Citation Nr: 18148699 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 16-61 635 DATE: November 8, 2018 ORDER New and material evidence having been submitted the claim for entitlement to service connection for peripheral artery disease (PAD), to include as due to exposure to contaminated water at Camp Lejeune, is reopened. Entitlement to service connection for tinnitus is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service connected disabilities is granted. Entitlement to service connection for a left wrist condition is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tension headaches is denied. Entitlement to service connection for left side sciatic nerve damage is denied. Entitlement to service connection for right lower extremity radiculopathy is denied. REMANDED Entitlement to service connection for PAD, to include as due to exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for right knee osteoarthritis is remanded. FINDINGS OF FACT 1. An unappealed September 2013 rating decision originally denied the Veteran service connection for PAD based essentially on a finding that the evidence of record failed to show that such disability was due to service. 2. Evidence received since the September 2013 rating decision includes evidence not of record at that time that suggests the Veteran’s PAD was due to his service; relates to an unestablished fact necessary to substantiate the underlying claim of service connection; and raises a reasonable possibility of substantiating that claim. 3. The evidence reasonably shows the Veteran has tinnitus that began during service and has persisted since. 4. The Veteran’s service-connected low back, shoulder and bilateral foot disabilities are reasonably shown to prevent him from obtaining or following substantially gainful employment. 5. A left wrist condition is not shown. 6. Left side sciatic nerve damage is not shown. 7. Right lower extremity radiculopathy is not shown. 8. The Veteran’s bilateral hearing loss disability did not begin in service or manifest within the first post-service year, and is not otherwise related to service. 9. Chronic tension headaches are not shown. CONCLUSIONS OF LAW 1. New and material evidence has been received; the claim of service connection for PAD may be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 2. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for a schedular TDIU have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. 4. The criteria for service connection for a left wrist condition have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. § 3.303. 5. The criteria for service connection for left side sciatic nerve damage have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. § 3.303. 6. The criteria for service connection for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. § 3.303. 7. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 8. The criteria for tension headaches have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 1973 to March 1983. In a January 2018 rating decision, the RO granted the Veteran’s claim for service connection for lumbosacral strain, right shoulder subacromial and subdeltoid bursitis, and bilateral plantar fasciitis. The Veteran has not disagreed with the ratings assigned or the effective date of such ratings. Therefore, such are not before the Board at this time. Finally, in an April 2018 rating decision the RO granted the Veteran’s claim for service connection for acromioclavicular joint arthritis and denied the Veteran’s claim for TDIU. The Veteran has not disagreed with the rating or effective date assigned for his acromioclavicular joint arthritis, therefore such is not before the Board at this time. Petition to Reopen New and material evidence having been received, the claim for entitlement to service connection for peripheral artery disease (PAD), to include as due to exposure to contaminated water at Camp Lejeune is reopened. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. “New” evidence means existing evidence not previously submitted to agency decision-makers. “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. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003). The requirement of new and material evidence raising a reasonable possibility of substantiating the claim is a low threshold. Specifically, the language of 38 C.F.R. § 3.156 (a) creates a low threshold and the phrase “raises a reasonable possibility of substantiating the claim” should be viewed as “enabling rather than precluding reopening.” See Shade v. Shinseki, 24 Vet. App. 110 (2010). To substantiate a claim of service connection, there must be evidence of: a current claimed disability; incurrence or aggravation of a disease or injury in service; and a nexus between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Here, the Veteran was initially denied service connection for PAD in September 2013. At that time, he claimed that such disability was due to or began during his active duty service. The September 2013 rating decision found that while the Veteran had a history of arterial disease, there was no evidence of any peripheral artery disease during the Veteran’s service and no medical evidence indicating that his current disability was related to his service or began during his service. The Veteran was notified of that decision and his appellate rights, but did not initiate a timely appeal. Thus, that decision became final. Evidence in the record at the time of the September 2013 rating decision included service treatment records (STRs), service personnel records which confirm that the Veteran served at Camp Lejeune, and post-service treatment records. Evidence received since the September 2013 rating decision includes, among other documents, updated VA treatment records, and additional statements from the Veteran, including his allegation that his PAD was due to exposure to contaminated water at Camp Lejeune. Because the September 2013 rating decision specifically denied the claim because there was no evidence that the Veteran’s current PAD was due to service, such evidence and new theory of entitlement directly relates to previously unestablished elements of service connection needed to substantiate the Veteran’s claim. In light of the above, and particularly considering the low threshold for reopening established in Shade, the Board finds that the new evidence also raises a reasonable possibility of substantiating the underlying service connection claim. Therefore, it is both new and material, and the claim of service connection for PAD may be reopened. The downstream issue of service connection on de novo review will be discussed in the remand portion below. Service Connection Service connection may be granted for disabilities due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after discharge when the evidence establishes that disability was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may be established by showing continuity of symptomatology after discharge. 38 C.F.R. § 3.303 (b). Certain chronic diseases, to include arthritis and organic diseases of the nervous system (such as sensorineural hearing loss), may be presumed to have been incurred or aggravated in service, if they are manifested to a compensable degree within a specified period of time post-service. 38 U.S.C. §§ 1112; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). To substantiate a claim of service connection, there must be evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. Without competent evidence of a disability, the Board must deny the Veteran’s claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). As previously noted when there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim is to be denied. Gilbert, 1 Vet. App. at 55. Entitlement to service connection for tinnitus is granted. The Veteran alleges that he has tinnitus which began in service and has persisted since. It is critical to note, at the outset, that the Veteran is wholly competent to self-diagnose and report the onset and course of simple, lay-observable conditions such as tinnitus (which is diagnosed primarily based on subjective reports). Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). He is competent to testify as to the onset and frequency of tinnitus. Charles v. Principi, 16 Vet. App. 370 (2002). Thus, his own account of experiencing the initial onset of tinnitus in 1973 during service with continuity since is competent evidence of the history and course of his tinnitus. The Board finds no reason to doubt the veracity of those statements, and finds them credible. Thus, those statements, alone, are sufficient to establish entitlement to service connection on the basis that tinnitus began in service and has persisted since. Finally, the Board notes that the November 2016 VA examiner confirmed that the Veteran had tinnitus which began in 1973 after a M-14 was shot near him. The examiner opined that the Veteran had hearing loss and that his tinnitus was at least as likely as not a symptom associated with the hearing loss, as tinnitus is a known symptom associated with hearing loss. However, the examiner also found that the Veteran’s tinnitus was at least as likely as not caused by or a result of military noise exposure. As the examiner’s opinion is internally inconsistent, the Board affords it little probative weight. Accordingly, the Board finds the evidence is at least in relative equipoise as to whether the Veteran’s tinnitus began in service and has persisted. Resolving all remaining reasonable doubt in the Veteran’s favor, the Board finds the appeal in this matter must be granted. Entitlement to a TDIU is granted. The Veteran alleges that his service-connected shoulder, back and feet disabilities as well as the residuals from his strokes render him unable to obtain and sustain gainful employment. A TDIU rating may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purpose of meeting these schedular criteria, disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; disabilities resulting from common etiology or a single accident; disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; and multiple injuries incurred in action, will be considered as one disability. 38 C.F.R. § 4.16 (a). In considering whether TDIU is warranted, neither the veteran’s nonservice-connected disabilities nor his age may be considered. 38 C.F.R. § 4.19. The ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Here, the Veteran’s service-connected disabilities include mild left acromioclavicular joint arthritis (rated at 20 percent), right shoulder subacromial and subdeltoid bursitis (rated at 20 percent), lumbosacral strain claimed as a thoracolumbar spine condition (rated at 20 percent), bilateral plantar fasciitis (rated at 10 percent), residuals of 3rd digit left hand injury (rated at 10 percent), 3rd digit left hand scar (rated at 10 percent), and 3rd digit left hand scar (rated as noncompensable). As of September 2016, the Veteran’s combined evaluation was 60 percent with the bilateral factor and 70 percent from May 2017 with the bilateral factor. Thus, the schedular criteria for TDIU are met, and the only question is whether such rating is substantively warranted. In October 2016 the Veteran underwent a VA Shoulder and Arm Conditions Disability Benefits Questionnaire (DBQ). The examiner found that the Veteran’s left shoulder disability impacted his ability to perform any type of occupational task. The examiner further noted that his disability resulted in poor tolerance for heavy lifting or overhead shoulder motion limits options for some construction jobs, or jobs that require reaching up to high shelves with heavy weight. In December 2017 the Veteran underwent an additional VA shoulder and Arm Conditions DBQ. The examiner opined that the Veteran’s bilateral shoulder disability would impact his ability to perform any type of occupational task. The examiner further noted that the Veteran’s disability would limit his ability to lift or reach overhead with his arms. In December 2017 the Veteran underwent a VA Back Conditions DBQ. The examiner opined that the Veteran’s back disability does impact his ability to work. The examiner further noted that the functional impact of each condition is limited capacity to bend and lift as well as limited tolerance for standing, walking and running. In December 2017 the Veteran underwent a Foot Conditions DBQ. The examiner opined that the Veteran’s bilateral foot disability would impact his ability to perform any type of occupational task. The examiner further stated that the functional impact of each condition would be limited tolerance for running, prolonged standing or walking. In March 2018 the Veteran underwent an additional VA Shoulder and Arm Conditions DBQ. The examiner opined that the Veteran’s shoulder disability would impact his ability to perform any type of occupational task. The examiner further stated that his disability would limit his ability to lift or reach overhead with his arms. In March 2018 the Veteran underwent another VA Back Conditions DBQ. The examiner opined that the Veteran’s back disability would impact his ability to work. The examiner stated that the functional impact of each disability is that they would limit the Veteran’s ability to bend and lift as well as a limited tolerance for standing and walking. In March 2018 the Veteran underwent another VA Foot Conditions DBQ. The examiner opined that the Veteran’s foot disability would impact his ability to perform any type of occupational task. The examiner further stated that his disabilities would limit his tolerance for standing and walking. In addition, the examiner stated that the Veteran would be unable to run. Finally, the Board notes that the Veteran reported that he completed high school, but did not complete any additional education or training. Furthermore, the Veteran reported that after leaving the military he was self-employed as a painter until 2007 when he became too disabled to work, but had no other job experience. In light of the above, the Board finds that the evidence reasonably shows that the Veteran’s service-connected disabilities preclude obtaining or following substantially gainful employment. While the Veteran has also indicated that his stroke residuals also contribute to his inability to work, he is not service connected for such and therefore they cannot be taken into consideration in evaluating the Veteran for a TDIU. However, the Board finds that in light of the evidence of record and the Veteran’s training and education a TDIU is warranted. Entitlement to service connection for a left wrist condition, left side sciatic nerve damage, tension headaches, and right lower extremity radiculopathy are denied. The Veteran asserts that he has a left wrist condition, left side sciatic nerve damage, tension headaches and right lower extremity radiculopathy due to his service and service-connected low back disability. Service treatment records do not reflect any complaints or treatment of a left wrist condition, left side sciatic nerve damage, chronic tension headaches or right lower extremity radiculopathy. A January 1978 treatment record reflects the Veteran’s reports of financial hardship and associated tension headaches; however, such appear to be transient as there are no additional records of complaints or treatment for such. Post-service treatment records do not reflect treatment or diagnoses of a left wrist condition, left side sciatic nerve damage, chronic headaches or right lower extremity radiculopathy. In December 2017 and March 2018, the Veteran underwent thoracolumbar spine examinations. The examinations revealed no pathology affecting the Veteran’s sciatic nerve or right lower extremity. The physical examinations showed normal findings with regards to the Veteran’s sciatic nerve and no diagnosis of radiculopathy. The Board notes that the Veteran has not been afforded VA examinations in relation to this claims for his left wrist disability and headaches. In the instant case, VA’s duty to provide the Veteran with examinations has not been triggered. As previously noted his service treatment records are silent for complaints of or treatment for a left wrist disability or chronic tension headaches or pertinent symptoms. Significantly, the Veteran has not been diagnosed with a left wrist disability or chronic tension headaches. Moreover, there is no credible and competent evidence of record suggesting that the Veteran’s claimed disorders are related to service or began in service. The evidence of record contains only lay conclusory, generalized statements regarding an association with service that the Veteran is not competent to render. Accordingly, no examinations or medical opinions are required. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). The Board has considered the Veteran’s general contentions that he has these claimed disabilities due to his service and/or service-connected low back disability, but he is not competent to attest to such diagnoses as these require medical expertise. Again, the medical records do not reflect diagnoses of a left wrist condition, left side sciatic nerve damage, chronic tension headaches, or right lower extremity radiculopathy. The Veteran’s general contentions are outweighed by the lack of diagnoses or complaints reflected in the medical records. Absent a showing of a left wrist condition, left side sciatic nerve damage, chronic tension headaches, and right lower extremity radiculopathy, service connection for these disabilities cannot be granted. Thus, the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply, and the claims of service connection for a left wrist condition, left side sciatic nerve damage, chronic tension headaches, and right lower extremity radiculopathy must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Entitlement to service connection for bilateral hearing loss is denied. The Veteran contends that he has bilateral hearing loss as a result of noise exposure in service. On the June 1973 service enlistment examination, pure tone thresholds, in decibels, were as follows: 500 1000 2000 3000 4000 Right 10 5 0 N/A 0 Left 20 5 0 N/A 0 On a June 1976 examination, pure tone thresholds, in decibels, were as follows: 500 1000 2000 3000 4000 6000 Right 5 0 0 0 0 10 Left 10 5 0 0 10 5 On an October 1976 examination, pure tone thresholds, in decibels, were as follows: 500 1000 2000 3000 4000 Right 0 0 0 N/A 0 Left 5 0 0 N/A 0 On June 1980 separation examination, pure tone thresholds, in decibels, were as follows: 500 1000 2000 3000 4000 6000 Right 10 +5 -5 0 +5 +5 Left 10 +5 -5 0 +5 +5 On November 2016 VA audiological examination, pure tone thresholds, in decibels, were as follows: 500 1000 2000 3000 4000 6000 8000 Right 60 60 75 80 80 75 90 Left 70 80 90 90 105 100 100+ Speech audiometry revealed speech recognition ability of 44 percent in both ears. The Veteran reported no noise exposure prior to or after service, however he indicated that during training an M16 was fired near his left ear and that he also delivered parts to the flight lines and thus was exposed to noise from jets. The examiner opined that it is less likely than not that the Veteran’s hearing loss was the result of military service because audiometric tests were normal prior to separation and while there was a significant audiometric threshold shift after service, one was not shown during service. At the outset, the Board notes that, for VA purposes, 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. Thus, it is not in dispute that the Veteran has a current bilateral hearing loss disability. However, as bilateral hearing loss was not diagnosed in service, service connection for such disability is not warranted on the basis that it began in service and has persisted. Moreover, there is no evidence that sensorineural hearing loss first manifested to any degree in the first post-service year. Even affording the Veteran the benefit of the doubt, onset of hearing loss would have been several years after separation, at the earliest. Notably, the Veteran does not allege that he has had continuous symptoms of hearing loss since service. Thus, service connection for bilateral hearing loss is also not warranted on a presumptive basis as a chronic disease under 38 U.S.C. § 1112. What remains for consideration is whether the Veteran’s bilateral hearing loss may otherwise be directly related to service. To that end, the Board finds that the Veteran is competent to report exposure to hazardous noises in service and notes that while his military occupational specialty reflects that he was a cook, his Form DD 214 does reflect that he was awarded a rifle expert badge. Furthermore, an additional Form DD 214 reflects that he was a packaging specialist, therefore his claims of “delivering parts to the flight line” are in keeping with his duties. Therefore, acoustic injury in service is conceded. Consequently, the claim hinges on whether his current bilateral hearing loss is, in fact, related to the conceded noise exposure. Whether such a relationship exists is a medical question beyond the scope of lay observation. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). Thus, any explicit or implicit lay allegations of a medical nexus from the Veteran are not probative evidence. Here, the only pertinent medical opinion is from the November 2016 VA examiner. His negative opinion is based on the fact that there was not a significant threshold shift in service and normal audiometric testing at separation. Thus, the Board finds that opinion is supported by adequate rationale. Absent any other opinion or medical evidence to the contrary, it is highly probative and persuasive in this matter. Accordingly, service connection for bilateral hearing loss, on the basis that it is otherwise related to the Veteran’s service or noise exposure therein, is also not warranted. In light of the above, the Board finds the preponderance of the evidence is against finding the Veteran’s current bilateral hearing loss disability was incurred in, or is otherwise related to, his military service; thus, the benefit of the doubt rule does not apply, and the appeal in that matter must, unfortunately, be denied. REASONS FOR REMAND Entitlement to service connection for PAD, to include as due to exposure to contaminated water at Camp Lejeune is remanded. The Veteran alleges that his PAD is due to his active service, specifically due to exposure to contaminated water at Camp Lejeune. As previously noted the Veteran’s personnel records confirm that he served at Camp Lejeune, therefore potential exposure has been conceded. However, PAD is not among the enumerated diseases listed in 38 C.F.R. § 3.309 (f) as presumptively due to such exposure. Therefore, the presumptive provisions do not apply. However, such finding is not fatal to the Veteran’s claim; he may still establish service connection with affirmative evidence of a nexus between his PAD and his exposure to contaminated water or his service otherwise. Finally, the Veteran has never been examined in conjunction with his claim of service connection for PAD. Therefore, on remand, an examination which determines the etiology of the Veteran’s PAD and considers the Veteran’s allegation of exposure to contaminated water, should be obtained. In providing the requested opinions, the examiner should note that the mere fact that a condition is not noted by VA to be related to service at Camp Lejeune under 38 C.F.R. §17.400, is not, in and of itself, a sufficient basis to deny service connection for that condition. See generally Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009) (holding that it is inappropriate to “permit the denial of direct service connection simply because there is no presumptive service connection.”). Rather, if the condition is linked to service or to exposure to contaminated water by probative medical opinion, service connection can be granted. Therefore, on remand an examination which determines the likely etiology of the Veteran’s PAD should be obtained. Entitlement to service connection for right knee osteoarthritis is remanded. The Veteran alleges that he has right knee osteoarthritis, which began in and is due to his active duty service. The record reflects that during service the Veteran reported right knee pain and swelling. The Veteran’s condition was repeatedly attributed to insect bites; however, the Veteran contends that such was his knee disability manifesting. The record shows a post-service diagnosis of bilateral knee osteoarthritis; however, the Veteran reports that he did not seek medical treatment for such while in service or for many years after as he indicated that he did not have access to health insurance. This is sufficient to trigger VA’s duty to provide an examination. See 38 C.F.R. § 3.326; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Thus far, no VA examination has been provided. Thus, an examination and opinion should be obtained on remand. Due to the amount of time which will pass on remand, updated treatment records should be obtained and associated with the record. The matter is REMANDED for the following action: 1. Obtain updated treatment records. 2. Schedule the Veteran for an examination with an appropriate VA examiner to determine the likely etiology of his PAD. The claims file must be reviewed by the examiner in conjunction with the examination. After review of the claims file and examining the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s PAD arose in or is etiologically related to his military service, to include his exposure to contaminated drinking water at Camp Lejeune. The examiner should explain the reasoning for the opinions provided. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 3. Schedule the Veteran for a VA knee examination. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. All indicated studies should be conducted, and all findings reported in detail. The examiner must accomplish the following and must include a rationale to support any opinion provided. Provide a medical opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s right knee arthritis had onset during active service or was caused by active service. In doing so, the examiner is asked to address whether the Veteran’s in-service complaints of leg pain represent an in-service onset of such condition. The examiner should explain the reasoning for the opinions provided. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Unger, Associate Counsel