Citation Nr: 18147677 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 16-17 555 DATE: November 5, 2018 ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for a bilateral hearing loss disability is denied. Entitlement to service connection for a lower back condition is denied. Entitlement to service connection for a left ankle condition is denied. Entitlement to service connection for a right ankle condition is denied. Entitlement to service connection for bilateral plantar fasciitis is denied. Entitlement to service connection for a spleen condition is denied. Entitlement to service connection for a thyroid condition is denied. REMANDED Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for a kidney condition is remanded. Entitlement to service connection for an esophageal condition is remanded. FINDINGS OF FACT 1. The evidence of record is at least in relative equipoise that sleep apnea was caused by or incurred in service. 2. The evidence of record is at least in relative equipoise that tinnitus was caused by or incurred in service. 3. The preponderance of the evidence is against a finding that the Veteran has a bilateral hearing loss disability that was caused by or incurred in service. 4. The preponderance of the evidence is against a finding that the Veteran’s lower back condition was caused by or incurred in service. 5. The preponderance of the evidence is against a finding that the Veteran’s left ankle condition was caused by or incurred in service. 6. The preponderance of the evidence is against a finding that the Veteran’s right ankle condition was caused by or incurred in service. 7. The preponderance of the evidence is against a finding that the Veteran’s bilateral plantar fasciitis was caused by or incurred in service. 8. The preponderance of the evidence is against a finding that the Veteran’s spleen condition was caused by or incurred in service. 9. The preponderance of the evidence is against a finding that the Veteran’s thyroid condition was caused by or incurred in service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.310 (2017). 2. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.309, 3.310 (2017). 3. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.309, 3.310 (2017). 4. The criteria for entitlement to service connection for a lower back condition have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.309, 3.310 (2017). 5. The criteria for entitlement to service connection for a left ankle condition have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.309, 3.310 (2017). 6. The criteria for entitlement to service connection for a right ankle condition have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.309, 3.310 (2017). 7. The criteria for entitlement to service connection for bilateral plantar fasciitis have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.310 (2017). 8. The criteria for entitlement to service connection for a spleen condition have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.310 (2017). 9. The criteria for entitlement to service connection for a thyroid condition have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. 3.102, 3.303, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from July 1980 to February 1988 and in the United States Air Force from July 2005 to September 2005, to include service in Afghanistan. He had additional service in the United States Naval and Air Force Reserves. This case comes on appeal of a May 2013 rating decision. As a preliminary matter, the Board notes that the VA Form 8, certifying the Veteran’s appeal to the Board, does not list service connection for a left ankle condition among the issues on appeal. This appears to be a clerical error, as the Veteran filed a substantive appeal as to all of the issues associated with his March 2016 statement of the case (SOC) and has not made any indication since then that he wished to limit his appeal. Accordingly, the Board will address the issue below. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.304. Service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Walker v. Shinseki, 701 F.3d 1331 (Fed. Cir. 2013). For chronic diseases listed in 38 C.F.R. § 3.309(a), including arthritis and organic diseases of the nervous system, the linkage element of service connection may also be established by demonstrating continuity of symptoms since service. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed.Cir.2013). 38 C.F.R. § 3.307(a)(3) provides for presumptive service connection for chronic diseases, including that become manifest to a degree of 10 percent or more within 1 year from the date of separation from service. Sensorineural hearing loss and tinnitus may be considered organic diseases of the nervous system for the purposes of 38 C.F.R. § 3.309(a). Service connection can be established for disability due to disease or injury incurred or aggravated in the line of duty during a period of active duty for training (ACDUTRA). 38 U.S.C. §§ 101(2), (22), (24), 1110, 1131 (2012); 38 C.F.R. §§ 3.1(d), 3.6(a), (c), 3.303 (2017); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). “Active duty for training” is defined, in part, as full-time duty in the Armed Forces performed by Reserves for training purposes. 38 U.S.C. § 101(22) (2012); 38 C.F.R. § 3.6(c) (2017). Service connection can be established for disability due to any injury incurred or aggravated in the line of duty during a period of inactive duty for training (INACDUTRA). INACDUTRA is defined as other than full-time duty performed by the Reserves. 38 U.S.C. § 101(23). Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d). 1. Entitlement to service connection for sleep apnea The Veteran was first diagnosed with sleep apnea following a January 2012 sleep study. At issue is whether sleep apnea was caused by or incurred in service. The Veteran’s service treatment records show no mention of sleep apnea or symptoms associated with sleep apnea. The Veteran, through his representative has asserted that he experienced symptoms associated with sleep apnea, such as intense snoring and hypersomnolence, beginning in active duty service, but did not know about sleep apnea and therefore did not seek out a sleep study. In support of his claim, the Veteran submitted a statement in November 2017 from his supervisor during his time on active duty in Afghanistan, V.B. V.B. stated that he shared a tent with the Veteran in Afghanistan, and that he and other soldiers could hear the Veteran snoring loudly, making grunting noises, and gasping to catch his breath while he slept. According to V.B., it became known that if people wanted to get to sleep, they needed to do so before the Veteran fell asleep, otherwise the volume of snoring and noises would keep them awake. V.B. also noted that the Veteran had difficulty staying awake during the day and would often sleep on his lunch break. As a layperson, V.B. is competent to describe his personal observations and his testimony is credible. In September 2017, the Veteran’s representative submitted a private medical opinion from Dr. D.C.B., a specialist in the field of sleep medicine. Dr. D.C.B. opined that it was as likely as not that sleep apnea had its onset in service or was caused by service. By way of rationale, Dr. D.C.B. pointed to the Veteran’s competent and credible statements while being interviewed that detailed his in-service symptoms and exposure to a variety of airborne irritants, to include insect repellant and pesticides, vehicle exhaust fumes, aircraft fuels, sand, dust, and burn pits. Dr. D.C.B. also acknowledged the statement from V.B. as further evidence. Dr. D.C.B. explained that exposure to airborne irritants, such as those described by the Veteran, may cause or worsen sleep apnea “via central or peripheral neurotransmitters that influence sleep stability, upper airway patency, and/or ventilatory control.” He went on to explain that “airborne irritants are able to directly affect the control center—the brain—which regulates the intricate mechanisms involved with sleep.” Additionally, airborne pollution may cause inflammation of the nose and throat, which causes swelling of the soft tissues, making it so the airway collapses more easily, causing or exacerbating sleep apnea. According to D.C.B., the Veteran’s described symptoms of sleep being interrupted by violent throat clearing and spitting were illustrative of this type of swelling and congestion. Dr. D.C.B.’s opinion is supported by significant medical rationale and corresponds with credible lay evidence; it is therefore probative. Notably, there is no evidence of record contradicting Dr. D.C.B.’s opinion. The Veteran has not undergone a VA examination related to this claim, and medical evidence speaks only to diagnosis and treatment, not to cause. As such, the Board finds that the evidence is at the very least in relative equipoise as to whether sleep apnea was either caused by or incurred in service. Accordingly, the Board will grant the claim of entitlement to service connection for sleep apnea. 2. Entitlement to service connection for tinnitus An August 2005 post-deployment assessment report includes “ringing in the ears” and appears to be the first point at which tinnitus is documented in the record. At issue is whether tinnitus was caused by or incurred in service. The Veteran underwent a VA examination for hearing loss and tinnitus in February 2013. The examiner noted complaints of tinnitus but opined that it was less likely than not that tinnitus was caused by or incurred in service, explaining that the Veteran did not have service-connected hearing loss and referenced medical literature stating that “only seldom does noise cause a permanent tinnitus without also causing hearing loss.” The VA examiner was asked for a follow-up opinion in April 2013. At that time, the examiner once again opined that it was less likely than not that tinnitus was caused by or incurred in service. The examiner referred to the August 2005 post-deployment assessment, stating that, although it noted ringing of the ears during deployment, either the Veteran or the evaluator handwrote “existing” next to the selection. The examiner opined that this meant that tinnitus was an existing condition and that there was otherwise no objective evidence in the Veteran’s service treatment records to support the onset of tinnitus during active duty. The Board finds the examiner’s opinions inadequate. First, the examiner pointed to a medical treatise stating that noise exposure only seldom caused tinnitus without hearing loss. Although this may be true, the Veteran is competent to describe the symptoms he has experienced; in this case, the Veteran has alleged that his tinnitus began during his deployment to Afghanistan. Reference to the medical treatise alone does not address the Veteran’s specific claim, nor does it provide an explanation as to why the Veteran’s competent lay testimony should not be considered credible or probative. Second, the examiner’s follow-up opinion relies solely on his interpretation of a notation on the Veteran’s post-deployment assessment that is not consistent with the Veteran’s statements or with other medical evidence of record. The record shows that on a July 2003 audiogram, there is no indication of tinnitus. The Veteran’s medical records associated with his 2005 call to active duty and his pre-deployment assessments do not document tinnitus. On the post-deployment assessment form referenced by the examiner, the relevant question asks, “Do you have any of these symptoms now or did you develop them anytime during this deployment?” The question offers the answer choices, “No,” “Yes During,” “Yes Now.” Regarding “Ringing of the ears,” the Veteran checked both “Yes During,” and “Yes Now,” next to which either he or the evaluator wrote the word “existing.” Resolving all reasonable doubt in the Veteran’s favor, the Board interprets this response as meaning that the Veteran developed ringing in the ears during service and that it continued up until the time of the assessment, not that it had pre-existed service. This interpretation is consistent with the fact that tinnitus was not documented on the July 2003 audiogram or on any pre-deployment records. It is also consistent with the Veteran’s statements that he worked around noisy aircraft in his role as an aircraft electronics technician during his deployment to Afghanistan. In light of the foregoing, the Board finds that the evidence is at least in relative equipoise that tinnitus had its onset during active duty service. The Veteran’s allegations, combined with the timeline of documented tinnitus in the medical record, are at least as probative as the VA examiner’s faulty opinion. Given that the evidence is in equipoise, the Board will grant the claim. 3. Entitlement to service connection for bilateral hearing loss 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. 38 C.F.R § 3.385. The Veteran underwent a VA hearing examination in February 2013. Although the examiner administered audiometric testing, he reported that the results were not reliable “despite repeated attempts and reinstruction.” According to the examiner, the results “were suggestive of a non-organic hearing loss/hearing loss component” as there was variability in responses to pure-tones of up to 15 [decibels] with retest, which was more than could be expected from retest variability. Accordingly, it is unknown whether the Veteran has a current hearing loss that meets the threshold for a hearing loss disability under VA regulations. Regardless, even if the Veteran does have a current hearing loss disability, there must still be evidence that it is at least as likely as not the disability was caused by or incurred in service. Here, that evidentiary threshold has not been met. The examiner noted that the Veteran’s hearing was within normal limits following both of his two active duty periods and that there were no significant threshold shifts. According to the examiner, an Institute of Medicine report on noise exposure in the military found that there was no scientific support for delayed onset noise-induced hearing loss weeks, months, or years after the exposure event. Therefore, given the Veteran’s normal audiometric results in close time following in-service noise exposure, as well as years later (see a November 2009 military audiogram), it was the examiner’s opinion that it was less likely than not that, even if any hearing loss disability were present meeting the standards for a disability under the provisions of 38 C.F.R. § 3.385, the hearing loss would be causally related to service. The Board finds that the examiner’s opinion is supported by medical rationale incorporating medical research and the specific facts of the Veteran’s medical history. Furthermore, there is no other evidence of record to suggest either that the Veteran has a current hearing loss disability or that it was caused by service. In light of this, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a current hearing loss disability that was caused by or incurred in service. As the preponderance of the evidence is against this finding, the “benefit of the doubt” rule is not applicable and the Board must deny the claim. See 38. U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for a lower back condition The Veteran’s treatment records from Gainesville VA Medical Center note a history of low back pain. Back pain first appears in the record in a September 2008 Reserve Component Health Risk Assessment, in which the Veteran lists the symptom as a physical condition that prevented him from brisk walking or running three miles. Although there is no specifically identified current diagnosis related to back pain, the Board notes that in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit Court of Appeals ruled that, even in the absence of a diagnosis or underlying pathology, pain alone can establish a current disability under 38 U.S.C. § 1110 if it results in functional impairment of earning capacity. For the purposes of this adjudication, the Board will assume as true that the Veteran has a current back disability under Saunders. Regarding the second criterion of service connection, an in-service injury, event, or onset, the Veteran himself has not identified an in-service injury or event that led to his current back pain, to include during service in the Reserves, nor has he asserted any service-related cause for his back disability. Service treatment records do not indicate that the Veteran sustained an in-service back injury during service. Indeed, on a January 1997 medical pre-screening form for the Air Force Reserves, the Veteran checked “No” when asked about a history of back trouble, indicating that he had not had any back injuries prior to that date, to include his active duty service from 1980 to 1988. There was also no indication of back pain on the Veteran’s August 2005 post-deployment evaluation after service in Afghanistan. Although back pain is noted on a September 2008 Reserve Component Health Risk Assessment, the Veteran has not stipulated, nor does the record show that such was due to any injury or disease sustained in performance of his reserve duties. In light of the foregoing, there is no evidence to indicate that his current back pain was caused by injury or disease during either active duty or a period of ACDUTRA or INACDUTRA. The preponderance of the evidence is therefore against a finding of a nexus between current back pain and service. As the preponderance of the evidence is against this finding, the “benefit of the doubt” rule is not applicable and the Board must deny the claim. See 38. U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for left and right ankle conditions. The Veteran’s treatment records from Gainesville VA Medical Center first document osteoarthritis of the bilateral ankles established by x-ray in October 2011. The Veteran therefore has a current bilateral ankle disability and the first requirement of service connection is satisfied. At issue is whether the bilateral ankle disability was caused by or incurred in service. Active duty and reserve service treatment records do not show any evidence of an in-service ankle injury. Indeed, the first evidence of record of any condition related to the ankles is the above-referenced October 2011 treatment record. The Veteran himself has not identified any in-service injury or event that might have caused the current ankle disabilities. Furthermore, the condition did not manifest to a degree of 10 percent or more within 1 year from the date of separation from service. The preponderance of the evidence is therefore against a finding that the Veteran’s current ankle disability was caused by or incurred in service. As the preponderance of the evidence is against this finding, the “benefit of the doubt” rule is not applicable and the Board must deny the claim. See 38. U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for bilateral plantar fasciitis VA treatment records from Gainesville VA Medical Center document a history of feet deformities with plantar fasciitis at least as early as February 2012, establishing a current diagnosis and satisfying the first requirement for service connection. At issue is whether plantar fasciitis was caused by or incurred in service. The Veteran’s plantar fasciitis diagnosis does not appear anywhere in the record prior to February 2012. Notably, in the Veteran’s September 2008 Reserve Component Health Risk Assessment, the Veteran referred to “fallen arches” as a physical condition that prevented him from brisk walking or running three miles. Plantar fasciitis was not implicated at that time. Service treatment records are silent for any in-service foot injury or incident of foot pain. On the Veteran’s January 1997 medical pre-screening form for the Air Force Reserves, he checked “No” when asked about a history of impaired use of feet. There was similarly no indication of foot trouble on the Veteran’s post-deployment assessment after deployment to Afghanistan. Furthermore, the Veteran has not identified an in-service injury or onset of plantar fasciitis. The preponderance of the evidence is therefore against a finding that the Veteran’s plantar fasciitis was caused by or incurred in service. As the preponderance of the evidence is against this finding, the “benefit of the doubt” rule is not applicable and the Board must deny the claim. See 38. U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to service connection for a spleen condition The Veteran has a current diagnosis of splenomegaly. A September 2011 sonogram at Gainesville VA Medical Center first identified an enlarged spleen. At issue is whether the condition was caused by or incurred in service. Service treatment records are silent for any indication of a spleen issue. There is no medical evidence of record to suggest that the spleen issue was caused by or incurred in service, and the Veteran himself has not identified an in-service onset of a spleen condition or an in-service event that would have led to a spleen condition. The preponderance of the evidence, therefore, is against a finding that splenomegaly was caused by or incurred in service. As the preponderance of the evidence is against this finding, the “benefit of the doubt” rule is not applicable and the Board must deny the claim. See 38. U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 8. Entitlement to service connection for a thyroid condition The Veteran’s medical history notes hypothyroidism. A September 2011 sonogram at Gainesville VA Medical Center first identified an abnormal thyroid, suggesting thyroid nodules. At issue is whether the condition was caused by or incurred in service. Service treatment records are silent for any indication of a thyroid issue. There is no medical evidence of record to suggest that the thyroid issue was caused by or incurred in service, and the Veteran himself has not identified an in-service onset of a thyroid condition or an in-service event that would have led to a thyroid condition. The preponderance of the evidence, therefore, is against a finding that a thyroid was caused by or incurred in service. As the preponderance of the evidence is against this finding, the “benefit of the doubt” rule is not applicable and the Board must deny the claim. See 38. U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for left and right knee conditions is remanded. The Veteran has claimed that he has a knee condition that was caused by an incident during service in Afghanistan in which he experienced a hard landing after being thrown forward from a crew area helicopter seat, striking both knees. He underwent a VA knee examination in April 2013. At that examination, the examiner opined that it would require resorting to speculation to say whether the Veteran’s current bilateral knee condition was caused by the described event. The Court of Appeals for Veterans Claims found that a VA medical examination is not inadequate merely because the medical examiner states he or she cannot reach a conclusion without resort to speculation. See Jones v. Shinseki, 23 Vet. App. 382 (2010). However, the Court did find in Jones that simply concluding that the cause of a disability could not be resolved without speculation, without providing any explanation why, was inadequate. Here the Board finds that the examiner did not provide an adequate medical explanation as to why the cause could not be identified without resort to speculation. Further, the examiner’s report appears not to have been based on a full review of the claims file. The examiner checked the box to indicate that he reviewed the Veteran’s claims file, but later stated “claims file and service medical records have been requested but are not yet available for review as of 0905 hours on 22 April 2013.” An update to the report noted at “1500 hours 22 April 2013” reported that “service medical records just received” showed a July 1985 sick call note regarding direct trauma to the left patella “not stating by what mechanism.” Service treatment records from that date show that the Veteran reported experiencing trauma via striking the left knee joint on a metal bar, and that he noted throbbing to the joint. On remand, a new examination should be provided in which the examiner has the opportunity to review the Veteran’s full claims file, after which the examiner should provide a medical opinion with full rationale for all conclusions reached. 2. Entitlement to service connection for a kidney condition is remanded. In November 2017, the Veteran submitted a private medical opinion regarding his current kidney disability, linking the disability to in-service exposure to asbestos. However, in-service exposure to asbestos has not been conceded. The Board notes that in a private medical opinion submitted September 2017 regarding the cause or onset of sleep apnea, the Veteran reported to the examiner that the gymnasiums in which he lifted weights frequently contained asbestos. There is no other information of record, however, to help substantiate this claim, and the Veteran has not provided any additional explanation for it. Service treatment records show that in August 1986 the Veteran was screened for asbestos exposure. He reported that he had been exposed to asbestos during his military career, but no further explanation was given. The evaluating physician did not opine on the probability of asbestos exposure and did not state whether formal placement into the Asbestos Medical Surveillance Program was warranted. The physician did not refer the Veteran to preventive medicine or occupational health. Still, the mere fact that the Veteran was screened indicates that there was some concern of asbestos exposure. The Board also notes that, aside from the order releasing the Veteran from the Air Force Reserves in December 2009, the Veteran’s military personnel records are not associated with the claims file. This information is necessary to identify any service in which the Veteran may have had exposure to asbestos. Accordingly, on remand, military personnel records should be obtained for the entirety of the Veteran’s service, and the Veteran should be afforded an opportunity to describe the specific instances and locations in which he was exposed to asbestos. 3. Entitlement to service connection for an esophageal condition Reserve health assessment notes from July 2009 document esophageal stenosis and Gainesville VA Medical Center records note that the Veteran underwent esophageal dilation for Schatzki’s ring in October 2011. The Mayo Clinic defines Schatzki’s ring as an abnormal ring of tissue located at the junction of the esophagus and stomach. The evidence therefore demonstrates that the Veteran has a current disability related to an esophageal condition. At issue is whether the current disability was caused by or incurred in service. In an August 2011 treatment note at Gainesville VA Medical Center, the Veteran reported difficulty swallowing and told his doctor that the problem started in 2005 while he was in the military reserve. Indeed, a May 2005 Reserve Component Preventive Health Assessment (RCPHA) noted that the Veteran had received an endoscopy for dysphagia and had undergone esophageal dilation. There is no evidence to suggest that an esophageal condition began during the Veteran’s first period of service. It is unclear, however, whether the condition began during a period of ACDUTRA or INACDUTRA. The May 2005 note also suggests that there may be medical records documenting the dilation procedure that are relevant to the claim and are not associated with the file. On remand, the AOJ should obtain records of the Veteran’s periods of ACDUTRA and INACDUTRA and assist the Veteran with obtaining any outstanding medical records related to the claim. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA knee examination. The examiner should review the entire claims file, to include a copy of this Remand, and the report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should clearly identify all current disabilities of the bilateral knees. Then, with respect to each such diagnosed disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability had onset in, or is otherwise related to service. If the examiner cannot provide an opinion without resort to speculation, he or she should explain why this is so and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. 2. Obtain the Veteran’s military personnel records and any other military records necessary that might verify the likelihood of the Veteran’s exposure to asbestos during service. 3. Afford the Veteran an opportunity to describe the specific nature of any in-service asbestos exposure. 4. Obtain the records identifying the dates in which the Veteran had ACDUTRA or INACDUTRA service with the United States Air Force Reserves. 5. Ask the Veteran to identify any outstanding medical records related to the esophageal dilation referenced in the May 2005 Reserve Component Preventive Health Assessment record, or any other outstanding medical records related to his esophageal condition. If the Veteran identifies such records, assist him in obtaining them. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Giaquinto, Associate Counsel