Citation Nr: 18144451 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 14-07 850 DATE: October 25, 2018 ORDER Entitlement to service connection for bilateral shin splints is denied. Entitlement to service connection for a bilateral hearing loss disability is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for carpal tunnel syndrome is granted. Entitlement to an evaluation in excess of 0 percent for nondisplaced fracture, left fifth phalanx is denied. Entitlement to an evaluation in excess of 30 percent for unspecified anxiety disorder with alcohol use disorder is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to an evaluation in excess of 10 percent for right anterior cruciate ligament tear, status post-surgical repair is remanded. FINDINGS OF FACT 1. Bilateral shin splints were not manifest during service and are not attributable to service. 2. A bilateral hearing loss disability is due to the Veteran’s exposure to excessive noise levels in service. 3. Tinnitus is attributable to service. 4. Carpal tunnel syndrome is attributable to service. 5. Nondisplaced fracture of the left fifth phalanx does not result in moderate impairment associated with the malunion, or nonunion of the tarsal or metatarsal bones of the foot. 6. Other specified anxiety disorder with alcohol use disorder is manifested by symptoms such as anxiety, sleep impairment, self-medication with alcohol, and anger and irritability, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. Shin splints were not incurred in service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 2. A bilateral hearing loss disability was incurred in service. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2017). 3. Tinnitus was incurred in service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017) 4. Carpal tunnel syndrome was incurred in service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017) 5. The criteria for a compensable rating for nondisplaced fracture, left fifth phalanx have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.31, 4.40, 4.45, 4.71a, Diagnostic Codes 5283 (2017). 6. The criteria for a disability rating in excess of 30 percent for other specified anxiety disorder with alcohol use disorder have been not met. 38 U.S.C. § 1155 (2012); C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9410 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1994 to April 1998. The Veteran had additional service in the U.S. Marine Corps Reserve from April 1998 to February 2002 and the Army National Guard from July 2006 to August 2012. The Board remanded the claim for the knees, anxiety disorder, and the shoulders in December 2017. The Board requested that a new VA examination of the right knee disability be obtained for compliance with Correia v. McDonald, 28 Vet. App. 158 (2016) and then for the AOJ to consider whether extraschedular referral for the right knee is warranted. The Board noted that if a left knee disability was found, that an examination for purposes of determining etiology be undertaken. VA treatment records had also been associated with the file without receipt of a waiver of AOJ review and a remand was necessary for issuance of an SSOC. With regards to the claims being decided here, all development requested in the December 2017 remand has been completed. For these reasons, the Board’s prior remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As noted in the relevant section, several issues are remanded for compliance with the prior Board remand. Service Connection Service connection may be established for disability resulting from personal injury or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110 (2012). To establish a right to compensation for a present disability, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); see also Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511–12 (1995). For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Bilateral shin splints The Veteran contends his shin splints occurred are due to service. Service treatment records show a complaint of shin pain and diagnosis of bilateral shin splints in June 1994. X-rays were noted as normal. A separation report of medical examination dated in February 1998 noted the lower extremities were normal. A report of medical history at separation the same month noted yes for broken bones and swollen joints, but the Veteran reported this response was related to the shoulders and right foot. The Veteran’s report of medical history at enlistment in the National Guard in July 2006 denied any relevant problems with lower extremities, except for a foot fracture at age 18. The medical examination for the National Guard that same month showed the Veteran’s lower extremities were clinically normal. The Veteran had a VA examination of the knees and lower leg in April 2016. While the Veteran had reported issues with the knees as well as meniscal tear and debridement and anterior ligament tear, but the examiner checked no for shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or other tibial or fibular impairment. The first post-service report of ongoing shin splints was the claim filed by the Veteran’s representative in November 2016. The Veteran had an additional VA examination in February 2018, with report dated in March 2018. The opinion states the Veteran had one complaint of shin splints in 1994, but separation examination had no complaints of shin splints. The next complaint of shin splints was during the VA examination. Therefore, it was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The Veteran’s private, National Guard, and VA treatment records do note pain and other issues of the knees, including arthralgia, along with an anterior cruciate ligament tear and pain in joint involving ankle and foot, predominately on the right. These issues are addressed elsewhere in this decision or the remand. Excepting one mention of pretibial pain in a VA treatment primary care note dated in July 2017, which had existed for about three weeks according to the note, there is no reports of tibial pain or shin splints in post-service medical records until the VA examination. The Board acknowledges that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran is competent to report pain and experiencing ongoing shine pain since service. Here, however, such statements are not credible. The Veteran denied issues in the relevant areas or otherwise having pain associated with shin splints in service, including at separation. The Veteran was clinically normal in the relevant areas and shin splints were not noted in the notes section on his separation examination. The Veteran had multiple years of treatment records, which are negative for any reports of issues with pain specifically related to the shin or tibia or shin splints generally. Therefore, the Veteran’s statements of continuous pain since service are not credible and contradict the medical evidence of record. Therefore, his statements are entitled to low probative value. In contrast, the VA examiner found there was no causal relationship between his current shin splints and the shin splints reported in service. The Veteran had only one report of shin splints in service and multiple years of medical records that did not note shins splints. The evidence of record, which the examiner reviewed, attests to normal findings in service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Consequently, the Board gives more probative weight to the VA opinion. In short, while the Veteran had shin splints noted in service, they resolved. In multiple examinations in service, both active duty and in the National Guard, and on his reports of medical history, no relevant issues were reported. There is no competent evidence of further shin splints or leg pain until many decades post service. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for shin splints. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Hearing loss disability The Veteran reports his bilateral hearing loss is due to exposure to loud noises in service. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. The Veteran’s February 1998 separation examination noted the Veteran’s ears were normal. An audiometer noted hearing was largely normal. On the Veteran’s separation report of medical history, he denied wearing a hearing aid or hearing loss. The Veteran’s National Guard enlistment examination in July 2006, which noted some hearing loss in both right and left ears, (largely in 4000 Hertz or more range worse of the left). The Veteran’s left ear had an auditory threshold in the 4000 Hertz range was 50 decibels and, therefore, already qualified a disability for VA purposes for that ear. The Veteran was only about 30 years old at the time of this enlistment. A February 2010 National Guard hearing conservation disposition associated with his service records note the Veteran had high-frequency hearing loss (mainly 40 decibels or above in the range of 4000 Hertz or more, worse on left). Additional National Guard audiograms in February 2011 and April 2012 noted increased hearing loss in both ears. VA treatment records note the Veteran uses hearing aids and his hearing was listed as “stable” in 2010.   The Veteran had a VA contractor examination in February 2018, dated in March 2018, with puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 LEFT 15 15 15 45 70 RIGHT 15 15 10 40 40 Speech discrimination (Maryland CNC) was 100 percent in right ear and 94 percent in left ear. Diagnosis was bilateral sensorineural hearing loss in the 500-4000 Hz and 6000 Hz or higher frequency ranges. The examiner stated she could not determine a medical opinion regarding the etiology of the Veteran’s ear hearing loss without resorting to speculation. The examiner listed, as her rationale, that there was a lack of audiometric data from 1998 and 2006. The Veteran’s hearing was normal at the time he originally enlisted in 1994. The Veteran denied any significant noise exposure outside the military. The Veteran reported a history of in-service noise exposure, including weapons, artillery, explosions, and trucks. In February 2010, the next time he was tested, hearing loss was present. Hearing loss had progressed on retesting in February 2011 and April 2012. The examiner stated the lack of testing in-between 1998 and February 2010 would make it extremely difficult to pinpoint the cause of the Veteran’s hearing loss. The examiner stated there was no way to confirm whether hearing loss was or was not the result of his military service. The Veteran has a bilateral hearing loss disability per VA regulations. The question of is in relative equipoise regarding nexus to service. The Board notes that the 2018 examination made several errors, such as stating there was no exit audiogram in 1998 or at the National Guard enlistment in 2006. Notwithstanding this, there is enough evidence of record to grant service connection. The Board finds that the Veteran was likely was exposed to significant levels of acoustic noise in service, as the Veteran reported a variety of different noise exposures. The Veteran competent and credible reporting such exposure. His primary specialty was logistics vehicle system operator and motor vehicle operator, which, at the very least, would require being around loud engines and motor vehicle noise. Hearing loss that qualified as a disability was documented as early as 2006. The examiner stated the Veteran had no other exposure to loud noises and the Board accepts this finding. Accordingly, giving the Veteran the benefit of the doubt, the Board finds that a bilateral hearing loss disability is due to service and the claim is therefore granted. 3. Tinnitus The Veteran contends his tinnitus is caused by in-service exposure to hazardous noises. However, the Veteran stated he was not sure when it began and tinnitus was intermittent. The examiner (same examination as listed in the bilateral hearing section above) noted that that the claimant’s tinnitus could be caused by exposure to loud noise while in the military, but she could not state for sure. She additionally stated that tinnitus is possibly caused by his medication, but she did not know what medications the Veteran took. However, on the etiology of tinnitus section, she reported the Veteran’s tinnitus is at least as likely as not (50% probability or greater) a symptom associated with hearing loss. Given the nature of the disability and the examiner’s positive opinion regarding tinnitus being attributable to bilateral hearing loss and hearing loss being due to service, service connection for tinnitus is also warranted. 4. Carpal tunnel syndrome The Veteran claims carpal tunnel syndrome as due to service. A March 1997 service record indicates that the Veteran had episodic shooting pain, throbbing pain, in the wrist with heavy lifting and working out. A January or June 1997 service note also seems to reference numbness and tingling in the hand. Review of the medical records showed a diagnosis of carpal tunnel syndrome in May 2015. According to VA treatment records, the Veteran was diagnosed with carpal tunnel syndrome after reporting numbness in his hands. Review of earlier VA records notes that hand pain and numbness had been noted in earlier treatment records. For example, an October 2011 VA rheumatology consultation note reported hand pain hand on and off for years, difficulty holding things, and limiting hand activity. Gripping things has been difficulty and his hands lock up. Occasionally the Veteran noticed swelling of his hands. The Veteran had a VA examination in February 2018, with the examination report dated in March 2018. The examiner’s opinion stated review of the medical records showed a diagnosis of carpal tunnel syndrome in May 2015. During his service, the examiner noted the Veteran had throbbing pain in his right hand in March 1997. The examiner stated that it was likely that the Veteran’s symptoms began in-service with the high demand of use of his hands and wrist and the insidious nature of the progression of carpal tunnel syndrome. However, given the gap in treatment records, the examiner stated she could not state whether it was a chronic disability which started in service and whether it was more likely than not due to service. The VA examiner stated the Veteran’s symptoms started in service, although she relied upon a gap in medical treatment records and the lack of chronicity in her rationale, which was negative regarding nexus. The examiner’s medical opinion was that the symptoms of his current carpal tunnel syndrome started in service. VA and service treatment records support such an assessment, as the Veteran reported multiple year symptoms later identified as carpal tunnel in 2011 and service record contain reports of similar on-and-off symptoms. Service connection is therefore warranted. Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R., Part 4. The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury. 38 U.S.C § 1155; 38 C.F.R. § 4.1. If the evidence for and against a claim is an equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinksi, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). 5. Nondisplaced fracture, left fifth phalanx The Veteran is rated at a 0 percent (noncompensable) rating for the left foot nondisplaced fracture, fifth phalanx under Diagnostic Code 5283. Pursuant to Diagnostic Code 5283, a 10 percent rating is warranted for moderate impairment associated with the malunion, or nonunion of the tarsal or metatarsal bones of the foot. A 20 percent rating is warranted for moderately severe impairment associated with the malunion, or nonunion of the tarsal or metatarsal bones of the foot. A 30 percent rating is warranted for severe impairment associated with the malunion, or nonunion of the tarsal or metatarsal bones of the foot. A note following Diagnostic Code 5283 provides that a 40 percent rating will be assigned if there is actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5283. 38 C.F.R. § 4.31 states in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. The Veteran had a VA contractor examination in February 2018, with an examination report dated in March 2018. This examination noted the Veteran had a nondisplaced fracture, left fifth phalanx, which occurred in 1995. The Veteran did not report pain, flare-ups, functional loss, or other complaints or evidence of pain. The examiner listed as not affected for both left and right foot severity. The examiner did report occasional use of a brace, but this was for carpal tunnel syndrome. There are VA treatment notes of foot pain, but, based on the negative findings in the February 2018 VA examination, these complaints do not seem to be due to nondisplaced fracture of the left fifth phalanx as opposed to other disabilities effecting the foot. As Diagnostic Code 5283 does not provide a noncompensable evaluation, a noncompensable disability rating is assigned when the requirements for a compensable evaluation are not met. In this case, the Veteran has not satisfied any of the threshold criteria for a compensable disability rating, and therefore, a noncompensable disability rating is warranted. The Veteran’s noncompensable rating accurately contemplates his (lack of) symptomatology. 38 C.F.R. § 4.31. 6. Anxiety disorder The Veteran’s unspecified anxiety disorder with alcohol use disorder is rated at 30 percent disabling. The Veteran is rated under Diagnostic Code 9413, unspecified anxiety disorder. Diagnostic Code 9413 (Unspecific anxiety disorder) is rated using the General Rating Formula for Mental Disorders (General Formula). The General Rating Formula for Mental Disorders provides that mental disorders are to be rated under 38 C.F.R. § 4.130 as follows: 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with normal retinue behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often,) chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 50 percent disabled for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened effect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or name. The “such symptoms as” language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means “for example” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). There are notes of the Veteran being anxious or having anxiety several times in treatment records. Except for these notes and some positive screens in alcohol abuse evaluations, the Veteran’s treatment records do not record treatment or medication for an anxiety disorder, alcohol abuse disorder, or any other related mental health issues. The Veteran was reported to be unemployed, but this was reportedly due to some difficulty with his hands and there is no evidence that this was due to an anxiety disorder. The Veteran had a VA examination in April 2016. The examiner reported the Veteran diagnosis was anxiety symptoms, including worry, loss of sleep, irritability, and panic attacks with alcohol use secondary to anxiety as a form of self-medication. The Veteran reported he had panic experiences in crowds and shakiness. The Veteran reported issues with anger, including irritable behavior and angry outbursts, and difficulty falling and staying asleep, averaging 4-5 hours of sleep per night. The examiner reported the Veteran had anxiety with panic attacks weekly or less often and chronic sleep impairment. The examiner noted that the Veteran’s affect, speech, thought processes, concentration, memory, insight, and judgement were normal or intact. There was no evidence of psychosis. The Veteran denied homicidal or suicidal ideation. The examiner noted that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran reported having a small group of friends. He reported being divorced, but nothing to suggest his divorce was due to an anxiety disorder or alcohol use disorder. The Veteran’s representative, in a November 2016 statement, reported the Veteran had daily panic attacks, mood disturbances, not being social, irritability, not liking being around people, memory problems, and decreased concentration. The Board notes that some of these symptoms are consistent with the VA examination; such as mood disturbances, not being social, irritability, and not liking being around people. The reports of daily panic attacks and memory and concentration problems are specifically contradicted by the examiner in the April 2016 examination. While these symptoms would be lay observable, and therefore the Veteran would be competent to report these issues, the Board finds them not credible, given the total lack of treatment or notations for panic attacks or memory and concentration issues or mental health problems more generally. Additionally, upon examination in April 2016, the Veteran was found to have intact memory and concentration. Therefore, such a statement is given little weight compared with the more probative medical examination and treatment records, which were negative for these symptoms. Further, there is still no showing of occupational and social impairment with reduced reliability and productivity due to such symptoms. The Veteran has not had the symptoms contemplated or more nearly approximated by a 50 percent or higher rating. The Board finds that the overall severity, frequency, and duration of the Veteran's symptoms are not on par with the level of severity contemplated by disability ratings in excess of 30 percent. Specifically, while the Veteran reported anger issues, panic attacks (weekly or less often), sleep impairment, and self-medication with alcohol, there is no showing of reduced reliability and productivity due to symptoms such as flattened affect, abnormal speech, memory impairment, disturbances of motivation or mood, panic attacks more than once a week, difficulty in understanding complex commands, or difficulty in establishing and maintaining effective work and social relationships. In conclusion, the Board finds that, throughout the appeal period, a disability rating of 30 percent is warranted for the Veteran’s service-connected anxiety disorder. The preponderance of the evidence is against a rating in excess of 30 percent. Neither the Veteran nor the representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Per the Board’s remand, the Veteran was scheduled for several VA examinations in December 2017, but there is no evidence that either he or the representative were notified of this, and the Veteran was listed as a no show for these examinations. VA treatment records note the Veteran was being treated for severe Lyme disease at the time. An SSOC was issued in January 2018. The Veteran was successfully scheduled for several VA examinations in February 2018, with reports dated in March 2018, but no corresponding SSOC issue for the below disabilities. Additionally, the examinations and SSOC did not provide requested opinions or considered requested development. 1. & 2. Bilateral shoulder disability Both service and VA treatment records report repeated treatments for shoulder pain and treatment in service records, including that he had a torn labrum in the right shoulder in service and current shoulder pain with supraspinatus muscle involvement. The only VA examination noted the Veteran had pain, which caused physical limitations, but the examiner’s opinion was unclear, suggesting that the Veteran’s shoulders were normal, and stated that there was not enough medical documentation to determine a timeline on these conditions, but did not record or consider the Veteran’s statements. A new medical examination is necessary to determine existence of a disability and etiology. 3. Left knee The prior Board remand requested that, if a left knee disability was found, an opinion regarding whether such a disability was caused or aggravated by a right knee disability should be provided. A VA contractor examination in February 2018, with report dated in March 2018, for the lower leg and knee found the Veteran had abnormal or outside normal range of motion due to pain with evidence of crepitus and pain, weakness, and lack of endurance. No opinion was provided regarding etiology. 4. Right anterior cruciate ligament tear, status post-surgical repair An additional examination with findings relevant to knees – although focused on shin splints – was undertaken in February 2018 with the examination report dated in March 2018, but the SSOC for the above captioned was issued in January 2018 and therefore did not consider all the evidence, to include this examination. See 38 C.F.R. § 20.1304(c). As an examination of the left knee requested above, as a matter of course, includes testing of the right knee, these issues are considered intertwined. The January 2018 SSOC also did not include any reference referral extraschedular consideration, as the Board had requested, as that specific issue had been raised by the Veteran’s attorney. The matters are REMANDED for the following action: 1. Obtain an examination regarding the existence and etiology of the Veteran’s bilateral shoulder disability. The examiner should elicit the Veteran’s medical history. If the examiner determines that the medical records are not sufficient to give an opinion regarding etiology, rely upon the Veteran’s statements regarding medical history and symptoms in giving an opinion. 2. Obtain an examination regarding the etiology of the left knee disability and the severity of right knee anterior cruciate ligament tear. 3. Obtain any outstanding VA treatment records. 4. The AOJ should consider whether an extra-schedular rating is warranted and, if so, refer the issue for extraschedular consideration. If not warranted, the SSOC must so state. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Yoffe, Associate Counsel