding that the Veteran’s sleep apnea is aggravated by his service-connected rhinitis disability. There is evidence of a current disability. The Veteran has been diagnosed with obstructive sleep apnea and has been prescribed a CPAP machine. See April 2010 VA treatment record. The evidence includes a June 2014 VA private medical examination by Dr. Ellis. The report indicated that the drainage from the Veteran’s sinuses as well as thickening of the mucous membranes in the back of his throat and upper respiratory tract had “contributed to and aggravated his sleep apnea.” There are no contradictory medical opinions of record. For these reasons, the Board finds that the weight of the evidence supports the claim that the Veteran’s OSA is, at least in part, aggravated by his service-connected rhinitis disability. Resolving all reasonable doubt in the Veteran’s favor, the Board finds that service connection for OSA is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Right and Left Wrist CTS On review of all evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s bilateral wrist CTS is related to service. Initially, the Board finds that the Veteran has been diagnosed with bilateral wrist CTS. See April and June 2003 VA treatment records (noting right and left wrist CTS with brace). The evidence includes a June 2014 VA private medical examination by Dr. Ellis. The report indicated that the Veteran served in the Air Force for 20 years as an air surveillance technician in AWACS (Airborne Warning And Control System). Dr. Ellis confirmed a diagnosis of CTS and stated that the Veteran’s bilateral wrist medial epicondylitis and ulnar nerve impingement of cubital tunnel syndrome were caused by “repetitive typing on a straight keyboard on the AWACS planes for many years.” Similarly, the tendinitis in his wrists and impingement of the ulnar nerves at the wrist, (i. e., CTS) was also caused by many years of repetitive typing on a straight keyboard on the AWACS planes. There are no contradictory medical opinions of record. For these reasons, the Board finds that the weight of the evidence supports the claim that the Veteran’s bilateral wrist CTS is related to service. Resolving all reasonable doubt in the Veteran’s favor, the Board finds that service connection for right wrist CTS is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Hearing Loss Impaired hearing is considered a disability for VA compensation purposes when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Court has held that a veteran may establish the required nexus between current hearing loss disability and his term of military service if he can show by competent evidence that his hearing loss disability resulted from the in-service acoustic trauma even where the hearing loss disability does not arise in service. Godfrey v. Derwinski, 2 Vet. App. 352 (1992). Upon review of all the evidence of record, the Board finds that the Veteran does not have a hearing loss disability for VA compensation purposes. VA treatment records include a January 2010 VA audiology consultation note. During the evaluation, puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz in the right ear were 515, 15, 15, 20, and 20 respectively. In the left ear, puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz were 10, 15, 15, 20, and 20 respectively. Speech recognition scores for both ears was “excellent.” In a February 2015 VA audiological examination report, puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz in the right ear were 10, 10, 10, 10, and 15 respectively. In the left ear, puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz were 5, 10, 10, 10, and 10, respectively. Speech recognition for both ears was 98 percent. The audiogram results shown above do not meet the definition of hearing loss as required by 38 C.F.R. § 3.385. The remaining evidence of record does not demonstrate a current bilateral hearing loss disability as required by 38 C.F.R. § 3.385. Because the evidence does not show that the Veteran’s hearing loss is to a disabling degree as required under 38 C.F.R. § 3.385, the weight of the evidence demonstrates that the Veteran’s bilateral hearing loss has not met the threshold to establish current hearing loss “disability,” and the claim must be denied. The Court has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer, 3 Vet. App. 225; see also Rabideau, 2 Vet. App. 143 -44. Because the preponderance of the evidence is against the claim for service connection for bilateral hearing loss, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Sinusitis Service treatment records show that the Veteran was seen for sinusitis, bronchitis, rhinitis, post-nasal drip, and pharyngitis during service. The Veteran has already been awarded service connection for rhinitis. See July 2015 rating decision. This award was based, in part, on a June 2015 VA medical opinion where it was noted that the Veteran’s allergic rhinitis was “a continuation of the same condition and its symptoms that were present while the Veteran was in in the Air Force.” The threshold element is evidence of a current disability. A February 2015 VA examination report diagnosed the Veteran with allergic rhinitis and specifically indicated that the Veteran did not have chronic sinusitis. X-rays showed evidence of well-aerated and clear sinuses. VA treatment records do not contain any diagnosis of sinusitis. In support of his claim, the Veteran submitted a private medical examination from Dr. Ellis. During the evaluation, it was noted that the Veteran had multiple upper respiratory infections, sinus infections, and fullness in his nose. Since service, the Veteran had continued to have the same symptoms in his sinuses with drainage and nasal fullness. Dr. Ellis diagnosed the Veteran with pansinusitis. Although Dr. Ellis diagnosed the Veteran with a type of sinusitis, the Board finds the February 2015 VA examination report more probative as it pertains to the Veteran’s diagnosis. In this regard, unlike Dr. Ellis (who only performed a physical examination of the Veteran), the VA examiner reviewed X-rays of the Veteran’s sinuses, which reasonably would provide more objective evidence of the Veteran’s condition. Dr. Ellis’ examination included just a visual examination of the Veteran’s ears, nose, and throat. For these reasons, the Board finds that the most probative evidence of record demonstrates a diagnosis of rhinitis, but not sinusitis. As such, the preponderance of the evidence shows that the Veteran does not have a diagnosis of sinusitis; his symptoms have been attributed to the already service-connected rhinitis disability Because the preponderance of the evidence is against the claim for service connection for sinusitis, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Laws and Analysis for Right and Left Radiculopathy Disability Rating The Veteran’s radiculopathy has been rated under Diagnostic Code 8520 (for incomplete paralysis of the sciatic nerve). Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis, 20 percent for moderate incomplete paralysis, 40 percent for moderately severe incomplete paralysis, 60 percent for severe incomplete paralysis with marked muscular atrophy, and 80 percent for complete paralysis where the foot dangles and drops, with no active movement possible of muscles below the knee and flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a (2017). Upon review, the Board finds that the evidence weighs in favor of a finding that the criteria for a 20 percent rating, but no higher, for the right and left lower extremity radiculopathy are met for the entire increased rating period on appeal. During a December 2013 VA spine examination, the examiner indicated that the Veteran had “moderate” symptoms of pain, paresthesias, and numbness in both lower extremities. The examiner specifically noted that the Veteran had “moderate” incomplete paralysis of the sciatic nerve root in both lower extremities. The remaining evidence of record, to include the private medical examination by Dr. Ellis in June 2014, does not address the severity of the Veteran’s radiculopathy. For these reasons, the Board finds that a 20 percent rating, but no higher for moderate incomplete paralysis of the sciatic nerves (right and left lower extremities) is warranted. REASONS FOR REMAND Left Knee Disorder and Right Hip The Board notes that in the July 2012 rating decision, the RO denied the Veteran’s claim for a left knee and right hip arthritis as there was no diagnosed arthritis disability pertaining to these joints. As discussed above, the evidence now includes a June 2014 private medical examination from Dr. Ellis. The report indicated that the Veteran was diagnosed with “traumatic arthritis” of the left knee and right hip; however, there is no indication that X-rays or other diagnostic imaging testing was conducted. This is especially problematic since past VA knee examination reports have not include a diagnosis pertaining to the left knee or right hip. A VA MRI report dated in 2011 showed “unremarkable sacroiliac joints” and a possible femoral acetabular impingement. For these reasons, the Board finds that new VA examinations are required to determine whether the Veteran has a left knee and/or right hip disability and, if so, whether it they are related to service or to a service-connected disability. Bilateral Elbow Disorder The June 2014 private medical examination from Dr. Ellis diagnosed the Veteran with bilateral elbow medial epicondylitis (a. k. a, tennis elbow). The report indicated that by the time the Veteran retired from service in 2001, he was having pain in both elbows radiating into the ring and little fingers. Dr. Ellis stated that the Veteran had bilateral cubital tunnel syndrome and CTS with ulnar nerve impingement from his elbows into the ring and little fingers. The Board notes that the Veteran has been awarded service connection for right and left upper extremity radiculopathy and bilateral CTS (granted herein). The Board finds that an examination is required to determine whether the Veteran has a separate and distinct elbow disability or whether his symptoms are attributable to his service-connected radiculopathy and/or CTS. Cervical Spine and Left Upper Radiculopathy Disorders The Veteran seeks service connection for a cervical spine disability and associated left upper extremity radiculopathy. The evidence includes the June 2014 private medical examination from Dr. Ellis. At that time, Dr. Ellis diagnosed the Veteran with degenerative arthritis of the cervical spine. Further, it was noted that the Veteran had fallen in 1997 causing injury to his thoracic back. At the time of the injury, it was noted that the Veteran did not have pain the cervical spine, “but within a few years” he began to have tightness between his shoulders and neck. It was then noted that the continued spasms in the thoracic paraspinous muscles “caused tightness his neck and degenerative arthritis in his neck.” The Board finds that the Veteran should be afforded a VA examination for several reasons. First, although Dr. Ellis diagnosed the Veteran with degenerative arthritis of the spine, there is no indication in the June 2014 examination report that objective testing was conducted, such as x-rays. Further, an October 2013 private MRI of the cervical spine shows a diagnosis of degenerative disc disease, but no diagnosis of arthritis. Moreover, Dr. Ellis did not provide a rationale as to how muscle spasms in the thoracic spine could result in degenerative arthritis in the cervical spine. Clarification is therefore needed. The Veteran’s claim for left upper extremity radiculopathy is intertwined with the cervical spine disorder; as such, this issue is also remanded. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records since June 2015 and associate them with the electronic claims file. 2. Schedule the Veteran for a VA examination of the left knee, to include x-rays. The claims file must be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. (a.) The examiner should list all diagnosis pertaining to the left knee. (b.) For each diagnosis, state whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s left knee disorder was incurred in service or is related to service. (c.) A complete rationale should be provided for the opinions given. 3. Schedule the Veteran for a VA examination of the right hip, to include x-rays. The claims file must be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. (a.) The examiner should list all diagnosis pertaining to the right hip. (b.) For each diagnosis, state whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s right hip disorder was incurred in service or is related to service. (c.) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s right hip disorder is either caused or aggravated by his service-connected thoracolumbar spine disability. (d.) A complete rationale should be provided for the opinions given. 4. Schedule the Veteran for an appropriate VA examination to address his bilateral elbow disorders. The claims file must be reviewed in conjunction with the examination. All indicated tests, to include any appropriate neurological testing, should be conducted and the results reported. (a.) The examiner is also asked to specifically address the Veteran’s symptoms pertaining to his elbows, and state whether such symptomatology is the result of a separate and distinct disability, or whether it is duplicative of or overlapping with the symptomatology of the already service-connected bilateral upper extremity radiculopathy and/or bilateral carpal tunnel syndrome disabilities. (b.) A complete rationale should be provided for the opinions given. 5. Schedule the Veteran for a VA examination of the cervical spine, to include x-rays. The claims file must be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. (a.) The examiner should list all diagnosis pertaining to the cervical spine and any associated neurological impairments. (b.) For each diagnosis, state whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s cervical spine disorder was incurred in service or is related to service. (c.) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s cervical spine disorder is either caused or aggravated by his service-connected thoracolumbar spine disability. (d.) A complete rationale should be provided for the opinions given. (Continued on the next page)   6. Thereafter, readjudicate the claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Casadei, Counsel