Citation Nr: 18151330 Decision Date: 11/20/18 Archive Date: 11/16/18 DOCKET NO. 15-43 916 DATE: November 20, 2018 ORDER Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for a sleep disorder is denied. Entitlement to service connection for headaches is granted. Entitlement to service connection for obesity is denied. REMANDED Entitlement to service connection for a right knee disability as secondary to a service-connected left knee disability is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to an evaluation in excess of 10 percent for a left knee disability is remanded. Entitlement to service connection for left ear hearing loss is remanded. Entitlement to a total disability rating based on unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a right ear hearing loss disability for VA purposes. 2. Resolving all reasonable doubt in the Veteran’s favor, tinnitus is manifested as a result of his active service. 3. The weight of the probative evidence is against the conclusion that the Veteran has a service-related sleep disorder other than sleep disturbances already compensated under his service-connected adjustment disorder with anxiety. 4. It is at least as likely as not that the Veteran’s headaches are due to the Veteran’s service connected adjustment disorder with anxiety. 5. Obesity is not a disorder for VA compensation purposes. CONCLUSIONS OF LAW 1. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C. §§ 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2018). 2. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1131, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(d) (2018). 3. The criteria for service connection for a sleep disorder, to include as secondary to service-connected anxiety disorder, have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2018). 4. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.159, 3.303, 3.304 (2018). 5. The criteria for entitlement to service connection for obesity have not been met. 38 U.S.C. §§ 1131, 1154(a), 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1979 to September 1986 in the U.S. Navy. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. Service Connection Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; 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, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2018). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) (2018) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 (2018) and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed in 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a)-(b) (2018). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA will consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to a determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. “It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). 1. Entitlement to service connection for right ear hearing loss The Veteran claims entitlement to service connection for right ear hearing loss. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran underwent audiometric testing at an October 2014 VA examination. His Maryland CNC speech recognition scores were 96 percent in the right ear and 96 percent in the left ear. The puretone thresholds, in decibels, are as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 15 25 25 LEFT 10 5 15 50 60 Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992). In the absence of proof of a present disability, there can be no valid claim for service connection. Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board recognizes and acknowledges as credible the Veteran’s statements of record as to hearing difficulties. However, as demonstrated in the October 2014 VA examination, the Veteran does not have right ear hearing loss for VA purposes per the diagnostic criteria. Here, there is simply no competent evidence of record to suggest that the Veteran has right ear hearing loss for VA compensation purposes. In the absence of evidence of a current disability, the Veteran’s claim for right ear hearing loss must be denied. 2. Entitlement to service connection for tinnitus A current diagnosis of tinnitus has been established. See October 2014 VA examination. According to the VA examiner, the Veteran stated his tinnitus began after he left the military. However, the Board acknowledges a more detailed account of record. Indeed, in an April 2014 statement, the Veteran provided a more detailed description of the onset and circumstances surrounding his tinnitus. Specifically, the Veteran explained that his tinnitus had its onset while he was in the Navy. He stated he was a cryptologic technician, and his major duties included copying Morse code. The Veteran described ringing in his ears which has steadily worsened. In October 2014, the Veteran was afforded a VA examination to assess the nature and etiology of his tinnitus. The Veteran reported bilateral, constant tinnitus, which had its onset after he left service. The examiner opined that the Veteran’s tinnitus is less likely than not caused by or a result of military noise exposure. The examiner supported this opinion by repeating the Veteran’s reported contention that his tinnitus began after he left the military. The Board affords this examination no probative value, as it is not shown to have been based on a review of the claims file, and is supported by an inadequate rationale. Indeed, a review of the Veteran’s claims file would have revealed the Veteran’s description of the onset of his tinnitus, as well as his MOS as a cryptologic technician, and a description of his symptoms. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). The Board first and foremost notes that VA concedes the Veteran’s exposure to noise while in service. The Board also finds that the Veteran’s statements and the lay statements of record are credible. The Board finds the April 2014 statement to be the most accurate description of circumstances surrounding the Veteran’s tinnitus. Furthermore, the Board acknowledges the Veteran’s consistent reports that his tinnitus became progressively worse after service. VA has conceded that the Veteran was exposed to loud noise in service; the lay reports of record have been consistent and specific in reporting tinnitus symptomatology; and observations regarding the onset of tinnitus are capable of lay observation. The Board has found the lay statements of record to be credible. Therefore, and resolving all reasonable doubt in the Veteran’s favor, as the evidence is at least in relative equipoise, service connection for tinnitus is granted. 3. Entitlement to service connection for a sleep disorder. The Veteran claims service connection for a sleep disorder. The discussion below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). Upon careful consideration of the Veteran’s allegations in conjunction with all the evidence of record and applicable law and regulations, and for the reasons set forth below, the Board finds that the evidence weighs against the Veteran’s service connection claim. The record reflects that the Veteran, until recently, did not have a diagnosed sleep disorder. Pursuant to a September 2017 sleep study, the Veteran now has a diagnosis of mild sleep apnea. Another sleep study conducted in 2013 was negative for sleep apnea. The Board notes that at the time of the Veteran’s claim for service connection of sleep problems, he did not have a diagnosis of sleep apnea, and related his sleep complaints to his other disabilities, including tinnitus and psychiatric disability. Indeed, the Veteran states in an April 2014 statement that the steady ringing in his ears makes it “real hard to sleep”. In addition, the Veteran submitted a private disability benefits questionnaire in November 2015 regarding his service-connected psychiatric disability. Pertinently, the Board notes that among the major symptoms associated with the Veteran’s service-connected adjustment disorder with anxiety is chronic sleep impairment. The same is confirmed in the Veteran’s March 2018 VA examination, as chronic sleep impairment is shown to be a major symptom of the Veteran’s adjustment disorder with anxiety. The Veteran is competent to report observable symptoms. His subjective reports are also credible. The Board acknowledges that the Veteran asserts he has chronic sleep impairment that has been associated with his service-connected adjustment disorder and tinnitus. The November 2015 and March 2018 examinations confirmed that finding. In these examinations, and until a September 2017 sleep study, a sleep disorder was not separately diagnosed. More pertinently, however, both the Veteran and the medical record show that sleep impairment is a symptom of the Veteran’s service-connected adjustment disorder, and is included in his currently assigned 70 percent evaluation. The Veteran’s medical record shows that a separate sleep disability diagnosis was ruled out in 2013, immediately prior to the Veteran’s filing of his claim, as well as throughout his treatment until November 2017. Also, neither the Veteran nor his representative have submitted supportive evidence additional to the Veteran’s own lay contentions that his disabilities cause a separate sleep disorder. Moreover, there is no competent medical evidence of a nexus between sleep apnea and service. While the Veteran is competent to report problems sleeping during and since service, he is not competent to identify the cause of his sleep problems or to attribute them to a diagnosis of sleep apnea. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). As such, there is an absence of competent evidence establishing a nexus between sleep apnea and service. Accordingly, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a sleep disorder, and is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. See 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2018). 4. Entitlement to service connection for headaches The Veteran is seeking service connection for headaches. He asserts that his headaches began while he was in the military in 1986. See April 2017 private medical opinion. The Board also notes that in an October 2014 VA examination, the Veteran stated he started having headaches in 1988. The Veteran’s service treatment records (STRs) are silent as to any treatment, complaints or diagnosis of headaches. In October 2014, the Veteran underwent a VA headaches examination. As previously noted, he reported his headaches had their onset after service in about 1988, that he never consulted a doctor about them, and that he believes they have something to do with his ear conditions. The Veteran described his headaches as intermittent, and precipitated with loud noise. The examiner diagnosed the Veteran with a migraine condition. After examining the Veteran and reviewing the medical evidence of record, the examiner determined that it is not at least as likely as not that the Veteran’s headaches are related to service. The examiner’s rationale was simply that there was no medical documentation of headaches in service treatment records. The Board assigns very little probative weight to the October 2014 VA examination, as it is supported by an inadequate rationale. A medical opinion is adequate when it is based upon consideration of the Veteran’s prior medical history and examinations, and also describes the disability in sufficient detail so that the Board’s “evaluation of the claimed disability will be a fully informed one.” Ardison v. Brown, 6 Vet. App. 405, 407 (2007). An adequate rationale must be provided for any medical opinion rendered; a conclusory, contradictory or incomplete analysis is not adequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007). Simply because headaches were not documented in service records does not preclude the possibility that the Veteran experienced headaches in service. The Board notes nonetheless that there is a private medical opinion of record dated in April 2017. This opinion was based on a medical evaluation, documented in a disability benefits questionnaire. The Veteran was confirmed to have tension headaches. The Veteran reported his headaches began in service in 1986, and have worsened over the years. The Veteran was also noted to take prescriptions for his headaches. Pertinently, the examiner noted that the Veteran’s headaches are caused by his service-connected adjustment disorder. Indeed, the examiner explained that medical evidence supports a link between psychological stress and headaches, as stress can be a predisposing factor to headaches, accelerate the progression of headaches into a chronic disorder, and precipitate headache episodes. The examiner cited to specific medical research, and states that based on said research, the medical evidence and the evaluation of the Veteran, it is reasonable to conclude that the Veteran’s headaches are precipitated by the service-connected adjustment disorder with anxiety. After carefully considering the evidence of record, the Board concludes that the preponderance of the evidence supports a finding that the Veteran has a current diagnosis of headaches that are caused by his service-connected anxiety disorder. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.310. In reaching this determination, the Board finds that the most probative evidence of record is the April 2017 private medical examination, as it is based on a thorough review of the claims file, a physical examination of the Veteran, takes into account the Veteran’s lay statements of symptomology, and provides adequate rationale for the conclusions reached. The October 2014 opinion did not take into account all the Veteran’s lay contentions, nor did it address service connection on a secondary basis or aggravation. The April 2017 medical opinion is the most persuasive and most probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Thus, service connection for headaches is granted. 5. Entitlement to service connection for obesity The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110; Degmetich v. Brown, 104 F. 3d 1328 (1997). The Veteran’s VA treatment records document a history of obesity. In fact, the Veteran’s record contains a June 2017 diagnosis of obesity. The Veteran contended in an April 2014 statement that his service-connected conditions, including his psychiatric and knee disabilities, which result in pain and stress, lead to obesity. However, the Board notes that the United States Court of Appeals for Veterans Claims has recently held that “there is currently no provision in the rating schedule to compensate for obesity.” Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). On the basis of these findings and following a full review of the record, the Board concludes that the record does not show that the Veteran currently suffers from a compensable disability, and service connection is consequently not warranted. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability as secondary to a service-connected left knee disability is remanded. The Veteran asserts that he has a current right knee disability due to his service-connected left knee disability. Specifically, the Veteran essentially states that as his service-connected left knee disability has increased in severity, right knee degenerative joint disease has resulted. See April 2014 statement. During an October 2014 VA examination, it was reported that the Veteran started having ongoing right knee pain since approximately September 2013, while working as a letter carrier with the Postal service. The Veteran described his right knee pain as constant, and increased with physical activity. It was further noted that his orthopedist had recommended a right arthroscopic procedure for the future. A physical examination of the right knee at that time revealed mildly diminished right knee flexion to 120 degrees with full extension to zero degrees. Repetitive motion did not produce additional symptoms or further loss of motion or function. MRI of the knee showed early degenerative joint disease, and a torn medial meniscus. Based on the Veteran’s history and the findings from the examination, the examiner diagnosed right knee medial tear, initially diagnosed in 2013; however, the examiner opined that it is less likely than not that the Veteran’s right knee condition was caused by or the result of his left knee disability. As an explanation, the examiner stated that the Veteran’s right knee condition had its onset when he had to do a lot of walking as a mail carrier in 2013 – and further, that there is no right knee condition shown in service. The Board notes that the October 2014 VA examination does not include an opinion on aggravation supported by a rationale. Also, the examiner considers only the Veteran’s right knee medial tear disability – failing to also consider or note the right knee osteoarthritis diagnosis. Furthermore, the Board notes that the examination occurred approximately one month prior to the Veteran’s right knee arthroscopic surgery, which he underwent in November 2014. See VA medical notes. In addition, review of the medical record shows that the October 2014 VA examiner’s opinion is in conflict with another VA doctor’s opinion of record. A November 2014 VA orthopedic surgeon’s note reflects the opinion that the Veteran’s right knee disability is related to his left knee disability. Specifically, the surgeon states that it is his opinion, within a reasonable degree of medical certainty, that the Veteran had a pre-existing arthritic condition in his right knee, mainly in the patellofemoral joint and medial compartment, which has been aggravated by favoring the left knee. See November 2014 note. Consequently, the Board finds that the October 2014 medical opinion is inadequate to fairly adjudicate the Veteran’s claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Once VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Thus, a remand for a new medical opinion is necessary to fairly adjudicate the Veteran’s claim. On remand, VA must provide a medical opinion that adequately considers the Veteran’s symptoms of pain, arthritis and abnormal stepping motion as potentially causing or aggravating his left knee disability; considers the Veteran’s lay statements; considers the medical evidence of record; and provides reasons and bases to support each opinion provided. 2. Entitlement to service connection for a bilateral foot disability and a high blood pressure disability are remanded. The Veteran claims entitlement to service connection for a bilateral foot disability and high blood pressure. The Board notes at the outset that the Veteran has not been afforded a VA examination in relation to these claims, so as to examine their nature and etiology. A medical examination or medical opinion is necessary in a claim for service connection when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2) (2012); 38 C.F.R. § 3.159 (c)(4)(i) (2018). The McLendon elements are satisfied with regard to a bilateral foot disability. Regarding the first element, in an October 2013 VA treatment note, the Veteran was diagnosed with hammertoes. When the agency of original jurisdiction (AOJ) denied service connection in its October 2014 rating decision, only complaints of foot pain and calcaneal spurs were noted as current disabilities. The Board also acknowledges the Veteran’s April 2014 statement that he has severe pain in his feet due to his hammer toes and increasing knee pain. Regarding the second element, while there is no evidence of foot complaints in service, the Board notes that the Veteran is service-connected for a left knee disability, which was assessed to be related to service in a December 2003 VA examination due to an in-service injury, including a fall. Regarding the third and fourth elements, there is an indication that a foot disorder could be related to service due to the in-service injury which caused his left knee disability, but insufficient evidence of record by which the Board can make a decision. Furthermore, the Veteran suggests in the April 2014 statement that his bilateral foot pain and hammer toe disability may be related to his service-connected knee disability. Indeed, the Board again notes that it affords the Veteran every benefit of the doubt. As the four McLendon elements are satisfied, the Veteran is entitled to a VA examination and medical opinion. The McLendon elements are also satisfied with regard to a high blood pressure disability. Regarding the first element, the Veteran’s record contains a June 2017 diagnosis of hypertension. Regarding the second McLendon element, the Veteran claimed in an April 2014 statement that his service-connected conditions, including his psychiatric and knee disabilities, which result in pain and stress, lead to high blood pressure. Therefore, it seems the Veteran is claiming service connection for hypertension as secondary to his service connected disabilities, rather than on a direct basis. Regarding the third and fourth elements, there is an indication that the Veteran’s hypertension could be caused by his service-connected psychiatric and knee disabilities, but insufficient evidence of record by which the Board can make a decision. Indeed, the June 2017 VA treatment note contains an explanation that treatment with antipsychotic medications includes the risk of elevations in blood pressure. As the four McLendon elements are satisfied, the Veteran is entitled to a VA examination and medical opinion. 3. Entitlement to service connection for hemorrhoids is remanded. The Veteran claims entitlement to service connection for hemorrhoids. The Veteran was afforded a VA examination in October 2014. The examiner stated there is no history of hemorrhoids, though it was also noted the Veteran had bleeding hemorrhoids in 2013, and a sphincterotomy in April 2014. The Veteran was further noted to take a stool softener, and to have such symptoms as frequent itching. The examiner cited diagnostic testing, including an August 2013 operative note, when the Veteran underwent a colonoscopy with hemorrhoid banding. The pre-operative diagnosis was rectal bleeding, and the post-operative diagnosis was hemorrhoids. Pertinently, the examiner opined that the Veteran’s hemorrhoids are less likely than not related to service. The examiner reasoned that service treatment records were reviewed, and no sufficient documentation was found with regard to hemorrhoids in service. The examiner also points to a 2006 rectal examination which was normal, as well as a statement that a 1997 sigmoidoscopy was normal. The Board notes that the Veteran’s service treatment records reflect that on the Veteran’s August 1986 separation examination, a clinical evaluation of the rectum and anus was abnormal. Specifically, a hemorrhoidal tag was noted. Yet, the examiner makes no mention of this in-service clinical evaluation, and instead states that there is insufficient evidence to show a hemorrhoid complaint in service. When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the Board finds that a new VA medical opinion is necessary to determine the nature and etiology of the Veteran’s hemorrhoid disability. 38 C.F.R. § 3.159(c)(4) (2018). 4. Entitlement to service connection for left ear hearing loss is remanded. The Veteran was afforded a VA examination in October 2014, which reflects that he does have left ear hearing loss for VA purposes. Furthermore, the Board notes that VA has conceded in-service acoustic trauma, given the Veteran’s MOS as a cryptologic technician, as well as his credible reports of harmful noise exposure. However, in providing the opinion that the Veteran’s hearing loss is less likely than not related to service, the October 2014 VA examiner reasoned only that the Veteran’s separation examination of 1986 was reflective of normal hearing. As the absence of evidence of hearing loss in service is not a bar to service connection for hearing loss, the Board finds this opinion to be inadequate. Hensley v. Brown, 5 Vet. App. 155 (1993). The claim will be remanded for an addendum opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 5. Entitlement to an evaluation in excess of 10 percent for a left knee disability is remanded. The Veteran is service-connected for a left knee disability, currently evaluated as 10 percent disabling. The Veteran seeks a higher disability evaluation. The Veteran was last afforded a VA examination to assess the nature and severity of his left knee disability in October 2014. Since then, review of the medical record shows that the Veteran’s knee pain has increased. The Veteran rated his knee pain as 6/10 in June 2017, and as 7/10 in August 2017. Furthermore, while the October 2014 VA examination noted no range of motion restriction for the left knee, a May 2017 evaluation showed that the Veteran’s left knee flexion is restricted. In addition, the Board acknowledges a September 2017 treatment note showing that the Veteran was administered a knee injection due to severe knee pain. See VA medical records. Pertinently, the record is indicative of a material worsening of the Veteran’s knee condition since his last VA examination of October 2014. In light of the above, the Board finds that an updated VA examination is necessary to ascertain the current severity of this disability. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); Snuffer v. Gober, 10 Vet. App. 400 (1997). 6. Entitlement to a total disability rating based on unemployability (TDIU) is remanded. The Veteran meets the schedular criteria for an award of a TDIU benefits under 38 C.F.R. § 4.16. However, the issue of entitlement to an evaluation in excess of 10 percent for a left knee disability has been remanded herein, as well as the claim of entitlement to service connection for a right knee disability. The Veteran’s claim for TDIU is inextricably intertwined with the service connection and increased rating claims for the knees. Indeed, the Veteran’s unemployability claim is based upon his knee complaints. Specifically, the Veteran states in an April 2014 statement that he has been off work since September 2013 due to the aggravated condition of his knees. As such, a final decision on the issue of entitlement to TDIU cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). A TDIU claim is an attempt to obtain an appropriate rating for a service-connected disability. When entitlement to a TDIU is raised during the adjudicatory process of the underlying disability, it is part of the claim for benefits for the underlying disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the underlying disabilities are the Veteran’s knee claims. Thus, a rating must be assigned by the AOJ for the Veteran’s left knee disability, and the claim of entitlement to service connection for a right knee disability must be further developed and adjudicated as set forth herein, before the Board renders a decision on the TDIU claim. The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2018). The matters are REMANDED for the following action: 1. Obtain and associate any outstanding VA and/or private medical records with the Veteran’s claims file. 2. Once the above has been completed, obtain an addendum opinion regarding the nature and etiology of the Veteran’s right knee disability, with a detailed rationale for the findings rendered. The claims folder must be made available to the examiner for review in connection with the examination, and the examiner must acknowledge such review in the addendum. The examiner must provide well-reasoned opinions as to the following: a. Whether it is at least as likely as not that the Veteran’s right knee disability was caused by the Veteran’s service-connected left knee disability or symptoms thereof, to include right knee osteoarthritis, meniscus tear, and abnormal stepping motion. b. Whether it is at least as likely as not that the Veteran’s right knee disability was aggravated by his service-connected left knee disability or symptoms thereof, to include right knee osteoarthritis, meniscus tear, and abnormal stepping motion. The examiner must address the Veteran’s lay contentions regarding left knee pain, tenderness, and flare-ups, as well as the current VA examinations and opinions of record. The examiner must also specifically address the positive nexus opinion of November 2014. A complete rationale must be given for all opinions and conclusions expressed. If the examiner finds that an in-person examination is necessary, then a new examination should be conducted. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any present bilateral foot disability. The examiner must identify all current foot disorders found to be present. All indicated tests and studies should be conducted. The examiner should address the following: a. Whether any diagnosed foot disability, to include hammertoes, is at least as likely as not (at least a 50 percent probability) related to service, to include a fall which has been established as causally related to the Veteran’s service-connected knee disability. b. Whether any diagnosed foot disability is at least as likely as not (at least a 50 percent probability) caused by the Veteran’s service connected disabilities, to include his left knee disability. c. Whether any diagnosed foot disability is at least as likely as not (at least a 50 percent probability) aggravated by the Veteran’s service connected disabilities, to include his left knee disability. The examiner must consider the Veteran’s injuries in service, to include a fall. 4. Schedule the Veteran for a VA examination by an appropriate examiner to determine the nature and etiology of his hypertension. The entire claims file must be made available to and be reviewed by the examiner. All indicated studies and tests should be performed. The examiner should provide complete rationale for all conclusions reached. The examiner is asked to provide opinions as to the following: a. Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension is related to active service, or was manifest within one year of his discharge from service. b. Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension was caused by his service-connected disabilities, to include his adjustment disorder with anxiety. c. Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension was aggravated by his service-connected disabilities, to include his adjustment disorder with anxiety. 5. Forward the Veteran’s claims file, including this remand, to an appropriate clinician for an addendum opinion regarding the nature and etiology of his hemorrhoids. The need for further examination is left to the discretion of the examiner. Following a review of the claims file, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hemorrhoids are related to service. The examiner must acknowledge and discuss the Veteran’s separation examination, which notes complaints and treatment for hemorrhoids. 6. Obtain an addendum opinion from an appropriate VA examiner to determine the nature and etiology of the Veteran’s left ear hearing loss. The entire claims file must be made available to and be reviewed by the examiner. The need for further examination is left to the discretion of the examiner. The examiner must determine whether the Veteran’s left ear hearing loss is at least as likely as not (at least a 50 percent probability) related to service, to include conceded exposure to hazardous noise in active service. The Board reminds the examiner that his or her rationale must be thorough – a mere statement that the Veteran’s hearing was normal at separation is not sufficient. 7. Schedule the Veteran for a VA examination to determine the current nature and severity of his left knee disability. The examiner must review the record and note such review in the examination report. The examination must include a review of the Veteran’s history and current complaints as well as a comprehensive evaluation and any tests deemed necessary. a. Conduct all tests and examinations deemed necessary, to include range of motion testing of both knees with active and passive motions as well as with weight-bearing and non-weight bearing. If any motion cannot be tested, explain why. If factors such as pain, weakness, fatigability or incoordination limit range of motion or functional ability, discuss the impact and severity thereof. b. Determine whether the Veteran experiences any flare-up episodes or has any complaints with repeated use over time. If there is any additional limitation of motion during a flare-up or with repeated use over time, provide an estimate, in degrees if possible, of the limitation of motion. If unable to provide an estimate, explain why. If there is any additional limitation of function during a flare-up or with repeated use over time, discuss its impact in terms of its severity, frequency and duration. If factors such as pain, weakness, fatigability or incoordination limit range of motion or functional ability during a flare-up or with repeated use over time, discuss its impact in terms of its severity, frequency and duration. If such factors do not limit range of motion or functional ability during a flare-up or with repeated use over time, explain why. If any opinion cannot be rendered without resorting to mere speculation, the examiner should state the same and explain why. The rationale for all opinions offered must be provided. If any examiner cannot provide an opinion without resort to speculation, he or she must provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiners are advised that the Veteran is competent to report history and symptoms and that his reports must be considered in formulating the requested opinions. If any examiner rejects the Veteran’s reports, he or she must provide a rationale for doing so. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G.C., Associate Counsel