Citation Nr: 18147897 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-02 151 DATE: November 6, 2018 ORDER Entitlement to service connection for neck disability is denied. Entitlement to service connection for right hip disability is denied. Entitlement to service connection for neuropathy is denied. Entitlement to service connection for acquired psychiatric disorder, to include anxiety, as secondary to service-connected disabilities, is granted. Entitlement to service connection for sleep apnea, to include as secondary to acquired psychiatric disorder, is granted. Entitlement to a rating higher than 10 percent for low back strain (back disability) is denied. Entitlement to an initial rating higher than 20 percent for left shoulder disability is denied. A 20 percent disability rating for left knee disability is granted, subject to subject to regulations governing payment of monetary awards. A 20 percent disability rating for right knee disability is granted, subject to subject to regulations governing payment of monetary awards. An effective date of May 11, 2009 for service connection for right knee disability is granted, subject to the criteria applicable to payment of monetary benefits. An effective date of May 11, 2009 for service connection for left hip disability is granted, subject to the criteria applicable to payment of monetary benefits. Entitlement to an effective date earlier than October 22, 2014 for the grant of service connection for left shoulder disability is denied. Entitlement to an effective date earlier than January 30, 2014 for the grant of service connection for back disability is denied. Entitlement to an effective date earlier than January 30, 2014 for the grant of service connection for left knee disability is denied. REMANDED Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for disability manifested by fatigue is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for headaches, to include as secondary to acquired psychiatric disorder and/ or sleep apnea, is remanded. Entitlement to an initial rating higher than 20 percent for left hip disability is remanded. Entitlement to a total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACTS 1. The Veteran does not have a neck disability. 2. The Veteran does not have a right hip disability. 3. The Veteran does not have a neuropathy. 4. The Veteran’s service-connected disabilities caused his acquired psychiatric disorder. 5. The Veteran’s sleep apnea is caused or aggravated by his acquired psychiatric disorder. 6. The Veteran’s back disability is not manifested by forward flexion of 60 degrees or less or combine range of motion of the thoracolumbar spine of 120 degrees or less; there is not muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 7. The Veteran’s left shoulder disability is not manifested by range of motion limited to 25 degrees from the side. 8. The Veteran’s bilateral knee disability is manifested by range of motion limited to 40 degrees in the right knee and 30 degrees in the left during repetitive use test. 9. The Veteran’s claim for service connection for right knee disability and left hip disability were received on May 11, 2009. 10. A current left should disability was shown on October 22, 2014. 11. The Veteran’s claim of service connection for back disability and left knee disability was not received earlier than January 30, 2014. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for neck disability have not been satisfied. 38 U.S.C. §§ 1111, 1154; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for entitlement to service connection for right hip disability have not been satisfied. 38 U.S.C. §§ 1111, 1154; 38 C.F.R. §§ 3.303, 3.304. 3. The criteria for entitlement to service connection for neuropathy have not been satisfied. 38 U.S.C. §§ 1111, 1154; 38 C.F.R. §§ 3.303, 3.304, 3.310. 4. The criteria for entitlement to service connection for acquired psychiatric disorder, to include anxiety, have been satisfied. 38 U.S.C. §§ 1111, 1154; 38 C.F.R. §§ 3.303, 3.304, 3.310. 5. The criteria for entitlement to service connection for sleep apnea, to include as secondary to acquired psychiatric disorder, have been satisfied. 38 U.S.C. §§ 1111, 1154; 38 C.F.R. §§ 3.303, 3.304, 3.310. 6. The criteria for entitlement to an initial rating higher than 10 percent for back disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237. 7. The criteria for entitlement to an initial rating higher than 20 percent for left shoulder disability have not been satisfied. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5201. 8. The criteria for an initial rating 20 percent rating for right knee disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 9. The criteria for an initial rating 20 percent rating for left knee disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 10. The criteria for an effective date of May 11, 2009 for right knee disability have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 11. The criteria for an effective date of May 11, 2009 for left hip disability have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 12. The criteria for an effective date earlier than October 22, 2014 for left shoulder disability have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 13. The criteria for an effective date earlier than January 30, 2014 for back disability have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 14. The criteria for an effective date earlier than January 30, 2014 for left knee disability have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1993 to July 1996. In January 2014 a claim for service connection for mental health condition was filed. Subsequently, the Veteran filed a statement in support of his claim contending that he has posttraumatic stress disorder (PTSD). Review of the record shows that the he does not have diagnosis of PTSD. Rather, he is diagnosed with anxiety. Therefore, the Board has re-characterized the issue on appeal as entitlement to service connection for a psychiatric disorder, to include anxiety, to make clear that the issue before the Board is entitlement to a psychiatric disability, regardless of the particular diagnosis. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service Connection The Veteran is seeking service connection for neck disability, right hip disability, neuropathy, acquired psychiatric disorder, and sleep apnea. Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In the alternative, secondary service connection may be established for a disability that is proximately due to, or the result of, or aggravated by a service-connected disease or injury. Establishing secondary service connection requires evidence of: (1) A current disability (for which secondary service connection is sought); (2) an already service connected disability; and (3) that the current disability was either (a) caused or (b) aggravated by the service connected disability. 38 C.F.R. § 3.310 (a); see also Allen v. Brown, 7 Vet. App. 439 (1995). 1. Neck disability, Right hip disability, and Neuropathy. The evidence of record does not reflect neck disability, right hip disability, and neuropathy. The Veteran underwent an October 2014 neck, hip and peripheral nerve examinations, where the examiners specifically found that the Veteran does not have neck disability, neck disability or neuropathy. Although the Veteran contends that he has these disabilities, the evidence of record does not demonstrate that the Veteran has the requisite medical training, expertise, or credentials needed to provide a diagnosis of a current disability. Therefore, the Veteran is not competent to say whether he has current neck and right hip disabilities, as well as neuropathy. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). In the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). As no current disability has been established for neck disability, right hip disability, and neuropathy dur, service connection for those conditions is not warranted.   2. Acquired Physiatric Disorder The Veteran’s attorney avers that the Veteran’s anxiety disorder is secondary to his service-connected disabilities. The Veteran is diagnosed with anxiety as reflected in an April 2016 Disability Benefit Questionnaire (DBQ); thereby there is a current disability. The Veteran is service-connected for left hip, left shoulder, low back, and bilateral knee disabilities. VA did not provide the Veteran with an examination to determine the relationship between his psychiatric disorder and his service-connected disabilities. However, a nexus opinion provided by Dr. H. Henderson in April 2016 reflects that the Veteran’s anxiety is more likely than not caused by his service-connected low back disability, left hip disability, left shoulder disability, and bilateral knee disabilities. The examiner indicated that medical literature reflects a correlation between anxiety and chronic medical issues, such as the Veteran’s service-connected disabilities. The examiner has reviewed the Veteran’s claims file and medical literature, as well as conducted an interview with the Veteran. Therefore, the Board finds this medical opinion adequate and highly probative. In sum, based on the April 2016 opinion from Dr. H. Henderson, it at least as likely as not that the Veteran’s service-connected disabilities cause his acquired physiatric disorder. Therefore, resolving all reasonable doubt in the Veteran’s favor, service connection for acquired physiatric disorder is granted. 3. Sleep Apnea A May 2016 DBQ reflects that the Veteran was diagnosed with sleep apnea in May 2015. Affording the benefit of the doubt to the Veteran, the Board finds that the first element of a secondary service connection claim is satisfied. In light of the Board’s finding above, the Veteran’s acquired psychiatric disorder, anxiety, is service-connected. In the May 2016 DBQ, Dr. H. Skaggs explained that the Veteran’s sleep apnea requires the use of CPAP, which he has been unable to use because of his anxiety. According to Dr. H. Skaggs, not using the CPAP results in aggravation of his sleep apnea. Dr. H. Skaggs further indicates that medical literature reflects that sleep apnea is more prevalent in individuals with anxiety than those without diagnosis of anxiety. For these reasons, Dr. H. Skaggs concluded that the Veteran’s sleep apnea is more likely than not caused or aggravated by the Veteran’s anxiety. Dr. H. Skaggs interviewed the Veteran and reviewed the claims file, as well as medical literature. The Board finds Dr. H. Skaggs’s opinion adequate and highly probative. Based on the aforementioned evidence, the Board finds that the Veteran’s claim for secondary service connection for sleep apnea is granted. Increased Rating The Veteran is seeking an increase rating for his back disability, left shoulder disability, and bilateral knee disability. The VA’s Schedule for Rating Disabilities is used to determine disability ratings once a disability is service-connected. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In the Rating Schedule, diagnostic codes (DC) are assigned to specific disabilities. These DCs designate percentage ratings based on the average functional impairment of the Veteran due to a service-connected disability. 38 C.F.R. §§ 3.321, 4.10. 1. Back Disability The Veteran’s back disability is rated as 10 percent disabling under DC 5237. DC 5237 is part of the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, a 20 percent rating is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or when there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the thoracolumbar spine. Note (1) to the General Rating Formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. In this case, the record does not reflect that the Veteran has neurological impairments. Nor is there evidence of bowel or bladder impairment; as such, the Board need not discuss such impairments. The General Rating Formal also provides alternative rating criteria for Intervertebral Disc Syndrome (IVDS). Here, there is no evidence that the Veteran’s disability has resulted in IVDS requiring prescribed bed rest. On this basis, the Board finds that it need not further discuss these alternative rating criteria. The evidence in the record does not show limitation of range of motion that is consistent with a rating higher than 10 percent. That is, the October 2014 examination elicited a forward flexion greater than 90 degrees with pain starting at that point. He had 30 degrees or greater extension, 20 degrees of bilateral flexion and bilateral rotation. Therefore, this examination found a combined ranger of motion well over 120 degrees. Based on these results, the schedular criteria of less than 60 degrees of forward flexion or a combined range of motion of less than 120 degrees is not satisfied for an evaluation of 20 percent rating to be warranted. The Board recognizes that VA must also analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, pain that does not result in additional functional loss does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Here, the Veteran reported flare-ups that causes additional pain. The Board recognizes that the examinations of record was not conducted during flare-ups. However, repetitive use test revealed 85 degrees of forward flexion, 25 degrees of extension, and 15 degrees of bilateral lateral flexion and bilateral lateral rotation. Therefore, while there is additional limitation of range of motion after exertion, it is still not consistent with a 20 percent disability rating. Based on this examination, even after repeated use, the Veteran’s impairment is less than what is contemplated for a 20 percent rating. As previously stated, increase pain during flare-ups alone without additional functional loss is not grounds for assigning a higher rating. Therefore, the Board finds that the preponderance of the evidence is against a finding that the severity of the Veteran’s back disability is consistent with a 20 percent rating under DC 5237. 2. Left Shoulder The Veteran’s left shoulder disability is rated as 20 percent disabling under DC 5003-5201. As noted above, under DC 5003, arthritis is rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. If the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, DCs 5003. The DCs pertaining to limited motion of the shoulder are DCs 5200 and 5201, and his disability has been rated under the criteria in DC 5201. Under DC 5201, limitation of motion of the arm, a 20 percent rating is assigned when the arm can only be lifted to shoulder level, for both the major and minor side. Motion limited to midway between the side and shoulder level on the major side warrants a 30 percent rating, but on the minor side warrants a 20 percent rating. Motion limited to 25 degrees from the side on the major side warrants a 40 percent rating, but on the minor side warrants a 30 percent rating. Id., DC 5201. Additional DCs relating to the shoulder will not be discussed, as the Veteran’s condition is not manifested by ankylosis (DC 5200) or impairment of the humerus (DC 5202), or impairment of clavicle or scapula (DC 5203). VA must also analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, pain that does not result in additional functional loss does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes that the Veteran is right-handed, therefore his left shoulder is rated as his minor side. Id. The evidence of record weighs against rating higher than 20 percent for the Veteran’s left shoulder disability. During an October 2014 examination, the Veteran’s left shoulder flexion and abduction was limited to 70 degrees with pain starting at that point. His flexion and abduction was reduced to 65 degrees after repetitive use test. The examiner noted that the Veteran has approximately 5 degrees additional reduction of range of motion during flare-ups. If that additional 5 degrees reduction is from the range of motion recorded after repetitive use test, the Veteran would still have 60 degrees of abduction. Therefore, even when account of additional functional loss during flare-up, the evidence of record reflects that the Veteran has range of abduction that is greater than 25 degrees from the side. The Board finds this examination adequate and highly probative. Notably, the Veteran has not challenged the adequacy of the exam. Nor has he identified another medical record that reflects the severity of his left shoulder disability. This examination does not reflect a level of impairment contemplated by a 30 percent disability rating. In sum, the evidence does not reflect a range of motion limited to 25 degrees from the side, even when considering pain after repetitive testing and during flare-up. Therefore, the Veteran’s left shoulder disability does not result in a limitation of range of motion that is consistent with the higher 30 percent rating under DC 5201 for a minor arm.   3. Bilateral Knee disability The Veteran’s left and right knee disabilities are assigned rating of 10 percent each under DC 5260. Under DC 5260, limitation of flexion of the leg, a 0 percent rating is assigned when flexion is limited to 60 degrees. A 10 percent rating is warranted when flexion of the leg is limited to 45 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees. For VA compensation purposes, normal flexion of the knee is to 140 degrees, and normal extension of the knee is 0 degrees. 38 C.F.R. § 4.71a , Plate II. The Court has held that in its evaluation of musculoskeletal disabilities, joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, No. 13-3238, 2016 WL 3591858 (Vet. App. July 5, 2016). Here, the Board recognizes that the October 2014 DBQ of record does not indicate whether all of the tests outlined in Correia have been conducted. Nevertheless, the examination is adequate to adjudicate the claim because it evaluated range of motion in the left and right knees, pain, additional limitation of motion and functional loss upon repetitive testing, as well as instability of the knees. Notably, range of motion comparison of the “undamaged” joint does not apply here as the Veteran has a bilateral knee disability. During the October 2014 examination, the Veteran’s right knee demonstrated 0 to 45 degrees of flexion with pain starting at that point. As to the left knee, the Veteran’s range of flexion is limited to 40 degrees with pain starting at that point. Based on this range of motion results, the Veteran’s bilateral knee disability is consistent with the 10 percent rating currently assigned. However, the Board has considered whether a higher evaluation is warranted based on 38 C.F.R. §§ 4.40, 4.45. To that end, evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45; Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). In this instance, the Veteran reports flare-ups with severe pain that interferes with his ability to walk. He stated that his flare-ups last two to three months at a time. The examination was not conducted while the Veteran is experiencing flare-up. However, the repetitive use test reflected a reduction in the range of motion. That is, the Veteran had 40 degrees of flexion in the right knee and 30 degrees in the left. Considering these results and affording the Veteran the benefit of the doubt, the Board finds that the Veteran’s bilateral knee disability approximates a level contemplated by a 20 percent disability rating. The Board recognizes that there are several DCs that are applicable to knee disabilities found in 38 C.F.R. § 4.71a (2017). However, DC 5261(extension), 5257(recurrent subluxation or later instability), 5256 (ankylosis of the knee), 5258 (dislocated semilunar cartilage), 5259 (symptomatic removal of semilunar cartilage), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are all inapplicable in this case. The evidence, in this case, simply does not reflect findings or a history consistent with these conditions. Effective Date The Veteran is seeking an effective date earlier than assigned for his service-connected back disability, left shoulder disability, left hip disability, right knee disability and left knee disability. Section 5110(a), Title 38, United States Code, provides that “[u]nless specifically provided otherwise in this chapter, the effective date of an award based on an original claim... of compensation... shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor.” The implementing regulation, 38 C.F.R. § 3.400, similarly states that the effective date of service connection “will be the date of receipt of the claim or the date entitlement arose, whichever is the later.” The VA administrative claims process previously recognized formal and informal claims. A formal claim is one that has been filed in the form prescribed by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151 (a). An informal claim may be any communication or action indicating intent to apply for one or more benefits under VA law. Thomas v. Principi, 16 Vet. App. 197 (2002); 38 C.F.R. §§ 3.1 (p), 3.155(a). An informal claim must be written and it must identify the benefit being sought. Although a claimant need not identify the benefit sought “with specificity,” some intent on the part of the veteran to seek benefits must be demonstrated. VA has a duty to fully and sympathetically develop a veteran’s claim to its optimum. Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998). This duty requires VA to “determine all potential claims raised by the evidence, applying all relevant laws and regulations,” and extends to giving a sympathetic reading to all pro se pleadings of record. If at any time after VA issues a decision on a claim, VA receives or associates with the record relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding 38 C.F.R. § 3.156 (a). Such records include, but are not limited to, service records that are related to a claimed in-service event, injury, or disease. 38 C.F.R. § 3.156 (c) (1). An award made based all or in part on such records is effective on the date entitlement arose or the date VA received the previously decided claim, whichever is later, or such other date as may be authorized by the provisions of this part applicable to the previously decided claim. 38 C.F.R. § 3.156 (c) (3). 1. Right Knee and Left Hip The Veteran filed service connection claim for right knee disability and left hip disability in May 11, 2009, which was denied by way of a September 2009 rating decision. However, the Veteran did not file a notice of disagreement with that rating decision. Rather, he filed another claim in January 30, 2014. The Regional Office (RO) granted service connection for right knee disability and left hip disability in a December 2014 rating decision and assigned the January 30, 2014. The Board notes that the Veteran’s complete service treatment record (STR) did not become part of the record until March 2014. Considering the relevance of the information in the Veteran’s STRs, and affording the Veteran the benefit of the doubt, the Board finds that the RO’s grant of service connection for back disability in December 2014, at least in part, relied on the STRs that were associated with the claims file after the denial in May 2009. Therefore, the September 2009 rating decision was not final; thereby the Board finds that the appropriate effective date for the Veteran’s service-connected right knee disability and left hip disability is May 11, 2009. 2. Left Shoulder The Veteran has not filed a claim for left shoulder disability. Notwithstanding, the RO scheduled him for left shoulder examination on October 22, 2014 that found that he has left shoulder degenerative joint disease that is etiologically related to his military service. Because October 22, 2014 is the earliest date the record reflects a current disability, that is the appropriate effective date for service connection for left shoulder disability. 3. Back and Left Knee Although the Veteran asserts that service connection for back disability and left knee disability should be effective earlier than January 30, 2014, he does not contend that he filed the claims earlier than this date. After thorough review of the record, the Board finds that there is no evidence of record that shows a claim for either service-connection for back disability or left knee disability before the effective dates assigned. Notably, in May 2009, the Veteran filed a service connection claim for right knee disability and left hip disability and did not make a general claim for service connection. Particularly, the claim did not raise the issue of service connection for either back disability or left knee disability. The service connection claims for back disability and left knee disability were granted based on the Veteran’s multiple parachute jumps and not in-service diagnosis. For these reasons, this case is distinguishable from Sellers v. Wilkie, CAVC No. 16-2993 (August 2018). Therefore, an effective date earlier than January 30, 2014 is not warranted for the Veteran’s service-connected back and left knee disabilities. REMANDED ISSUES The Board regrets further delay, but additional development is necessary before adjudicating the remaining claims. A. Tinnitus, Disability Manifested by Fatigue, and Hypertension The Board cannot make a fully-informed decision on the issue of entitlement to service connection for tinnitus, disability manifested by fatigue, and hypertension because no VA examiner has opined whether the condition is related to the Veteran’s military service. B. Headaches As to the claim of service connection for headaches, the Veteran reported that his headaches started in 1999. See May 2016 DBQ. However, the nexus opinion provided by Dr. H. Skaggs indicates that the Veteran’s headaches are casused by his anxiety and sleep apnea. The opinion, however, does not address the Veteran’s report of headaches decades before the diagnosis of sleep apnea or anxiety. For this reason, the Board finds the opinion inadequate and a remand to obtain an adequate opinion is necessary before the Board can adjudicate the claim.   C. Left Hip As to the Veteran’s claim of increase rating for left hip disability, the Veteran underwent an examination in October 2014. The Board finds the examiner’s remarks in the examination report internally inconsistent. On the one hand the examiner states that the Veteran’s left hip abduction ends at 15 degrees and objective eviendec of painful motion begins at 15 degrees. On the other hand, in the next sentence, the examiner states that the Veteran’s left hip abduction ends at 25 degrees and objective evidence of painful motion beginst at 25 degrees. For this reason, a remand is necessary to obtain an adequate examination that reflects the severity of the Veteran’s left hip impairment. D. TDIU With respect to the Veteran’s claim for a TDIU, the Veteran has indicated that he is unable to maintain a job because of his disabilities. In light of the above awards for service connection, adjudication of the Veteran’s claim for TDIU must be deferred pending the assignment of disability ratings and effective dates for those grants, which are assigned by the AOJ in the first instance. The matters are REMANDED for the following action: 1. Update VA treatment records. 2. After completion of directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any tinnitus. The examiner must opine whether the Veteran’s tinnitus is at least as likely as not related to an in-service injury, event, or disease. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner 3. After completion of directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any disability manifested by fatigue. After reviewing the claims folder in its entirety, the examiner should answer the following questions: Does the Veteran at least as likely as not (50 percent or greater probability) have a distinct disability manifested by fatigue? If so, is the Veteran’s disability manifested by fatigue at least as likely as not (50 percent or greater probability) etiologically related to his military service? If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. After completion of directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hypertension. After reviewing the claims folder in its entirety, the examiner should answer the following questions: Does the Veteran have hypertension? If so, is the Veteran’s hypertension at least as likely as not (50 percent or greater probability) etiologically related to his military service? The examiner is asked to consider and comment on whether the Veteran’s blood pressure reading noted in his service treatment records in April 1993, January 1995, March 1995, July 1995, and October 1995 were a manifestation of hypertension. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 5. After completing directive #1, schedule the Veteran for VA examination to determine the nature and etiology of his headaches. The examiner should review the claims file in its entirety and provide an opinion answering the following questions: Is the Veteran’s headaches at least as likely as not (50 percent or greater probability) etiologically related to his military service? In the alternative, the examiner should consider whether the Veteran’s headaches at least as likely as not (50 percent or greater probability) caused by the Veteran’s service connected acquired psychiatric disorder; and Is it at least as likely as not (50 percent or greater probability) that the Veteran’s headaches aggravated his acquired psychiatric disorder. In the alternative, the examiner should consider whether the Veteran’s headaches at least as likely as not (50 percent or greater probability) caused by the Veteran’s service connected sleep apnea; and Is it at least as likely as not (50 percent or greater probability) that the Veteran’s headaches aggravated his sleep apnea. The examiner is asked to consider and comment on the Veteran’s lay statement regarding the onset of his headaches. The term “aggravated” in the above context means a chronic worsening of symptoms, and not temporary or intermittent flare-ups of symptoms which resolve and return to the baseline level disability. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 6. After completion of directive #1, schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected left hip disability. The examiner should provide findings regarding all symptoms and describe the severity of each symptom. A complete rationale should be provided for all opinions. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is the case. 7. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement for a TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S.SOLOMON