Citation Nr: 18148112 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-19 469A DATE: November 6, 2018 REMANDED Service connection for bilateral knee disability is remanded. Service connection for bilateral foot is remanded. Service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1983 to September 1993 in the United States Army. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision issued by the Department of Veterans Affairs (VA). 1. Entitlement to service connection for bilateral knees disability is remanded. 2. Entitlement to service connection for bilateral foot disability is remanded. Issues 1-2. The Veteran contends that his bilateral lower extremity (BLE) arthritis of the knees and feet were caused by his military service. In an October 2018 correspondence, the Veteran endorsed that he logged repeated jumps during active duty. He cited examples of paratrooper training, combat encounters, helicopter jumps, and other occurrences, which he asserts contributed to the manifestation of traumatic arthritis of his knees and feet. In March 2012, the Veteran was afforded a VA examination for his knees and feet. The Board finds that the VA medical opinion associated with that examination is inadequate because it does not address the Veteran’s theory of direct causation. Therefore, to ensure that VA has met its duty to assist, remand is required. 3. Entitlement to service connection for sleep apnea is remanded. The Veteran contends that he developed sleep apnea as a result of his service. In an October 2018 correspondence, his representative argued that service connection for sleep apnea had not been considered on a direct basis. She also cited to medical literature supporting a causal relationship between PTSD and sleep apnea. The Veteran submitted a May 2012 correspondence from a fellow service-member describing sleeping in the same quarters as the Veteran. Sergeant WM endorsed that the Veteran snored loudly, would choke and gasp for air and wake up during the night. He also noticed that the Veteran would nod off during the day and then awake and not recall being asleep. The questions for the Board include the following: 1) whether the Veteran’s obstructive sleep apnea was incurred in or caused by military service; and 2) whether the Veteran’s sleep apnea was caused by or aggravated beyond its natural progression due to service or a service connected PTSD. In March 2013, the Veteran was afforded a VA examination for his sleep apnea. Based on a January 2012 sleep study, a diagnosis of obstructive sleep apnea was confirmed. The examiner opined that the Veteran’s sleep apnea was not caused or aggravated by his service connected chronic fatigue syndrome (CFS). The examiner did not address whether the Veteran’s sleep apnea was directly related to service and, also, whether it was caused or aggravated beyond its natural progression by the Veteran’s service-connected disability as raised by the Veteran. The Veteran’s representative cited to literature supporting a relationship between sleep apnea and PTSD. Therefore, to ensure that VA has met its duty to assist, remand is required for an supplemental medical opinion in this matter. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s any current knee and foot disability to findings for include arthritis. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including jumping experiences and combat activity. 2. Obtain a medical opinion from an appropriate clinician on whether the Veteran’s obstructive sleep apnea is at least as likely as not incurred during service or proximately due to service-connected PTSD disability. The clinician should specifically address whether the symptoms of in-service snoring reflect onset of or an early manifestation of later diagnosed sleep apnea. The clinician should specifically address the medical literature supporting a causal relationship between PTSD and sleep apnea referenced by the Veteran’s representative. 3. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. A. Macek, Associate Counsel