Citation Nr: 18149218 Decision Date: 11/09/18 Archive Date: 11/08/18 DOCKET NO. 10-49 507 DATE: November 9, 2018 ORDER Entitlement to service connection for loss of sight and/or vision disability is denied. Entitlement to service connection for right ear hearing loss disability is denied. Entitlement to service connection for bilateral knee disability is denied. REMANDED Entitlement to service connection for degenerative disc disease of the lumbar spine is remanded. Entitlement to service connection for bilateral leg disability manifested by numbness/weakness is remanded. Entitlement to service connection for an acquired psychiatric disability, to include depression is remanded. Entitlement to service connection for a heart disability is remanded. FINDINGS OF FACT 1. Although the Veteran had an injury to the eyes in service, he had normal vision upon separation. 2. The most probative clinical evidence of record is against a finding that the Veteran has a current eye and/or vision disability which was incurred in service or aggravated by service. 3. The Veteran had right ear hearing loss disability for VA purposes shown prior to entrance into service; the Veteran’s preexisting right ear hearing loss disability did not increase beyond its natural progression during service. 4. The most probative clinical evidence of record is against a finding that current right ear hearing loss disability was incurred in service. 5. The most probative clinical evidence of record is against a finding that the Veteran has a current knee disability causally related to, or aggravated by, service and/or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral eye and/or vision disability are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304. 2. The criteria for service connection for right ear hearing loss disability are not been met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.306, 3.307, 3.309. 3. The criteria for service connection for bilateral knee disability are not been met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.306, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1975 to May 1977. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2010 and July 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. These matters were previously before the Board in June 2015 and were remanded for development. They have now returned to the Board for further appellate consideration. During the pendency of the appeal, in a May 2018 rating decision, the RO granted service connection for left ear hearing loss disability and tinnitus; thus, those issues are no longer for Board consideration. At the time he filed his current claim in 2010, the Veteran submitted a VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative, in favor of The American Legion (AL). Recently, on October 15, 2015, the VA received a VA Form 21-22 in favor of Disabled American Veterans (DAV). Under the provisions of 38 C.F.R. § 20.1304(a), an appellant has 90 days following the mailing of notice that an appeal has been certified to the Board and the appellate record has been transferred to the Board, or until the date the appellate decision is promulgated by the Board, whichever comes first, during which he may submit a request for a change in representation. In this case, a notification letter was sent to the Veteran advising him that his appeal had been certified and transferred to the Board as required under the provisions of 38 C.F.R. § 19.36 (2014) on July 10, 2018. Therefore, in this case, the date that comes first under 38 C.F.R. § 20.1304(a) for purposes of requesting a change in representation is 90 days from the date of the notification letter, October 8, 2018. The Board normally cannot accept a request for a change in representation after this 90-day grace period unless good cause is shown in a written motion to account for the delay in the submission of the request. 38 C.F.R. § 20.1304(b). There was no accompanying explanation as to why this change in representation was not submitted in a timely manner. In fact, it was submitted accompanying another claim for benefits. Accordingly, to the extent the Veteran's October 15, 2018, 21-22 can be considered a request to appoint a new representative, it is not accepted as part of this appeal and the appellant still is represented, in this appeal only, by The American Legion. Service Connection Legal Criteria 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 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection may also be awarded on a presumptive basis for certain chronic diseases, to include degenerative joint disease (arthritis) and hearing loss, listed in 38 C.F.R. § 3.309(a), that manifest to a degree of 10 percent within one year of service separation. Id. §§ 3.303(b), 3.307. Service connection may be awarded on the basis of continuity of symptomatology for those conditions listed in 38 C.F.R. § 3.309(a) if a claimant demonstrates (1) that a condition was noted during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); 38 C.F.R. § 3.303(b). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Entitlement to service connection for an eye/vision disability The Veteran contends that he has an eye disorder as a result of an in-service injury/assault. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran did have an incident in service with regard to his eyes, the evidence is against a finding that he has a current disability which began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service treatment records (STRs) dated in May 1976 reflect that the Veteran complained of being struck by a chain during an assault after glass penetrated a vehicle window; the STR notes “glass in both eyes.” The eyes were flushed with saline; examination under U.V. light showed no damage to the cornea. The Veteran was prescribed Visine. Subsequent records in the next eleven months are negative for complaints of the eyes/vision. The Veteran’s 1977 separation examination reflected normal eyes and visual acuity (20/20). Thus, approximately a year after the incident, the Veteran did not have symptoms of an eye disability and had normal eyes. The post-service medical record reflects complaints of, and treatment for eye problems (e.g., ulcers, itching, feeling of “grit in eyes,” film in eyes, frequent use of Visine) as early as February 1985. See, e.g., February 1985 VA Medical Certificate; see also April 1985, and June 1985 VA Treatment Records. However, this is more than seven years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, during the pendency of his claim, ulcers of the eye have not been found on examination. A July 2010 VA examination report reflects that the Veteran was diagnosed with presbyopia and had no other eye problem. The clinician stated that that the Veteran needs glasses “to read just like most patients over the age of 40. This has nothing to do with getting glass in the eye.” The examiner found that there were no physical findings of abnormal duct function, chronic conjunctivitis, or residuals of an eye injury. Since that time, the Veteran has received VA treatment for complaints of a “gummy” feeling in eyes, yellow discharge, and pink eye. A November 2014 VA ophthalmology consultation note reflects “normal tension glaucoma suspect,” dry eye syndrome, and refractive error with presbyopia. An August 2016 VA optometry note reflects that the Veteran complained of monocular ghosting/shadowing, occasional floaters, and blurred vision. A February 2017 VA examination report reflects that the Veteran’s “glaucoma suspect which had been diagnosed in 2012 had resolved, with no evidence of loss of retinal nerve fiber layer.” In essence, although in 2014 it was suspected that the Veteran had glaucoma, by 2017, there was no evidence of optic nerve damage or elevated intraocular pressure to support such a diagnosis. The clinician also found that there was no neurological ocular cause for the Veteran’s prior apparent visual field defects. The examiner also noted a diagnosis of age-related nuclear cataracts in 2016. Service connection is not allowed for refractive error of the eyes, including myopia, presbyopia and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. § 3.303 (c). The 2017 VA examiner found that it is less likely as not that the Veteran has an eye disability causally related to service. The examiner noted, in pertinent part, as follows: The Veteran does have contracted visual fields in both eyes but this is not consistent with glaucomatous visual field loss. His optic nerves show no sign of glaucomatous damage on exam today. . . .The Veteran’s eye injury occurred on May 5, 1976. He was diagnosed with Dry eye syndrome on February 15, 2011. Dry eye syndrome occurs due to inadequate production of tears. Tear production decreases with age and dry eyes are a part of the natural aging process. As the Veteran was diagnosed with Dry eye syndrome almost thirty-five years after his eye injury there is no causal relationship. . . . Presbyopia is a normal aging change that occurs when a person reaches their 40s. It is not caused by disease or injury. The Veteran has a small amount of refractive error in both eyes (hypermetropia and regular astigmatism) due to the shape of his eyes. He has normal vision in each eye and thus no disability from presbyopia or refractive errors. The VA examination combined opinions are probative, because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report having experienced difficulty with vision and/or his eyes, he is not competent to provide a diagnosis for VA purposes in this case or determine that these symptoms were manifestations of the eye injury in service. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board also finds that any clinical opinion based on continuity of symptoms since service lacks probative value as the evidence does not support such continuity. Although the Veteran reported upon separation that he had, or had previously had, eye trouble, his Report of Medical Examination for separation reflects 20/20 vision bilaterally for both distant and near vision. Moreover, it is negative for findings of dry eye, glaucoma, or other eye/vision defects or disabilities. In sum, the Veteran had an injury to the eyes in service but it did not cause or aggravate a disability post-service, and the Veteran does not have a current eye/vision disability which warrants service connection. The probative evidence is against a finding that any of his reported eye and/or vision symptoms is causally related to his in-service injury. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to service connection for right ear hearing loss disability The Veteran entered service in July 1975. His January 1975 Report of Medical Examination for enlistment purposes reflects that upon audiometric testing, his hearing acuity for the right ear was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 10 -- 45 In Hensley v. Brown, 5 Vet. App. 155, 157 (1993) the Court held that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Therefore, the Veteran’s entrance examination report reflects abnormal hearing. 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 of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies 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’s auditory threshold for the right ear was 45 at 4,000 Hertz; thus, it was a disability for VA purposes. A pre-existing injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306. Aggravation may not be conceded, however, where the disability underwent no increase in severity during service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. If a presumption of aggravation under section 1153 arises, due to an increase in a disability in service, the burden shifts to the government to show a lack of aggravation by establishing “that the increase in disability is due to the natural progress of the disease.” 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004). A May 1976 audiometric evaluation report reflects that that upon audiometric testing, his hearing acuity for the right hear was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 10 -- 5 The Veteran separated from service in May 1977. His April 1977 Report of Medical Examination for separation purposes reflects that upon audiometric testing, his hearing acuity for the right ear was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 15 15 10 15 Thus, although the Veteran had a pre-existing disability for VA purposes prior to service, he no longer had a disability for VA purposes upon separation. Therefore, the evidence is against a finding that the Veteran’s pre-existing right ear hearing loss disability was aggravated (i.e. increased in severity) by active service, and service connection is not warranted under 38 C.F.R. § 3.306. The Board has also considered whether the Veteran is entitled to service connection assuming arguendo that he did not have a preexisting right ear hearing loss disability. The Veteran was afforded a VA audiological examination in May 2010. At that time, the Veteran reported experiencing loud noise from tank engines and firing, as well as truck engines and wreckers while working in maintenance in the military. His DD 214 reflects that his military occupational specialty as the equipment of a tow truck operator. The 2010 VA examiner opined that hearing loss was less likely as not caused by or a result of noise exposure in-service. With respect to hearing loss, the examiner noted that the Veteran underwent audiometric examinations in-service in 1975, 1976, and 1977, and found that the 1976 audiometric examination indicated hearing within normal limits, “suggesting that the moderate loss at induction [in 1975] in the (R) ear was possibly due to a temporary threshold shift.” Additional VA record reflect that the Veteran received audiology services, and obtained hearing aids. The Veteran was afforded another examination in January 2017. The examiner noted in pertinent part, as follows: The 1975 exam documented that veteran had a moderate (45dB) threshold in the (R) ear. . . . The veteran’s 1977 test results indicate a mild loss (30dB) at 500Hz in the (R) ear. The 1975 entrance exam documents clear and unmistakable evidence that the veteran had a hearing loss at induction. The normal bilateral thresholds that were tested indicated on veteran’s 1976 exam is clear and unmistakable evidence that the pre-existing moderate hearing loss in the (R) ear was likely due to a temporary threshold shift . . . therefore the 1975 exam did not document a [permanent] hearing loss at induction. . . . The examiner also noted that the Veteran’s discharge results documented a mild loss bilaterally at 500 Hz, and that his post-service VA records from 2012 and 2013 demonstrate that the mild loss at discharge at 500 Hz was not the result of a significant permanent threshold shift from entrance to separation. The examiner found that the Veteran’s threshold shift of 10 dB from entrance to separation is not considered a significant threshold shift but instead normal test re-test variance. The examiner stated in pertinent part, as follows: As no permentant [sic] decreased significant threshold shift form veteran’s 1975 to his 2013 exam was noted in the [right] ear at 500 Hz or at any other frequency from entrance to separation; it is my opinion veteran’s current [right] ear hearing loss is less likely as not due to loud noise exposure while in service. The Board finds the opinion probative as it is adequately supported by the record and provides an adequate rationale. Thus, the evidence is against a finding that service connection is warranted. The Board also finds that any clinical opinion based on continuity of symptoms since service lacks probative value as the evidence does not support such continuity. The Veteran’s April 1977 Report of Medical History for separation purposes reflects that he denied hearing loss. The Board notes that the Veteran reported several other complaints; thus, if he noticed difficulty with hearing acuity, it would have been reasonable for him to have reported such as he reported other complaints. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to service connection for bilateral knee disability The Veteran contends that he has a bilateral knee disability secondary to his service-connected right foot disability. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress, by the service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of a knee disability, and the preponderance of the evidence is against finding that even if he had a knee disability it would be proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A December 1999 Physical Functional Capacity Assessment record reflects that the Veteran had normal flexion of the knees and no motor loss of the lower extremities. Subsequent clinical records reflect complaints of the legs, to include the knees, but without an actual diagnosis of a knee disability. A February 2008 VA examination report reflects that the Veteran reported that his knee pain began about 2 years prior (or in approximately 2006; more than three decades after separation from service); he endorsed popping of the knees. He stated that his leg/knee pain was the result of being out of balance due to his service-connected right foot disability. Upon examination, the examiner found that the Veteran had an antalgic gait on the right, and asymmetry of temperature with the left foot/ankle being cooler. The examiner noted that the right-sided symptoms found on examination are the opposite side as radiating pain in the past. The examiner also found mild knee effusion, and mild tenderness of the posterior knee with positive right “crepitance” and click. The Veteran had full range of motion with pain at the end of the range of motion. A radiology report reflected a negative study of both knees and that the bony structures appeared intact. The examiner found no pathology for a bilateral leg condition, and stated in pertinent part as follows: A leg condition separate from the back condition is described by the patient as affecting his [bilateral] knees. Xray evaluation and exam revealed no pathology. As a condition is not found, it is less likely as not caused by or a result of the [Veteran’s service-connected right foot disability.]. Even if found, degenerative changes of the knee would be unlikely related to foot pain as the increased rest described would be associated with less knee joint stress.” The Board acknowledges that the examiner found mild knee effusion, mild tenderness, and positive right “crepitance”, click; however, the examiner found no actual disability of the knee. The Veteran underwent another VA examination in 2017. The Veteran reported that he has some popping and discomfort in his knees as a result of his service-connected foot disability. The Veteran also denied any known knee injury and had no recollection of any active duty injury. The Veteran denied any flare-ups of the knees. Upon examination, he had full range of motion with no pain noted upon examination, to include on weight bearing. There was also no objective evidence of localized tenderness or pain on palpation, and no objective evidence of crepitus. The Veteran had full muscle strength. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. There was no instability upon joint testing. The Veteran had no meniscus disability. X-rays showed no acute fracture or dislocation. The examiner found that there was no clinical exam or radiographic exam evidence of a right or left knee disorder or disability. The examiner also noted that the Veteran was able to bear weight on his service-connected right foot and that his “gait appeared to be mildly antalgic, but this gait pattern was not consistent and decreased in intensity with conversational distraction. The Board finds, based on the record as a whole, and with consideration of the Federal Circuit’s decision in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) that the Veteran does not have a knee disability for VA purposes. Not only is the radiology evidence against a finding of a disability, but the record as a whole is against such a finding. The Veteran does not have knee symptoms which cause functional impairment such as to warrant a finding that he has a disability. The Board acknowledges the VA clinical records which note that the Veteran has a knee “condition” and numbness (see diagnosis of sensory neuropathy of the legs in 2009, and March and May 2010 VA clinical records); however, these notations are based on neurological leg findings and complaints. (As discussed in the remand section below, the Board is remanding the issue of entitlement to a leg disability (other than the knee) as secondary to a service-connected disability.) The Board has also considered that the Veteran contends that he has balance problems due to his knee; however, the Board finds that the VA examination findings, to include the most probative 2017 findings, are more credible than the Veteran’s contentions as to functional limitations due to his knees. Consistent with Federal Circuit precedent, in assessing functional impairment, a veteran’s lay assertions may be weighed against contrary medical evidence, but not categorically dismissed. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). In this regard, the Board notes that several clinicians have found the Veteran less than credible, or inconsistent, with regard to claimed symptoms of various physical and mental symptoms. A June 1978 VA examiner, with regard to the Veteran’s foot, found that the Veteran was evasive and it is impossible to get any specific details of his problem, and that his musculoskeletal examination was entirely within normal limitations, including his right foot. It was noted that the Veteran “would withdraw and wince when pressure was put over the head of the first metatarsal on the right, but when his attention was diverted this could be manipulated without difficulty.” A November 1982 VA examiner for the Veteran’s right foot found that the Veteran’s “subjective complaints do not correlate too well with the objective findings.” An August 1985 VA examination report reflects that the Veteran entered the office carrying a cane and limping slightly but it was found that he could ambulate without the cane and his “effort was not totally full during this part of the examination.” An August 1999 examiner for SSA purposes found that the Veteran’s mental symptoms were “not more than partially credible relative to disabling severity.” A December 1999 examiner for SSA purposes found that, with regard to his back, there was “only partial support for the severity of his symptoms and no support for the necessity of a cane. Therefore, limitations are considered partially credible.” As noted above, the 2017 VA examiner also found that the Veteran’s gait and pattern were not consistent and decreased with conversational distraction. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit held that “‘disability’ in § 1110 refers to the functional impairment of earning capacity” and “pain in the absence of a presently-diagnosed condition can cause functional impairment,” en route to its conclusion that “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability.” 886 F.3d at 1363, 1368, 1369. However, a veteran cannot “demonstrate service connection simply by asserting subjective pain—to establish a disability, the veteran’s pain must amount to a functional impairment. To establish the presence of a disability, a veteran will need to show that [his] symptoms reach the level of a functional impairment of earning capacity.” Id. at 1367-68. The Board finds that the Veteran does not have knee symptoms which reach the level of functional impairment of earning capacity, and even, assuming arguendo, that he does have such severity of symptoms, the evidence does not support a finding that any such disability is as likely as not causally related to, or aggravated by, service, or a service-connected disability. The Board also acknowledges a July 1975 STR complaint of medial aspect right knee pain of one day in duration with an impression of a strained knee, and a record four days later for a follow-up which notes that the knee was within normal limits with normal extension, flexion, no effusion, and no abnormal physical findings, and that the Veteran could return to duty. The Veteran’s April 1977 Report of Medical History for separation purposes (ETS)(Expiration of term of service) reflects that he denied a trick or locked knee. His Report of Medical Examination reflects that evaluation of his lower extremities was normal. Moreover, the Veteran has not credibly asserted, and the evidence of record, does not support a finding of continuity of symptoms since service. There is not competent credible evidence of record upon which ot base service connection on a direct incurrence basis. While the Veteran may believe that he has a bilateral knee disability proximately due to or aggravated beyond its natural progression by a service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between different parts of the body and/or interpretation of radiographic findings. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examination reports. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND Entitlement to service connection for degenerative disc disease of the lumbar spine is remanded. The Veteran contends that he has a back disability which is secondary to his service-connected right foot disability. He has been diagnosed with “failed back syndrome”, lumbago, degenerative disc disease, lumbar facet joint arthropathy. A February 2008 examination report reflects the opinion of the examiner that the Veteran’s back condition was less likely as not caused by or a result of the service-connected right foot sesamoiditis. The examiner reasoned that the limp associated with the Veteran’s antalgic gait did “not displace his center of gravity sufficiently to be significant stress to the lumbar discs.” The examiner further noted that the Veteran had been employed in construction and heavy equipment and that “occupational factors of whole body vibration and bending and twisting are significant risks for pain” and that literature reflects that occupational factors of whole body vibration and bending and twisting are significant risks for back pain and the Veteran’s work with heavy equipment was as likely as not associated with his back disability. A supplemental VA opinion was obtained in February 2017. The clinician again found that the Veteran’s back disability was less likely as not due to a service-connected disability, and also opined that it was less likely as not aggravated by a service-connected disability. The clinician initially stated that a 2000 record noted an injury to the Veteran’s back in 1993, but the clinician subsequently stated that the first evidence of a lumbar spinal problem visible in any of his medical records does not appear until over twenty years after the Veteran’s military discharge in 1977. 1990 records reflect that the Veteran reported pain in the low back with an onset of September 9, 1990 and which the Veteran related was due to picking up a trailer to hook to the back of his truck. It was noted that there was no past history of injury to the low back. Thus, the earliest complaint was approximately 13 years after separation from service and after a post-service incident. An August 1993 correspondence from chiropractor R. Casada reflects that the Veteran entered his office in May 19, 1993 with a complaint of pain in the cervical and thoracic spine and related that on that day, while operating a ditch witch, he snagged his equipment on rocks causing him to jerk his neck. Additional records reflect that the Veteran reported an injury to the low back while operating a back hoe in July 1993. The Board finds that a supplemental opinion, which acknowledges the earliest complaint in 1990 may be useful in providing a more accurate report. In addition, although the Veteran now contends that his back pain is secondary to a service-connected disability, and the 1990 and 1993 records note a different etiology, subsequent records reflect that the Veteran again injured his back in 1998 while working in his yard and subsequently had pain in the low back and numbness in the left leg. (See December 1998 Private Treatment Records, Dr. A.S.N., see also December 1999 Physical Residual Functional Capacity Assessment.) SSA records reflect that his pain first began to affect his activities “immediately upon [the second] injury in 1998”. Additional records continue to reflect low back pain due to the 1998 incident, and the Veteran’s “heavy weight lifting and repetitive bending and twisting of his back in his job. (See May 2000 Dr. Casada record and January 2001 Dr. Flynn record). A July 1999 record reflects that the Veteran was seen for back and neck pain, and had a desiccated disc in the lumbar area. SSA records reflect that the Veteran that the pain began “when I first injured my back in 1993 [and] the second time in 1998”. As noted above, the claims file includes the opinions of several clinicians that the Veteran has been less than credible with regard to the severity of his right foot disability. Thus, any opinion based on the Veteran’s report of a severe limp must consider these findings. Entitlement to service connection for bilateral leg disability manifested by numbness is remanded. The Veteran contends that he has a leg disability due to his service-connected right foot disability. 2008 and 2017 VA examination reports reflect that the Veteran does not have a bilateral leg disability. However, clinical records do reflect that the Veteran has weakness/numbness in the legs. A March 2010 progress note (lake Cumberland) reflects that the reported low back pain and leg pain and weakness so severe that he is almost unable to walk. A November 2014 VA record reflects that the Veteran has severe sensory neuropathy involving the arms and legs though an EMG/NCV was not done and the Veteran was not interested in pursuing it further. If, and only if, the evidence supports a finding that the Veteran has a back disability which is as likely as not causally related to, or aggravated by, the Veteran’s service-connection foot disability is further development warranted. In such a case, a supplemental opinion should be obtained as to the exact functional impact that the Veteran’s back disability has on his legs. Entitlement to service connection for an acquired psychiatric disability, to include depression is remanded. The Veteran’s January 1975 Report of Medical History for enlistment purposes reflects that the Veteran reported that he had, or had previously had, frequent trouble sleeping, and depression or excessive worry. A January 1975 psychiatric consultation note for enlistment purposes reflects that the Veteran reported having periodic episodes of depression in association with his mother’s death five years prior. On examination there was no evidence of depression or psychosis. He was diagnosed with immature personality and deemed “ok” for acceptance into military service. The Veteran entered service on July 10, 1975. Two weeks later, a July 25, 1975 STR reflects that the Veteran was treated for hyperventilation and diagnosed with adjustment disorder. There are no further STRs noting acquired psychiatric disability symptoms. The Veteran’s 1977 Report of Medical History for Separation purposes reflects that he denied frequent trouble sleeping and depression or excessive worry. His corresponding Report of Medical Examination in 1977 reflects that his psychiatric evaluation was normal. Post-service treatment records show treatment for anxiety in 1998. A May 1999 record (Lake Cumberland Regional Hospital) reflects that the Veteran was diagnosed with major depression and panic disorder. The records reflect that the Veteran’s stressors were a divorce, not working due to back pain, that he expects to be evicted, that his house was to be auctioned, and that he was not sleeping due to back pain. An August 1999 record (Dr. Gatschenberger) for Division for Disability Determination (Frankfort, Kentucky) purposes reflects that the Veteran reflects that the Veteran had major depression which “tends to stem from marital difficulties.” The Veteran was afforded a VA psychological examination in June 2013. The examiner provided a diagnosis of depressive disorder NOS, and stated that the Veteran’s history of depression “appears to be situationally based,” and that “current reports of untreated depression appear to be related to heart and back problems/health decline with a course of depressive symptoms peaking during times of increased situational life stress.” Most recently, she noted that his “back and heart problems have resulted in a change in his quality of life and resulted in some depression for the Veteran.” She therefore concluded that his depressive disorder was less likely than not incurred in or the result of his reported complaints of depression while in the military. A February 2017 VA examination report reflects that the Veteran does no longer meets the DSM-5 criteria for PTSD, depression, or anxiety. The Board finds that the claim for service connection for an acquired psychiatric disability is inextricably intertwined with the claim for service-connection for a back disability. Entitlement to service connection for a heart disability is remanded Because a decision on the remanded issues of entitlement to service connection for a psychiatric disability could significantly impact a decision on the issue of entitlement to service connection for a heart disability, the matters are inextricably intertwined. If, and only if, the evidence supports a finding that the Veteran has a psychiatric disability which is as likely as not causally related to, or aggravated by, service or a service-connected disability, is further development warranted. In such a case, a medical opinion should be obtained.   The matter is REMANDED for the following action: 1. Obtain a supplemental opinion to the February 2017 opinion which addresses: (a.) whether it is at least at likely as not that the Veteran’s back disability was caused by his service-connected right foot disability; and (b.) whether it is at least at likely as not that the Veteran’s back disability was aggravated by his service-connected right foot disability. If the clinician who provides the opinion is the same clinician who provided the February 2017 opinion, the clinician should note whether the clinical evidence of a back injury in September 1990 and another injury in 1993 changes his opinion offered in February 2017. (His rationale had noted that there were no medical records of a back complaint for more than 20 years after separation from service, approximately 1999.) See September and October 1990 private records, SSA records, 1999 and 2000 Dr. Casada record, January 2001 Dr. Flynn. The claims file includes the opinions of several clinicians that the Veteran has been less than credible with regard to the severity of his right foot disability. Thus, any opinion based on the Veteran’s report of a severe limp should consider those clinical findings. 2. IF, AND ONLY IF, the evidence supports a finding that the Veteran has a back disability which is as likely as not causally related to, or aggravated by, the Veteran’s service-connection foot disability, obtain a supplemental opinion which addresses: (a) whether it is at least at likely as not that the Veteran has a leg disability that was caused by his service-connected back disability; and (b) whether it is at least at likely as not that the Veteran has a leg disability was aggravated by his service-connected back disability. The clinician should identify the leg disability by diagnosis or functional impact. 3. IF, AND ONLY IF, the Veteran’s psychiatric disability is service-connected, obtain a medical opinion which addresses: (a.) whether it is at least at likely as not that the Veteran has a heart disability that was caused by his service-connected psychiatric disability; and   (b.) whether it is at least at likely as not that the Veteran has a heart disability that was aggravated by his service-connected psychiatric disability. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Wishard