Citation Nr: 18146619 Decision Date: 11/01/18 Archive Date: 10/31/18 DOCKET NO. 16-30 341 DATE: November 1, 2018 ORDER The petition to reopen the claim of service connection for a lumbar spine disorder is denied. The petition to reopen the claim of service connection for nervousness and anxiety is denied. Service connection for depression is denied. Service connection for a bilateral shoulder disorder is denied. Service connection for a bilateral knee disorder, claimed as secondary to the lumbar spine disorder, is denied. Service connection for peripheral neuropathy of the bilateral lower extremities is denied. Service connection for peripheral neuropathy of the bilateral upper extremities is denied. Service connection for a bilateral hand disorder, claimed as due to carpal tunnel syndrome, is denied. Service connection for hypertension is denied. Service connection for erectile dysfunction is denied. Service connection for a sinus disorder is denied. Service connection for a lung disorder is denied. REMANDED Service connection for a bilateral hip disorder is remanded. Service connection for a traumatic brain injury (TBI) is remanded. FINDINGS OF FACT 1. In October 2012, the Veteran filed claims for service connection for a lumbar spine disorder and nervousness disorder that were denied in an August 2013 rating decision. 2. The Veteran did not file new and material evidence or a notice of disagreement within one year of the rating decision and it became final. 3. Since the August 2013 rating decision, new and material evidence has not been associated with the claims file that suggests the Veteran’s current lumbar spine disorder began in service or is related to an in-service injury or event. 4. Since the August 2013 rating decision, new and material evidence has not been associated with the claims file that suggests the Veteran’s nervousness disorder began in service or is related to service. 5. The Veteran was diagnosed with depression many years after separation from service and it is not otherwise related to service. 6. The Veteran’s bilateral shoulder disorder, manifested by limited range of motion, began many years after separation and is not otherwise related to service. 7. The Veteran does not have a current bilateral knee disorder. 8. The Veteran does not have peripheral neuropathy of the bilateral lower extremities, and his lower extremity radiculopathy is caused by his nonservice-connected lumbar spine disorder. 9. The Veteran does not have peripheral neuropathy of the bilateral upper extremities or carpal tunnel syndrome. 10. The Veteran does not have carpal tunnel syndrome or a current bilateral hand disorder. 11. The Veteran’s hypertension manifested many years after separation and is otherwise unrelated to service. 12. The Veteran’s erectile dysfunction manifested many years after separation and is otherwise unrelated to service. 13. The Veteran does not have a sinus disorder associated with his in-service sinus fracture and surgery, and his allergic rhinitis began many years after separation from service. 14. The Veteran’s lung condition, manifested by shortness of breath, began many years after separation from service and is otherwise unrelated to service. CONCLUSIONS OF LAW 1. The August 2013 rating decision denying service connection for a lumbar spine disorder and nervousness and anxiety disorder is final. 38 U.S.C. § 7103 (2012); 38 C.F.R. § 20.1100 (2017). 2. The criteria to reopen the claim of service connection for a lumbar spine disorder have not been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria to reopen the claim of service connection for nervousness and anxiety disorder have not been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 4. The criteria for service connection for depression have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 5. The criteria for service connection for a bilateral shoulder disorder have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 6. The criteria for service connection for a bilateral knee disorder have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 7. The criteria for service connection for peripheral neuropathy of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 8. The criteria for service connection for peripheral neuropathy of the bilateral upper extremities have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 9. The criteria for service connection for a bilateral hand disorder have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 10. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 11. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 12. The criteria for service connection for a sinus disorder have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 13. The criteria for service connection for a lung disorder have not been met. 38 U.S.C. §§ 1131, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS There are private treatment records that are not associated with the claims file, but the Board finds that a remand is not necessary to attempt to obtain them. VA previously attempted to obtain these records, and upon discovering that the physician charges for copies of the medical records, notified the Veteran that he was responsible for obtaining his records. The Veteran did not submit them to VA. Thus, VA has already attempted to obtain the outstanding records. Regarding current treatment, the Veteran did not authorize VA to access private treatment records, despite receiving adequate VCAA notice, and has not alleged that these records are important to the present matter. Accordingly, a remand is not necessary to attempt to obtain these records. As a preliminary matter, the Board notes that for most of the claims below, the Veteran merely filed claims for compensation without specific allegations of in-service injuries or treatment. He has made general statements about a “fall” that he felt caused his back condition, as well as general statements about body “injuries” during service. He has not, however, provided additional details about in-service symptoms or injuries or stated why he feels these conditions should be service-connected. He has also made no allegations of continuity of symptoms following service, nor has he identified any medical professional who has suggested any of the claimed conditions are related to his service in some way. 1. The petition to reopen the claim of service connection for a lumbar spine disorder is denied. Prior unappealed decisions of the Board and the RO are final. 38 U.S.C. §§ 7104, 7105(c) (West 2014); 38 C.F.R. §§ 3.160 (d), 20.302(a), 20.1100, 20.1103, 20.1104 (2015). If, however, new and material evidence is presented or secured with respect to a claim which has been denied, VA shall reopen the claim and review the former disposition of the claim. Manio v. Derwinski, 1 Vet. App. 145 (1991). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). 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. See id. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See id. New and material evidence need not be received as to each previously unproven element of a claim to justify reopening thereof; 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, 117-120 (2010). The RO denied service connection for a lumbar spine disorder, including arthritis, in August 2013 because the evidence did not demonstrate a link between service and the lumbar spine disorder. The Veteran did not file a notice of disagreement or submit new and material evidence within one year, and the rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. At that time, the evidence included the Veteran’s statements, service treatment records, VA medical records through July 2013, SSA records, private treatment records within the SSA claims file, and a VA spine examination with a negative nexus opinion. The Veteran filed a petition to reopen his claim in August 2014. Since then, new VA medical records have been associated with the claims file. While these records are “new,” they are not “material” because they do not address an unestablished fact necessary to substantiate the claim, i.e. a nexus between service and the spine disorder. Specifically, the new medical records do not suggest that the Veteran’s spine disorder began in or is related to an in-service event or injury. As new and material evidence has not been received since the final August 2013 rating decision, the Veteran’s petition to reopen the claim of service connection for a lumbar spine disorder is denied. 2. The petition to reopen the claim of service connection for nervousness and anxiety disorder is denied. The RO denied the Veteran’s claim for service connection for nervousness and anxiety disorder in August 2013 because the evidence did not demonstrate a link between service and the disorder. The Veteran did not file a notice of disagreement or submit new and material evidence within one year, and the rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. At that time, the evidence included the Veteran’s statements, service treatment records, VA medical records through July 2013, SSA records, and private treatment records within the SSA claims file. The Veteran filed a petition to reopen his claim in August 2014. Since then, new VA medical records have been associated with the claims file. While these records are “new,” they are not “material” because they do not address an unestablished fact necessary to substantiate the claim, i.e. a nexus between service and a nervousness and anxiety disorder. Specifically, the new medical records do not suggest that the Veteran has a nervousness and anxiety disorder related to service or that it began in service; instead, the new mental health treatment records suggest the Veteran’s anxiety was substance-induced. As new and material evidence has not been received since the final August 2013 rating decision, the Veteran’s petition to reopen the claim of service connection for a nervousness and anxiety disorder is denied. 3. Service connection for depression is denied. The Veteran contends that he is entitled to service connection for depression. The Board finds, however, that the Veteran is not entitled to service connection because the evidence does not show his depression is related to service. The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for relevant symptoms or diagnoses, and the separation psychiatric examination was normal. The Veteran’s private records associated with his SSA disability claims file show that he complained of anxiety and nervousness in October 2009, but do not document complaints or diagnoses of depression. The Veteran’s post-service VA medical records date to 1996, but do not show relevant complaints until a positive depression screening in June 2010. He was referred to mental health for an evaluation and was diagnosed with anxiety and insomnia after losing his job in February 2010. In June 2011, he reported experiencing symptoms of depression, hypersomnia, impaired concentration, and anxiety for the last 1.5 years since his work supervisor died and he was terminated from his job. After an examination, he was diagnosed with depression. Subsequent VA mental health records relate his mental health symptoms to his history of alcohol abuse. For example, the Veteran underwent a mental health evaluation in March 2013 and reported that he “gets the shakes every once in a while and thinks it’s his nerves.” He denied manic, depressive, or anxious symptoms and it was noted that “he can give no other anxious/nervous symptoms.” He was only diagnosed with alcohol dependence and chronic noncompliance with medication. Similarly, at a June 2013 mental health visit, the Veteran was diagnosed with ETOH abuse vs. depression (early remission) and anxiety disorder vs. substance induced-anxiety. In sum, the Veteran’s service treatment records and post-service medical records show that his depression manifested many years after service and was not otherwise related to service. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of symptoms in service or evidence that relates current symptoms to service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Service connection for a bilateral shoulder disorder is denied. The Veteran contends that he is entitled to service connection for a bilateral shoulder disorder. The Board finds, however, that the Veteran is not entitled to service connection because he does not have a shoulder disorder that is related to an in-service injury or event. The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for relevant symptoms or diagnoses, and the separation examination was normal. The Veteran’s VA medical records from 1996 to 2015 are associated with the claims file and do not document a shoulder disorder or relevant symptomatology. Similarly, his private medical records that are associated with his SSA disability claims file do not show treatment for a shoulder disorder. In February 2012, however, he underwent a physical examination for his SSA disability claim and right shoulder pain and abnormal range of motion bilaterally was documented. Arm muscle strength and sensory results were normal and a shoulder diagnosis was not rendered. To the extent the Veteran’s limited range of motion constitutes a bilateral shoulder disability, the Board finds that service connection is not warranted because the service records are negative for relevant complaints and post-service records do not show treatment for a shoulder disorder until 2012, more than 30 years after separation from service. Importantly, the Veteran worked in construction for 20 years after service. There is no suggestion his symptoms are somehow related to service. In sum, the competent and credible evidence does not show that the Veteran has a bilateral shoulder disorder that is related to an in-service event or injury. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of symptoms in service or evidence that relates current symptoms to service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Service connection for a bilateral knee disorder is denied. The Veteran contends that he is entitled to service connection for a bilateral knee disorder. The Board finds, however, that the Veteran is not entitled to service connection because there is no evidence of a knee disorder during the period on appeal. The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for relevant symptoms or diagnoses, and the separation examination was normal. Subsequent medical records do not show relevant diagnoses. While VA treatment records date to March 1996, there is no record of knee diagnoses or relevant symptomatology such as limited range of motion. The Veteran in fact underwent a physical examination for his SSA disability claim in February 2012 which revealed normal knee range of motion and muscle strength and his diagnoses did not include a knee disorder. To the extent the Veteran contends he has a bilateral knee disorder, his statements are not competent because he does not have the medical knowledge or expertise necessary to render a diagnosis. In sum, the competent and credible evidence does not show that the Veteran has a bilateral knee disorder. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of a current condition or symptoms in service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 6. Service connection for peripheral neuropathy of the bilateral lower extremities is denied. The Veteran contends that he is entitled to service connection for peripheral neuropathy of the bilateral lower extremities. The Board finds, however, that the Veteran is not entitled to service connection because there is no evidence that the Veteran has lower extremity peripheral neuropathy or that his lumbar radiculopathy is related to service. The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for symptoms of peripheral neuropathy, nor is peripheral neuropathy documented on the separation examination. The Veteran’s VA medical records from 1996 to 2015 are associated with the claims file and do not document a diagnosed peripheral neuropathy disorder. In February 2004, he was assessed with low back pain and probable radiculopathy. In February 2012, the Veteran underwent a physical examination for his SSA disability claim which revealed a positive straight leg test and he was diagnosed with a history of back pain and radiculopathy. There was no reference to peripheral neuropathy in the examination or diagnoses. In short, the competent and credible evidence does not show that the Veteran has bilateral lower extremity peripheral neuropathy. While the Veteran contends he has peripheral neuropathy, his statements are not competent evidence of a current disorder because he does not have the requisite medical knowledge, training, or expertise to render such a diagnosis and he has not submitted competent evidence supporting his contentions. To the extent the Veteran seeks service connection for lumbar radiculopathy, his lumbar radiculopathy is associated with his nonservice-connected back disorder and cannot be service-connected. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of a current condition or symptoms in service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 7. Service connection for peripheral neuropathy of the bilateral upper extremities is denied. The Veteran contends that he is entitled to service connection for peripheral neuropathy of the bilateral upper extremities. He also claimed entitlement to service connection for a hand disorder secondary to carpal tunnel syndrome. The Board finds, however, that the Veteran is not entitled to service connection because there is no evidence of an upper extremity peripheral neuropathy disorder or carpal tunnel syndrome during the period on appeal. The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for relevant symptoms of peripheral neuropathy or carpal tunnel syndrome, nor are these disorders documented on the separation examination. Subsequent medical records do not show diagnoses of upper extremity peripheral neuropathy or carpal tunnel syndrome. While VA treatment records date to March 1996, the only documentation of relevant complaints is a June 2010 primary care record which notes that the Veteran has difficulty writing when he gets nervous. Similarly, an October 2009 private record, located in his SSA claims file, shows he was treated for hand tremors and symptoms of anxiety and nervousness. He was not diagnosed with peripheral neuropathy or carpal tunnel syndrome at either visit. Importantly, neither the Veteran’s VA records nor his SSA records document peripheral neuropathy, carpal tunnel syndrome, or relevant symptomatology such as numbness and weakness. The Veteran in fact underwent a physical examination for his SSA disability claim in February 2012 which revealed normal range of motion, muscle strength, and sensory results. While the Veteran contends he has peripheral neuropathy and/or carpal tunnel syndrome, his statements are not competent evidence of a current disorder because he does not have the requisite medical knowledge, training, or expertise to render such a diagnosis and he has not submitted competent evidence supporting his contentions. In sum, the competent and credible evidence does not show that the Veteran has bilateral upper extremity peripheral neuropathy or carpal tunnel syndrome. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of a current condition or symptoms in service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 8. Service connection for a bilateral hand disorder, claimed as due to carpal tunnel syndrome, is denied. The Veteran contends that he is entitled to service connection for a bilateral hand disorder due to carpal tunnel syndrome. The Board finds, however, that the Veteran is not entitled to service connection because there is no evidence of carpal tunnel syndrome or a hand disorder. The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for relevant symptoms or diagnoses, and the separation examination was normal. Subsequent medical records do not show treatment for bilateral hand issues or diagnoses of carpal tunnel syndrome. While VA treatment records date to March 1996, the only documentation of relevant complaints is a June 2010 primary care record which notes that the Veteran has difficulty writing when he gets nervous. Similarly, an October 2009 private record, located in his SSA claims file, shows he was treated for hand tremors and symptoms of anxiety and nervousness. He was not diagnosed with a hand disorder or carpal tunnel syndrome at either visit. Importantly, neither the Veteran’s VA records nor his SSA records document carpal tunnel syndrome or relevant symptomatology such as grip issues, limited range of motion, or numbness. The Veteran in fact underwent a physical examination for his SSA disability claim in February 2012 which revealed normal range of motion, muscle strength, and sensory results. While the Veteran contends he has carpal tunnel syndrome, his statements are not competent evidence of a current disorder because he does not have the requisite medical knowledge, training, or expertise to render such a diagnosis and he has not submitted competent evidence supporting his contentions. In sum, the competent and credible evidence does not show that the Veteran has a bilateral hand disorder or carpal tunnel syndrome. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of a current condition or symptoms in service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 9. Service connection for hypertension is denied. The Veteran contends that he is entitled to service connection for his hypertension. The Board finds, however, that the Veteran is not entitled to service connection because his hypertension manifested many years after separation from service and is otherwise not related to service. Because hypertension is listed as a “chronic disease” in 38 C.F.R. § 3.309, a presumptive service connection analysis is warranted. See 38 C.F.R. 3.303(b). The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for or diagnoses of high blood pressure, and his blood pressure at separation was 114/76. The Veteran’s VA medical records from 1996 to 2015 are associated with the claims file and, despite undergoing routine blood pressure testing, do not document hypertension until June 2010. Private medical records associated with his SSA disability claims file show that elevated blood pressure was initially documented in February 2009 and he was diagnosed with hypertension in October 2009. Importantly, during the February 2012 SSA physical examination, the Veteran reported “a 2.5-year history of high blood pressure” and “has been on medication since diagnosis.” After review of the evidence, the Board finds that he is not entitled to presumptive service connection afforded to chronic diseases under 38 C.F.R. § 3.309 because there is no evidence of the disease in service, shortly after service, or a continuity of symptomatology from service to diagnosis. Instead, the evidence shows the Veteran’s hypertension was diagnosed in 2009, approximately 30 years after separation from service, and does not otherwise relate it to service. For these reasons, service connection on a direct basis is also not warranted. The Board notes that the Veteran submitted a hypertension DBQ in May 2015. The examination report noted, however, he was diagnosed in 2010 and did not include a nexus opinion. Accordingly, it was not relevant to the issue at hand, which was whether the Veteran’s hypertension was related to service. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. 10. Service connection for erectile dysfunction is denied. The Veteran contends that he is entitled to service connection for erectile dysfunction. The Board finds, however, that the Veteran is not entitled to service connection because his erectile dysfunction manifested many years after separation from service and is otherwise not related to service. The Veteran’s service treatment records are associated with the claims file and appear to be complete. The service records do not show treatment for or diagnoses of erectile dysfunction, and his separation examination was normal. The Veteran’s VA medical records from 1996 to 2015 are associated with the claims file and do not document treatment for erectile dysfunction until August 2014. Private medical records associated with his SSA disability claims file, dated from 2009 to 2010, do not document complaints or treatment regarding erectile dysfunction. After review of the evidence, the Board finds that he is not entitled to service connection because his erectile dysfunction manifested in 2014, more than 30 years after separation from service, and the evidence does not suggest it is otherwise related to service. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of symptoms in service or evidence that otherwise relates his hypertension to service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 11. Service connection for a sinus disorder The Veteran seeks service connection for a sinus disorder. The Board finds, however, that the Veteran does not have a sinus disorder that began in or was caused by service. The Veteran’s service treatment records show that the Veteran sustained a depressed fracture to the anterior wall of his frontal sinus due to a car crash in October 1977 and underwent an open reduction to repair the fracture that same day. An October 1977 record noted that there were “no apparent post-operative complications” and the Veteran had “a good forehead contour.” Head x-rays were completed in January 1978 and were within normal limits. Subsequent records do not show follow-up complaints or relevant treatment, and the Veteran’s separation examination was normal. Thus, while the Veteran sustained an injury to his sinuses in service, his service treatment records do not show that he experienced chronic residuals following surgery. Furthermore, post-service medical records do not show that the Veteran has a sinus disorder related to the in-service accident and surgery. While VA treatment records date to 1996, they do not contain relevant complaints or diagnoses until June 2011, when the Veteran was diagnosed with allergic rhinitis. Private medical records associated with the SSA disability claims file show treatment for sinusitis in May 2010; otherwise, they do not show relevant treatment or complaints. Finally, the February 2012 SSA physical evaluation does not document sinus issues or a diagnosis. The Veteran was also afforded a VA sinus examination and x-rays of the paranasal sinuses in March 2015. The x-rays revealed swelling nasal choanae, but the remainder of the visualized soft tissues and bony structures were radiographically within normal limits. After examination, review of the claims file, and x-rays, the examiner only diagnosed the Veteran with allergic rhinitis. The Board thus finds that the Veteran does not have a current sinus disorder related to his in-service injury or sinus surgery. Instead, current medical records only show diagnoses of allergic rhinitis, which began approximately 30 years after service. Importantly, the Veteran has not submitted lay or medical evidence specifically supporting his claim that he has a current sinus disorder related to service. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. 12. Service connection for a lung disorder is denied. The Veteran seeks service connection for a bilateral lung disorder, but has not specified the nature of his lung disorder and how it is related to service. His medical records show treatment for “shortness of breath.” To the extent that his shortness of breath constitutes a disability, the Board finds that it did not begin in service and is not otherwise related to service. The Veteran’s service treatment records are associated with the claims file and do not show treatment for respiratory issues or disorders. At separation, a heart murmur was detected and he was referred to internal medicine for an evaluation. The internal medicine report noted that he was “totally asymptomatic” with no history of rheumatic heart disease, palpitations, chest pains, shortness of breath, or edema and that he had “done well in PFTs.” It was also noted that he had a history of smoking. He was diagnosed with a functional murmur and determined qualified for separation. Post-service private records, associated with the Veteran’s SSA disability claims file, show that he underwent a cardiovascular study in February 2009 because of his history of dyspnea and a heart murmur. The results revealed no pulmonic insufficiency. During his February 2012 SSA physical examination, the Veteran reported a two-year history of shortness of breath as well as a history of smoking and alcohol. His cardiovascular and lungs evaluations were normal, and neither a heart murmur nor a respiratory condition was noted. A chest x-ray was conducted in February 2012 and showed hyperinflated but clear lungs. Finally, VA medical records from the period on appeal include numerous physical examinations that show regular rate and rhythm for the Veteran’s heart without murmur, rub, gallop, or click, including from December 2013, August 2014, and March 2015. The records also do not show evidence of a respiratory diagnosis. The Veteran underwent a chest x-ray in June 2011, which showed clear lungs and no evidence of acute disease. In February 2013, he was diagnosed with shortness of breath with minimal exertion and instructed to take his hyperlipidemia medication as prescribed. He underwent another chest study in March 2013 which further showed expanded and clear lungs and no active cardiopulmonary disease. After review of the evidence, the Board finds that the evidence weighs against service connection. There was no evidence of shortness of breath or other respiratory symptoms in service. Furthermore, the Veteran reported during his SSA physical examination that his shortness of breath began in approximately 2009 or 2010, or 30 years after separation from service. In short, the evidence shows that his shortness of breath began many years after separation from service and is not related to an in-service disease, event, or injury. The Board thus finds that the preponderance of the evidence is against service connection and the claim is denied. Because there is no evidence of symptoms in service or evidence that otherwise relates his shortness of breath to service, an examination was not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). REASONS FOR REMAND 1. Service connection for a bilateral hip disorder is remanded. The Veteran presented to VA with complaints of chronic hip pain and was diagnosed with mild degenerative joint disease in his bilateral hips in January 2004. His service treatment records also show that he injured his left hip while falling off the rack in service and was diagnosed with possible left hip osteoarthritis in November 1976. A remand is therefore necessary to afford the Veteran a VA hip examination and medical opinion. 2. Service connection for a TBI is remanded. The Veteran underwent a VA TBI examination in September 2015, and the examiner rendered a negative nexus opinion because the service records did not show that the Veteran experienced, or was treated for, concussion symptoms after his October 1977 motor vehicle accident. November 1977 service treatment records show, however, that the Veteran complained about being “bothered by light” and “blurring at times.” Furthermore, a March 2015 VA headaches medical opinion determined that “it is at least as likely as not the Veteran suffered from a post traumatic brain injury and a subsequent post concussive headache.” The Board finds that a remand is necessary to obtain an addendum medical opinion that addresses these favorable facts. The matters are REMANDED for the following action: 1. Obtain the Veteran’s Houston VAMC records from October 2016 to the present. 2. Schedule the Veteran for a VA hip examination to assess the nature and etiology of his bilateral hip disorder. After review of the claims file, including the service treatment records documenting left hip and thigh treatment, the examiner should respond to the following: (a.) Is the Veteran’s left hip disorder at least as likely as not related to his in-service left hip injury? (b.) Is the Veteran’s right hip disorder at least as likely as not related to his in-service left hip injury? (c.) If not, is the Veteran’s right hip disorder was caused or aggravated by his left hip disorder? 3. Forward the Veteran’s claims file to the TBI examiner who completed the September 2015 TBI examination or another appropriate examiner if he is unavailable. After a review of the claims file, including this opinion, the examiner should respond to the following: (a.) Is it at least as likely as not that the Veteran incurred a TBI in service following the October 1977 motor vehicle accident? (b.) The examiner should address the November 1977 service treatment record for vision complaints and the March 2015 VA headaches medical opinion that stated, “it is at least as likely as not the Veteran suffered from a post traumatic brain injury and a subsequent post concussive headache.” MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Lavan, Associate Counsel