Citation Nr: 18151343 Decision Date: 11/20/18 Archive Date: 11/16/18 DOCKET NO. 16-31 753 DATE: November 20, 2018 ORDER Entitlement to service connection for allergic rhinitis is granted. Entitlement to a rating in excess of 20 percent for residuals of a T12 fracture is denied. REMANDED Entitlement to service connection for bilateral knee strain is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his allergic rhinitis began in service. 2. The Veteran’s thoracolumbar spine disability is manifested by pain and limitation of motion with flexion greater than 30 degrees, without ankylosis or incapacitating episodes requiring bed rest prescribed by a physician. The Veteran is already in receipt of a separate rating for right lower extremity radiculopathy. CONCLUSIONS OF LAW 1. The criteria for service connection for allergic rhinitis are met. 38 U.S.C. §§ 1110, 1111, 5107(b) (2014); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 2. The criteria for an initial rating in excess of 20 percent for residuals of a T12 fracture have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code (DCs) 5237, 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S Marine Corps from December 1993 to December 1997, and in the Reserves with periods of active duty from April 2003 to April 2004, November 2005 to April 2006, and from February 2008 to February 2009. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The August 2014 rating decision on appeal granted service connection and provided a 10 percent rating for T12 fracture, effective November 4, 2012. A May 2016 rating decision provided an increased 20 percent rating, effective November 4, 2012. Additionally, right lower extremity radiculopathy was granted. The Veteran’s January 2015 notice of disagreement included disagreement with denials of service connection for headaches, left ear hearing loss, and a skin rash. In April 2016, he withdrew his claim for hearing loss. In a May 2016 rating decision, entitlement to service connection for headaches and a fungal infection were granted. In May 2017, the Veteran submitted a timely notice of disagreement for an earlier effective date and increased rating related to his headaches, and “service connection” for a skin rash (although this was considered granted with the “fungal infection” issue). An August 2017 Statement of the Case (SOC) addressed the earlier effective date claim and an increased rating for his fungal infection condition. An August 2017 rating decision provided an increased 50 percent rating for his headaches. The Veteran did not submit a timely substantive appeal for these issues. The Veteran requested a DRO hearing in May 2017. One was scheduled for August 2017; however, the Veteran failed to appear. Entitlement to a total disability rating based upon individual unemployability (TDIU) is an element of all increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board has considered the applicability of addressing a claim for TDIU; however, the record does not indicate that the Veteran is unemployed or marginally employed. Treatment records indicate that his is employed as a writer and tv producer. 1. Entitlement to service connection for allergic rhinitis The Veteran has argued that he is entitled to service connection for a “sinus condition” as the condition began in service, and he believed it was related to his exposure to burn pits. The Veteran’s service treatment records are incomplete. The United States Court of Appeals for Veteran's Claims (Court) has held that in cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Review of his available service treatment records included a denial of sinus problems on a January 1999 dental medical history, and a notation of “seasonal rhinitis” on his May 2002 periodic medical examination. He also had complaints of rhinorrhea, shortness of breath, and dizziness with standing in April 1994. He had a productive cough, nausea, and vomiting. He was only assessed with otitis media (ear infection) and provided antibiotics. He was seen again twice in May 1994, and was assessed with an upper respiratory infection which progressed into bronchitis. The record also contains a February 2009 post-deployment questionnaire, after seven months in Iraq. He reported his health was excellent in the past month, which was the same as prior to his deployment. He reported he had not been seen by a healthcare provider since he returned from deployment. He stated that he did not have any current health concerns or conditions related to his deployment. He did not wish to schedule an appointment with a healthcare professional. The earliest VA treatment record is from August 2009, and noted the Veteran recently returned (10/08) from Iraq, and was being seen for an initial history and physical with VA. He reported a prior medical history of chronic intermittent low back pain and a broken finger. Physical examination did not note any nasal/allergic rhinitis symptoms. The Veteran was provided a rhinitis examination in August 2014. He reported that when he was stationed in Iraq in 2008, he initially caught what was commonly known as “the crud” from new exposure to the dust in the region. He stated that this cleared up in about 10 days, but he was left with a residual of a persistent rhinorrhea. He awakens with this on many, but not all, mornings. It seems to resolve somewhat through the course of the day. The examiner only saw one note in his service treatment records regarding a complaint of rhinitis, dated in April 1994. The complaint of rhinitis was linked to an upper respiratory tract infection, according to the examiner. There were “no other entries regarding sinus issues.” The Veteran stated that after service he has received treatment through VA, where he was “just given nasal sprays. No work-up was done and eventually he stopped coming in for care for that concern,” and he buys over-the-counter nasal spray which provides good, but temporary, results. He stated he underwent allergy testing, which were negative so far. Under the diagnosis section, the examiner selected that the Veteran did not now have, nor had he ever been diagnosed with a sinus, nose, throat, larynx, or pharynx condition. However, under a following section, the examiner selected that the Veteran had rhinitis. Diagnostic testing, including imaging studies and biopsy, had not been performed. The examiner provided a negative nexus opinion, finding that the Veteran’s sinus condition was less likely than not incurred in or caused by the claimed in-service injury/illness because “there was a single entry in his service treatment records” related to ear/nose/throat issues dated in 1994, for a “general” upper respiratory tract infection. The Veteran was noted to currently suffer from “what seems to be an allergic rhinitis, but there is nothing in his service treatment records to connect these two conditions to each other.” Neither is there anything in his service or post-service treatment records that is “a real and permanent injury or disability to this veteran.” October 2014 and May 2015 VA treatment records included that the Veteran had post-nasal drainage. It is unclear from VA records when the Veteran was initially prescribed medication for his post-nasal drainage, but several records show he was prescribed Flunisolide nasal spray to use as needed. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that the Veteran is competent to describe his in-service symptoms and any on-going treatment he has been provided. As noted above, his service treatment records are incomplete as his entrance and separation evaluations are not currently contained in the record. The limited service treatment records do include a notation of seasonal rhinitis in 2002. The Veteran is presumed to have entered service in sound condition as his entrance evaluation is not currently available. Post-service VA treatment records include complaints of post-nasal drip which was treated with a prescription for a nasal spray. The August 2014 VA examiner diagnosed allergic rhinitis, and noted that the Veteran had never received a full work-up for his nasal complaints. Although the examiner provided a negative nexus opinion, it appears that the examiner missed the notation of seasonal rhinitis in 2002 (the periodic examination was in the dental treatment records). Although the examiner noted that the Veteran’s rhinitis is minor, he was diagnosed with allergic rhinitis in the examination and the claim currently on appeal is simply for entitlement to service connection. Given an in-service notation of seasonal rhinitis in service, a current diagnosis of allergic rhinitis, and that the Veteran is presumed to have entered service in sound condition, the Board will resolve reasonable doubt in the Veteran’s favor and finds that his allergic rhinitis began in service. 2. Entitlement to a rating in excess of 20 percent for residuals of a T12 fracture The Veteran contends that his thoracolumbar spine disability warrants a rating in excess of 20 percent. As noted in the introduction, the Veteran’s spine disability was granted in an August 2014 rating decision which initially provided a 10 percent rating. In April 2016, the Veteran reported to a DRO (decision review officer), that his back had worsened since his last examination. Following additional examination, the Veteran’s thoracolumbar spine disability rating was increased to 20 percent. The Veteran had not provided any additional statements or arguments related to his claim for a rating in excess of 20 percent, but he submitted a substantive appeal in July 2016. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must consider the extent to which a veteran may have additional functional impairment beyond the limitation of motion objectively demonstrated, such as when the symptoms are most prevalent due to the extent of the pain and painful motion, weakness, premature or excess fatigability, and incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The rating schedule is intended to recognize actually painful, unstable, or malaligned joints due to healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to cases of painful motion in which there is a finding of arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Case law and VA guidelines anticipate that VA examiners will use information procured from relevant sources, including lay statements, to estimate additional functional loss during flare-ups of musculoskeletal disability. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243), unless Diagnostic Code 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a. Notably, ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine; A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating; A 40 percent rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; A 20 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Diagnostic Code 5243 provides ratings for incapacitating episodes for intervertebral disc syndrome (IVDS) as follows: having a total duration of at least one week but less than 2 weeks during the past 12 months (10 percent); having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months (40 percent); having a total duration of at least 6 weeks during the past 12 months (60 percent). “[A]n incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.” 38 C.F.R. § 4.71a (Diagnostic Code 5243, Note 1). The Veteran first sought VA treatment in 2009, and reported his medical history of chronic intermittent low back pain since 1995. An April 2011 record noted the Veteran was in a very minor accident while riding a motorcycle, with injury to a left toe. At that time, he had he had full range of motion of his neck and back without pain or tenderness to palpation. A September 2013 VA treatment record was noted to be a “baseline medical visit” with his primary care provider. He reported worsening low back pain since injury in service. His symptoms included daily back pain, difficulty with sitting still for long periods of time, and difficulty with car rides and sleeping more than five hours. He reported that “a good stretching regime” helped. He did not take any medications for his back symptoms. He also reported a history of urinary urgency, but denied loss of bladder control or saddle anesthesia. Regarding his urinary urgency, it was “suspected OAB” (overactive bladder) and to consider a urology referral. In March 2014, the Veteran reported a remote history of a motor vehicle accident and a fall in service, with worsening back pain in the past year. He had mid-back and paraspinals pain with occasional shooting pain up to the shoulder blade. His pain averaged a 3 out of 10, but regularly flared to a 7 or 8 out of 10 for which he would take three Advil. Advil would improve his pain back down to a level 3. His pain was worse with forward flexion. He had a negative straight leg raise test. Unfortunately, in April 2014, the Veteran was involved in a multiple vehicle car accident with increased neck and back pain and symptoms. In July 2014, the Veteran sought VA chiropractic treatment, and noted he had good results from chiropractic care in the past. He reported histories of falling from a one-story building and being struck by a car as a pedestrian in service. He stated his current back pain was a 4/10 with his worst pain being a 10/10. The pain was in the T12-L3 area and was described as “stiffness.” The pain was constant, but varied in intensity. He exercised by walking in a canyon three times per week. On physical evaluation, he had normal thoracic kyphosis and normal lumbar lordosis. He had 85 degrees of forward flexion with his knees straight. He was “intact” neurologically, but had “muscle tightness.” On another chiropractic care record, he noted his pain prevented him from walking more than one mile, from picking heavy weights off the floor (but he could pick up heavy weights from a table), from sitting or standing for more than 30 minutes, and that it was painful to look after himself but he was able to do so by being slow and careful. He also noted that his pain caused him to have less than 4 hours of sleep. In August 2014, the Veteran was afforded a VA spine examination. He had a history of fracture of the T12 from 1996, and a sacroiliac injury. He gave a history of falling from a rooftop in 1996, and suffering a compression fracture of his T12 vertebrae. He was seen at a hospital at Camp Pendleton and placed in traction for two days. He was hospitalized for four days and then released home, where he was placed on light duty for 45 days before returning to his unit. One year later, he was struck by a motor vehicle as a pedestrian, on his right side. He stated that studies done at the time showed a rotational defect to the spine, and he was almost Medical Boarded out because of this second back injury, but “finally managed to barely pass his fitness test.” He remained in the service until 2009. Currently, he will awaken with back pain if he stays in bed for too long or if he “slacks off in his back-stretching exercises routine.” He reported that he does experience flare-ups on those days when he has remained in bed for too long or has not kept up with his stretching. His back would become more stiff and painful, with decreased range of motion to the back. He stated he has had to alter his work schedule or miss work during these flares. On range of motion testing, he had flexion to 90 degrees with no objective painful motion. His extension, lateral flexion, and rotation were all 30 degrees or greater without objective painful motion. He was able to complete repetitive range of motion testing without a change to his range of motion. He had localized tenderness to his supinatus and paraspinal muscles of the midback. He did not have muscle spasm or guarding which resulted in abnormal gait or spinal contour. His muscle strength testing and deep tendon reflexes were normal throughout. He had a normal sensory evaluation, and he denied any radicular pain or other symptoms. The examiner found that he did not have radiculopathy. The Veteran reported using a back brace when on long road trips or when he anticipated being seated for a long period of time. X-rays showed mild degenerative disc disease in the lower thoracic spine to L2, osteophyte formation of lower thoracic, L1 and L4 vertebral bodies, anterior height loss/wedging of T12 vertebral body, and minimal degenerative change in the left sacroiliac joint. Regarding functional impact, the Veteran reported that during acute flares of his condition he had to re-schedule his work day or miss work altogether. He reported he missed work completely roughly once per month, but admitted that he had to alter his work schedule a couple times per week to accommodate his back if he wants to still get work done that day. He reported that movement helped his back, and he did daily back stretching exercises with good results. If he does not do his stretches for a week or so, his back would worsen, and sedentary activities aggravated his back. A March 2015 chiropractor record included the Veteran’s complaint of pain at a level 7 out of 10. His forward flexion was limited to 80 degrees. He had positive face loading and tight hip flexors/adductor tests. A May 2015 chiropractor record included the Veteran’s complain of recently increased back pain due to sitting/flying for work. He had “observed limited forward flexion with pain,” but this was not provided in terms of degree of motion lost. Another May 2015 VA treatment record noted the Veteran had borderline prostate hypertrophy and had stopped taking the medication for treatment of his urinary symptoms. In May 2016, the Veteran was afforded an additional VA spine examination. He reported constant low back pain, more prominent on the left, that increased with bending and lifting. His pain would radiate to the back of the right thigh, and his symptoms improved with rest and stretching. He denied any bowel or bladder symptoms, and denied any distal motor deficits. He reported flare-ups where he could not “lift heavy objects, walk, bend or stand for prolonged periods due to pain in the back.” On range of motion testing, he had flexion to 65 degrees, extension to 25 degrees, and bilateral flexion and rotation to 25 degrees, each. The examiner noted the abnormal range of motion was due to pain. There was evidence of pain with weight-bearing, and pain with each direction of motion (flexion, extension, etc.). After repetitive use testing, the Veteran’s range of motion did not change. The examiner noted that the Veteran was not being examined immediately after repetitive use over time, or during a flare-up, and that the examination was neither medically consistent nor inconsistent with the Veteran’s statements regarding functional loss. The examiner noted that pain would significantly limit the functional ability of the Veteran’s spine with repeated use over time, and the examiner was able to describe the loss in terms of range of motion. The examiner found that the Veteran’s flexion would be limited to 60 degrees with repetitive use over time. Similarly, the examiner found that his flexion would be limited to 60 degrees during a flare-up of symptoms. He had normal muscle strength and deep tendon reflex tests. He had a normal sensory examination except for decreased sensation of the right foot/toes (L5). He had negative straight leg raise tests bilaterally. He reported symptoms of right lower extremity radiculopathy. The examiner found that the Veteran had mild right sciatic nerve radiculopathy, and that he did not have left lower extremity radiculopathy. The examiner found that the Veteran did not have intervertebral disc syndrome (IVDS) of the spine. X-rays were taken, which documented arthritis. The Veteran’s thoracic vertebral fracture did not result in loss of 50 percent or more of height. X-rays of the thoracic spine from May 2016 showed degenerative disc disease at the thoracolumbar junction. The examiner selected that the Veteran would be limited to light physical work due to his diagnosis. A February 2017 chiropractor record included the Veteran’s complaint of pani at a level 6 or 7 out of 10, with mild upper, mid, and low back pain. The weather was making him feel stiff, and he had traveled a lot for work, which made his pain worse through prolonged sitting. He reported he was walking 2 miles (the canyon walks) three times per week. In April 2017, the Veteran was afforded a fee-basis VA examination. He was assessed with chronic lumbosacral strain with spasm, and lumbosacral IVDS with moderate right sciatic radiculopathy. The Veteran reported flare-ups of back symptoms, described as “limited by pain which radiates from low back to right lower extremity in activities such as prolonged sitting, standing, walking, repetitive bending, and heavy lifting.” He stated the overall functional impairment was “impaired prolonged sitting, standing, walking, repetitive bending, and heavy lifting.” He had forward flexion to 80 degrees, extension to 20 degrees, right and left lateral flexion to 25 degrees, and right and left lateral rotation to 25 degrees. There was evidence of pain with weight-bearing, and in all directions of range of motion testing (flexion, extension, etc.). He had mild tenderness to palpation of the lumbosacral spine, the paralumbar muscles had increased tone, and the right sciatic notch region was tender. After repeat motion testing, the Veteran had flexion to 75 degrees, extension to 15 degrees, and right and left lateral flexion and lateral rotation to 20 degrees, each. The examiner noted that the Veteran’s pain, weakness, fatigability or incoordination would significantly limit functional ability with repeated use over time, and that the range of motion would be flexion limited to 60 degrees, extension to 10 degrees, and lateral flexion and rotations to 15 degrees, each. The examiner noted that the Veteran’s spine was not being examined during a flare-up, and that he was not able to describe the functional limitations of the Veteran’s spine during a flare-up in terms of range of motion without mere speculation. “Objective determination of whether the veteran is experiencing a flare-up or not can only be determined by someone like the [primary care physician] who has prior acquaintance with the veteran’s body and has determined a non-flare-up base like for comparison.” The examiner noted that he could not “confirm nor refute flare-up status” in all examinations, and could, therefore, “not verify if the objective [range of motion being observed] after repetitive sue represents [range of motion] during flare-up or not without resorting to speculation.” The Veteran had normal muscle strength and normal deep tendon reflexes throughout. He also had a normal sensory evaluation, including of the lower right extremity. He had a positive straight leg raise test on the right. He denied left lower extremity radicular symptoms. Regarding his right lower extremity, he reported mild constant pain, moderate intermittent pain, moderate paresthesias/dysesthesias, and mild numbness. The examiner noted that the nerve root involved was the right femoral nerve, of moderate severity. He did not have other neurological abnormalities. He had not had any episodes of acute signs and symptoms of IVDS requiring bedrest prescribed by a physician and treatment by a physician in the past 12 months. He did not use any assistive devices. The examiner noted that there was objective evidence of pain on passive range of motion testing of the back, but no evidence of pain on non-weight bearing testing. Based on the probative evidence of record, the Board finds no basis to award a rating higher than the current 20 percent. To merit the next higher rating of 40 percent under the General Rating Formula, there must either be forward flexion of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. The range of motion testing provided during his 2014, 2016, and 2017 VA examinations did not meet this standard. Moreover, none of the VA examiners found evidence of ankylosis. The Board notes that the Veteran’s range of motion decreased significantly during his 2016 examination. His chiropractic records from 2014 and 2015 included findings of forward flexion from 80 to 85 (including more records than cited above). His current 20 percent rating has been applied for the entire period on appeal despite the 2016 examination including the first notation from a VA examiner that his flexion would be limited to 60 degrees after repeated use or during a flare-up. Furthermore, the Veteran’s lay statements do not provide additional details regarding functional impairment such that an increased 40 percent rating may be applicable. He has generally noted that he had improvement of spine pain and function with stretching and movement. His chiropractic care records included his report of exercising through walking 2 miles, three times per week. He has reported increased pain with prolonged sitting, standing, and lying down (including an impact on his ability to sleep). The 2016 and 2017 examiners provided opinions on the additional functional loss the Veteran was likely to have during flare-ups of pain or after repeated use. Both examiners found that he would be additionally limited to 60 degrees of flexion. Indeed, his 2016 flexion was limited to 65 degrees, which was the greatest loss of flexion recorded throughout his claims file and may represent his loss during more severe symptom onset. As 60 degrees of flexion is 30 degrees more than that required for the next higher rating (40 percent), the Board does not feel that the Veteran’s symptoms, even during a flare-up or after repeated use, more nearly approximate the next higher rating. The Board notes that the Veteran is separately rated for right lower extremity radiculopathy, and he has not appealed the rating assigned for that additional disability. His VA treatment records include notations of urinary urgency, which have been attributed to a diagnosis of overactive bladder, as well as benign prostatic hypertrophy. He was prescribed medication related to these diagnoses, although it appears he stopped taking the medication at some point due to side effects. VA examiners did not diagnose additional neurological disorders related to the Veteran’s spine condition. As such, there are no additional neurological disorders which should be separately granted in this appeal. The Veteran has not undergone spinal surgery, and there was no indication of scars related to his service-connected spine condition. Entitlement to a rating in excess of 20 percent for residuals of a T12 fracture is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for bilateral knee strain is remanded. During his April 2016 meeting with a DRO, the Veteran reported that his bilateral knee strain was due to his 1995 fall from a one-story building and the cumulative trauma from carrying a heavy pack and participating in physical training, including martial arts, in service. He was afforded a VA knee examination in May 2016, where the examiner diagnosed bilateral knee strain and provided a negative nexus opinion. The examiner’s rationale was that the Veteran’s service treatment records singularly included a 1997 note of right shin pain with normal diagnostic work-up, and no additional treatment related to his knee in service or post-service. The examiner did not specifically address the Veteran’s contention that his knees were injured in his 1995 fall or that his knee strain was due to the cumulative effects of 8 years of military service. Additionally, the Board notes that the service treatment records currently contained in the claims file are incomplete. They do not contain entrance or separation examinations for the Veteran’s various periods of service. Although there are records related to both his 1995 fall from a building and 1996 motor vehicle accident, there are no records related to his 1995 hospitalization with traction. On remand, an attempt should be made to obtain any missing, available service treatment records. Thereafter, an addendum medical opinion must be sought. The matter is REMANDED for the following action: 1. Obtain the Veteran’s complete service treatment records. Records currently in the claims file are incomplete (do not include entrance and separation examination, records from his 1995 hospitalization, or more than one record from his period of service from 2008 to 2009). All records/responses received must be associated with the electronic claims file. 2. After any additional VA treatment records are obtained, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s bilateral knee strain is at least as likely as not (50/50 probability or greater) related to his service, to include his 1995 fall from a one-story building, his 1996 incident where a car backed into him (as a pedestrian), and his indication that his knee strain is due to the cumulative impact of physical activity in service (including participation in martial arts). If the examiner determines that the Veteran must be interviewed or examined in order to provide the addendum opinion, then an additional examination must be scheduled. (Continued on the next page)   A complete rationale must accompany each expressed opinion. 3. After completing the development requested above, readjudicate the Veteran’s claim. If any of the benefits sought are not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. The case should then be returned to the Board, if otherwise in order. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel