Citation Nr: 18152588 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 16-31 688 DATE: November 23, 2018 ORDER The claim for service connection for sleep apnea is granted. The request to reopen the finally disallowed claim of service connection for patellofemoral syndrome (PFS) of the right knee is denied. The request to reopen the finally disallowed claim of service connection for hypertension is granted. The claim for service connection for gout, also claimed as metatarsalgia, is denied. The claim for service connection for psoriatic arthritis and rheumatoid arthritis, to include the elbows, hands, feet, right knee, and fingers is denied. The claim for an increased rating for PFS of the left knee with Baker's cyst, rated 10 percent, is denied. REMANDED The claim for service connection for hypertension is remanded. FINDINGS OF FACT 1. The record evidence establishes that the onset of the Veteran’s sleep apnea was during active service. 2. Although notified in February 2010, the Veteran did not appeal a January 2010 decision which denied reopening of claims for service connection for hypertension and PFS of the right knee. 3. The evidence received since the January 2010 rating decision as to a claim for service connection for PFS of the right knee is not new and does not establishes a reasonable possibility of substantiating that claim for service connection for PFS of the right knee. 5. The evidence received since the January 2010 rating decision as to a claim for service connection for hypertension is new and establishes a reasonable possibility of substantiating that claim for service connection for hypertension. 6. Gout, and metatarsalgia, are first shown years after active service and are unrelated to the Veteran’s military service. 7. Psoriatic arthritis and rheumatoid arthritis, to include the elbows, hands, feet, right knee, and fingers, are first shown years after active service and are unrelated to the Veteran’s military service. 8. The Veteran’s PFS of the left knee with Baker’s cyst is manifested by painful but a noncompensable degree of limited motion and there is no instability. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea are met.38 U.S.C. §§ 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 310 (2018). 2. The January 2010 rating decision that denied reopening of claims for service connection for hypertension and for PFS of the right knee is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104(a), 20.200, 20.302, 20.1103 (2018). 3. The criteria to reopen the finally disallowed claim of service connection for PFS of the right knee are not met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 4. The criteria to reopen the finally disallowed claim of service connection for hypertension are met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 5. The criteria for service connection for gout, also claimed as metatarsalgia, are not met. 38 U.S.C. §§ 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 310 (2018). 6. The criteria for psoriatic arthritis and rheumatoid arthritis, to include the elbows, hands, feet, right knee, and fingers, are not met. 38 U.S.C. §§ 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 310 (2018). 7. The criteria for an increased rating for PFS of the left knee with Baker’s cyst, rated 10 percent disabling, are not met. 38 U.S.C. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had unverified active service in the U.S. Navy. The Veteran’s DD 214 shows that he had active service in the Army from and from October 1998 to October 1999, and he had 3 months and 8 days of prior active service. This appeal to the Board of Veterans’ Appeals (Board) arose from a June 2013 decision of a Department of Veterans Affairs (VA) Regional Office (RO). Background The Veteran’s service treatment records (STRs) include a March 1992 examination for transfer while he was in the Navy. He was 70 inches tall, weighed 181 lbs., and his blood pressure was 110/72. The Veteran’s STRs of his service in the Army include an August 1998 enlistment examination which found that the Veteran was 69 ¾ inches tall and weighed 173 lbs. His blood pressure was 119/67. An adjunct medical history questionnaire indicated that he had been honorably discharged from the Navy in 1993. An August 1998 Medical Prescreening form noted that the Veteran was 68 inches tall and weighed 165 lbs. An undated “Individual Medical History” (noting that an HIV test was done in August 1998) shows that the Veteran was 5 feet 11 inches in height and weighed 176 lbs. Another undated “Individual Medical History” (noting that a hearing test was done in November 1998) shows that the Veteran was 74 inches in height and weighed 183 lbs. An October 8, 1998, STR shows that the Veteran’s blood pressure was 115/73. A December 1998 left knee X-ray found no evidence of joint effusion or significant arthritic change. A December 8, 1998, service clinical records noted that the Veteran’s blood pressure was 125/64. A January 1999 record reported the results of a left knee MRI, and noted that the Veteran’s blood pressure was 180/60. In February 1999 it was 130/79 and also in that month it was 135/60. A May 5, 1999, service clinical record noted that the Veteran’s blood pressure was 120/50. Another service clinical record in May 1999 reflects diagnoses of chondromalacia of the patella/patellofemoral pain syndrome of the left knee, and low back pain. On a May 1999 examination in connection with a Medical Evaluation Board, the Veteran’s blood pressure was 144/82. He was 70 inches tall and weighed 220 lbs. In a summary of defects it was reported that he had increased systolic blood pressure and was to start a 5 day blood pressure check. In a May 1999 Medical History Questionnaire, in connection with a Medical Evaluation Board, the Veteran reported having or having had swollen or painful joints, cramps in his legs, a trick knee, back pain, and recent gain of weight. In a separate document the Veteran reported that as to swollen or painful joints, his knees would regularly swell and most of the time he had pain from his back down. As to cramps in his legs, sometimes he would fall due to leg cramps which felt like electric shocks from his low back down. As to a cyst, an MRI had shown a small Baker’s cyst [in his left knee]. As to recent weight gain, he had gained 45 lbs. since September because he was unable to exercise. A July 1999 Report of Medical Evaluation Board Proceedings discloses that the Veteran was released from active service due to his now service-connected disabilities of the left knee and low back. It was noted that he had begun to develop left knee pain in September 1998 without any knee injury. Attempts at rehabilitation were unsuccessful and while undergoing left knee treatment he had fallen on his back while descending some stairs, causing low back pain which radiated to the buttocks and legs. He was 70 inches in height and weighed 220 lbs. His blood pressure was 144/82. The Veteran first applied for VA disability compensation in September 1999 for disability of his back, knees, hips, and high blood pressure. A VA outpatient treatment (VAOPT) record (bearing a date in VMBS of October 18, 2001) dated January 1999 shows that the Veteran’s blood pressure was 180/60. VA clinical records of 2000 and 2001 show that the Veteran’s weight ranged from 197 lbs. to 210 lbs. His blood pressure readings ranged from systolic readings of 121 to 146, and diastolic readings of 52 to 63. On VA examination in August 2001 of the Veteran’s spine he complained of pain, weakness, stiffness, fatigability, and lack of endurance. On VA examination in August 2001 of the Veteran’s left knee he complained of pain and crepitus. It was reported that there were no constitutional signs of an inflammatory arthritis. A September 2002 VAOPT record shows that the Veteran’s weight was 198 lbs. There was no clubbing, cyanosis, edema, skin discoloration or ulcers of his extremities. Private nerve conduction velocity and electromyography studies in February 2004 revealed findings compatible with mild right L5-S1 radiculopathy. A private left knee MRI revealed myxoid degeneration of the posterior horn of the medical meniscus. On VA spinal examination in February 2004 the Veteran complained of low back pain with radicular symptoms. On the neurologic portion of the examination no abnormality was found. The diagnoses were mechanical low back pain with muscle spasm and L5-S1 herniated nucleus pulposus (HNP), and right L5-S1 radiculopathy by electrodiagnostic testing. On VA examination of the Veteran’s left knee in February 2004 he complained of constant moderate to severe pain of the anterior aspect and around the left knee joint. He had no need for crutches, braces, a cane or corrective shoes for ambulation. He had no episodes of dislocation or subluxation in the past year. He had no constitutional symptoms of inflammatory arthritis. He had left knee crepitus and a positive patellar grinding test. The diagnoses were PFS of the left knee, and myxoid degeneration of the posterior horn of the medical meniscus. VAOPT records show that in March 2008 the Veteran reported that he did not have high blood pressure but he thought that he weighed too much. In April 2008 the Veteran’s blood pressure was 128/79 and he weighed 262 lbs. [119.1 kilograms]. In May 2009 he denied having high blood pressure. Treatment records of the Mayo Primary Care Center from February to July 2009 reflect treatment for bilateral knee and low back pain. In February 2009 it was reported that the Veteran had had progressive bilateral knee and low back pain. He denied constitutional symptoms. He had a past medical history of being overweight. His blood pressure was 118/84 and he weighed 181 kilograms. In May 2009 his blood pressure was 124/82 and his weight was 115.4 kilograms. In June 2009, as to low back pain and bilateral patellofemoral pain, he had a greater than 10 year history with worsening over the last year of both knee and back pain. On examination in July 2009 there was no knee effusions or ligamentous laxity or instability but there was a positive patellar compression test. On VA examination in January 2010 of the Veteran’s left knee he complained of left knee stiffness, locking, weakness, and constant pain. He denied any subluxation or dislocation. Severe flare-ups occurred once or twice weekly, lasting up to several hours and were alleviated with rest and medications. He did not use any assistive device. On physical examination his gait was normal and he had a normal shoe wear pattern. There was tenderness to the left patellofemoral joint, popliteal region, and lateral joint line. Patellar grind test was positive. There was some crepitus on left knee motion. All of his ligaments were intact. Bilateral knee flexion was to 115 degrees with pain from 90 to 115 degrees. Extension was to 0 degrees, bilaterally, and without pain. On repetitive motion testing there was no additional limitation due to painful motion, fatigue, weakness or incoordination, and ranges of motion remained unchanged. He was not having a flare-up at the examination and the examiner reported that it would be speculative to report limitations during a flare-up. The diagnosis was left knee PFS. On VA spinal examination in January 2010 the Veteran complained of progressive low back pain which radiated into both legs and calves, and which was worse on the left than the right. A January 2010 rating decision denied a rating in excess of 10 percent for service-connected PFS of the left knee but increased the 10 percent rating for mechanical low back pain with muscle spasm and degenerative disc disease (DDD) at L5-S1 to 40 percent, effective July 13, 2009. That decision also denied reopening of claims for service connection for hypertension and for PFS of the right knee because new and material evidence had not been submitted. The Veteran was notified of that decision by RO letter dated February 1, 2010, but he did not appeal. Received since the January 2010 rating decision were clinical records of Dr. S. Tilak which show that in April 2008 the Veteran had nasal congestion. He was 6 feet tall and weighed 265 lbs. The assessments included acute sinusitis. In May 2008 he was rechecked for a sinus infection, at which time he weighed 262 lbs. His acute sinusitis had resolved. Later that month he weighed 258 lbs. In November 2008 he again had a sinus infection, and the relevant impression was acute sinusitis. It was noted that he had a history of allergies and had had upper respiratory symptoms for quite some time. It was suspected that he had a viral upper respiratory infection (URI). An August 2010 clinical record shows that the Veteran’s blood pressure was 132/70. In April 2011 he was evaluated for elevated blood pressure. It was noted that he was seeing a rheumatologist for osteoarthritis and rheumatoid arthritis, and he was having chronic pain in his hands, knees, and back. He did not have high blood pressure in the past, and denied chest pain, shortness of breath (SOB), headaches, and dizziness. He had been seen by a specialist in February and in March when his blood pressure readings had been 160/102 and 149/109. The impressions were: elevated blood pressure reading without diagnosis of hypertension; rheumatoid arthritis; generalized osteoarthritis; chronic pain; and unspecified backache. He was to monitor his blood pressure readings at home. It was noted that he had chronic pain and was to discuss this with Dr. Tilak because the elevated blood pressure could be due to pain. In July 2011 the Veteran was seen for a follow-up for a medication refill for hypertension. The relevant impression was unspecified essential hypertension. Records of the Arthritis & Osteoporosis Treatment Center show that in March 2011 show that the Veteran’s uric acid level was elevated, being 9.1 with the normal range being 4.0 to 8.0 mg/dL. His rheumatoid factor was elevated, being 16 with the normal range being less than 14 IU/mL. His blood urea nitrogen (BUN) was elevated, being 13 with the normal range being 7 to 25 mg/dL. He was evaluated in March 2011 for waxing and waning pain in his hands, wrists, elbows, shoulders, feet, ankles, hips, neck, shoulders, and back with blurry vision for the past two years which was progressively worsening. His blood pressure was 149/109 but he had not been diagnosed with hypertension in the past. On examination he had synovitis of all metacarpophalangeal (MCP) joints and all proximal interphalangeal joints of both hands, and in both wrists. The assessment was that he had symmetrical synovitis in the joints of the upper and the lower extremities, with marked decreased range of motion of the hips, suggestive of inflammatory arthritis, which was likely rheumatoid arthritis with dry scaly skin of the hands and elbows. It was also commented that he most likely had psoriatic arthritis. The possibility of spondyloarthropathy or ankylosing spondylitis was likely. Also reported were “R/o CTD [connective tissue disease] and Gouty arthritis since pt’s father has gout.” X-rays in March 2011 revealed mild degenerative disease of the medial and patellofemoral compartments. X-rays of the hand revealed minimal osteopenia of the MCP joints with joint space narrowing of the MCP, PIP, and DIP joints which might suggest possible inflammatory arthritis. X-rays of the feet revealed narrowing of both MTP joints and osteopenia suggestive of inflammatory arthritis. Records of the Arthritis & Osteoporosis Treatment Center in April 2011 show that the Veteran was 5 feet 11 inches tall and weighed 280 lbs. He had a history of rheumatoid arthritis, and X-rays had revealed osteopenia. When followed-up in April 2011 at the Arthritis & Osteoporosis Treatment Center it was noted that the Veteran had had pain for several years in his hands, wrists, elbows, shoulders, feet, knees, hips, and low back. Another physician had diagnosed him as having allergic conjunctivitis, not iritis. The assessments included rheumatoid arthritis, seropositive, very active; psoriatic arthritis, hyperuricemia; DJD of both knees; morbid obesity; and uncontrolled hypertension. Later in April 2011 the assessments included a history of sleep apnea and mild restriction on pulmonary function testing. An April 2011 clinical record from the Jacksonville Orthopaedic Institute shows that the Veteran had a 2 to 3 year history of right knee and bilateral hip pain. He had had other joint symptoms, such as in his left shoulder and wrist. He was being worked up by another physician for rheumatoid arthritis. After an examination and X-rays of the hips and right knee, the impression was bilateral hip and knee rheumatoid arthritis. The Veteran’s application to reopen claims for service connection for hypertension and right knee disability, as well as for service connection for psoriatic and rheumatoid arthritis and for gout and an increased rating for his left knee disorder was received on April 11, 2011. Records of the Southern Heart Group show that the Veteran was evaluated in May 2011 for chest pain and dyspnea. He had had arthritis for many years and was recently diagnosed as having rheumatoid arthritis. He had had a sensation of tightness and heaviness in his chest for many months, primarily after eating. He was unable to perform physical activity due to dyspnea and diffuse discomfort from arthritis. He had recently been started on blood pressure medication. His past medical history included hypertension, rheumatoid arthritis, psoriatic arthritis, gout, and sleep apnea. On examination his blood pressure was 130/80. An echocardiogram revealed normal left ventricular size and ejection fraction. The impressions were atypical chest pain; abnormal EKG (borderline left atrial abnormality); hypertension; rheumatoid and psoriatic arthritis; and an inability to ambulate due to arthritis. In a May 2011 letter the Veteran’s wife stated that during and since service, in 1998 – 1999, he snored loudly. He had sought medical help in May 2011 and a physician had “ordered a sleep study and he was diagnosed with sleep apnea” and now used a CPAP machine. At times when he snored he would stop breathing. He had been unable to exercise regularly and gradually gained weight. An undated private clinical record by Dr. B. Wang noted that the Veteran was 40 years of age (having been born in July 1971) and was seen at a Rheumatology clinic for long standing back pain of inflammatory character and peripheral musculoskeletal pain which had been ongoing for 10 to 12 years. He had had conjunctivitis and now noticed skin changes. He also had OSA and high blood pressure. X-rays had revealed findings in the sacroiliac joints compatible with sacroiliitis. On a return visit the assessment was inflammatory spondyloarthropathy, compatible with ankylosing spondylitis or psoriatic spondyloarthropathy. It was stated that clinically and radiographically he had an inflammatory spondyloarthropathy. In June 2011 the Veteran reported during service in 1999 he was treated for a Baker’s cyst and that medical literature stated that a Baker’s cyst was commonly associated with rheumatoid arthritis and osteoarthritis. He stated that “John P. Petralgia, MD, states that patients suffering from rheumatoid arthritis are especially susceptible to develop a Baker’s cyst.” He also cited to the Atlas of Common Pain Syndrome by Steven D. Waldman, MD, for a similar statement. He stated that his complaints reflected in a medical history questionnaire at service separation indicated that he had swollen or painful joints, cramps in his legs, and a growth, cyst or cancer. He reported that medication given during service were used in treatment of not only osteoarthritis but also gout and rheumatoid arthritis even though he was never screened for gout or rheumatoid arthritis during service. Also, he had elevated blood pressure readings on several occasions during service, and even at separation from service. He reported having taken Ibuprofen for 12 years, and that medical literature stated that this could lead to the onset of new hypertension or worsening of pre-existing hypertension. Dr. Tilak had prescribed Lisinopril for his hypertension. Also in June 2011, the Veteran submitted duplicates of service treatment records (STRs) which were previously of record. Private clinical records of Dr. M. Tilak of July 2011 show the following vital signs on dates reflected below: Date Weight Sitting Blood Pressure 11/4/2008 263 lbs 139/93 8/26/2010 283 lbs 132/70 4/4/2011 288 lbs 138/88 5/17/2011 286 lbs 124/91 7/12/2011 285 lbs 120/84 His current medications included Lisinopril. The relevant diagnoses were: elevated blood pressure reading without diagnosis of hypertension; rheumatoid arthritis; generalized osteoarthritis; chronic pain; unspecified essential hypertension; and myalgia and myositis, unspecified. An August 2011 statement from Dr. M. Antonio-Miranda shows that the Veteran been seen since May 2011, and a May 30, 2011 sleep study had yielded a diagnosis of obstructive sleep apnea (OSA). That physician opined that “[i]t is likely that [the Veteran’s OSA] has been undiagnosed for many years. He has gained weight over the years and it is likely that his [OSA] has contributed to his weight gain and difficulty losing it.” An undated statement from Dr. H. Arraut states that he had treated and examined the Veteran since May 2011. His diagnosis was OSA, which required the use of a CPAP machine. That physician had reviewed the Veteran’s service medical records from October 1998 to October 1999, and the Veteran’s history of sleep and weight gain during and after his military service. He had no other known risk factors that might have precipitated his OSA. Medical literature and medical studies had shown that not only did obesity have an association with OSA, but poor sleep from OSA tended to cause obesity. That physician stated that “[i]t is my opinion that is more likely than not [sic] that [the Veteran’s] sleep apnea started while he was serving in the military. His wife states that his snoring started in 1998 and he gained 45 pounds from October 1998 to May 1999. From 1999 until the present he has gained another 65 pounds as a result of his sleep apnea.” A private clinical record, undated but apparently prepared in August 2012 by R. J. Presutti, D.O., reflects that the Veteran had confirmed osteopenia, obesity, hypertension, diabetes mellitus, diabetic peripheral neuropathy, asthma, rheumatoid arthritis, and OSA hypopnea. A January 2013 decision of an Administrative Law Judge (ALJ) of the Social Security Administration (SSA) shows that the Veteran was awarded SSA disability benefits due to DDD, left shoulder disability, and sleep apnea. On VA spinal examination in May 2013 the Veteran reported that since his examination in 2010 he had had more low back pain and more difficulty moving around especially in past year. He had been diagnosed with rheumatoid and psoriatic arthritis in 2011. On VA examination of the Veteran’s knees in May 2013 it was noted that the Veteran had been diagnosed with bilateral DJD, and PFS of the left knee with a Baker’s cyst. He reported that since his knee examination 2010 his condition was worse. He had more pain and swelling. He also had a Baker's cyst of the left knee which would swell at times. He had been diagnosed with rheumatoid arthritis in 2011 which was affecting multiple joints, including both knees. He reported having had right knee pain in service which had been an intermittent problem since active duty. The right knee had become more painful and more frequently painful over the past 2 years. He had a known Baker's cyst of the left knee discovered in service and was told by his rheumatologist there was a right cyst as well, although this was not documented. The Veteran reported that flare-ups impacted function of the knee because of difficulty walking, and swelling which required that he rest. On examination there was left knee flexion to 125 degrees, with pain beginning at 110 degrees. Left knee extension was full and painless. After 3 repetitions of motion these ranges of motion were unchanged. He had functional loss or impairment due to limited left knee motion, painful motion, and disturbance of locomotion. He had tenderness or pain to palpation for joint line or soft tissues of both knees. Strength was normal, at 5/5, in flexion and extension of each knee. There was no anterior instability (Lachman test), posterior instability (Posterior drawer test), or medial-lateral instability (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion). There was no evidence or history of recurrent patellar subluxation/dislocation. He did not have a menisceal condition, and had not had a meniscectomy or any knee surgery. He did not use any assistive device(s) as a normal mode of locomotion. X-rays had revealed arthritis in both knees. The examiner stated that the Veteran’s knee condition impacted his ability to work because he could not climb up and down stairs or stand for long periods. After reviewing the record, the examiner opined that the Veteran's left knee DJD was caused by or a result of active duty but his right knee DJD was not caused by or a result of active duty. The rationale was that based on review of the medical records, medical literature, and the examiner’s clinical experience, the DJD of the left knee was as likely as not a result of this service and was found on X-ray in 2009, prior to his diagnosis of rheumatoid arthritis. Although, it was possible his inflammatory arthritis might be contributing to the current knee examination, the examiner could not separate this condition from the DJD of the knee that the examiner felt was secondary to his service and previously diagnosed left knee PFS. There was no evidence of a chronic right knee condition during service or for many years following separation. Thus, a chronic right knee condition could not be established as starting in service and a nexus could not be made. His leg cramps noted in service were electric shock sensations from his low back down his legs and was not a knee or leg condition. This most likely represented radicular symptoms from his lumbosacral spine. Also, the Veteran's left Baker cyst was caused by or a result of his active duty. There was no evidence of a right baker cyst, therefore, an opinion was not warranted because a right Baker’s cyst could not be found on the current examination and there was no evidence of it in the records. Even if this was documented in the last 2 years, which the examiner could not find, it could not be related to active duty since there was no evidence of this during his active duty. On VA examination of the Veteran’s feet in May 2013 it was reported that the Veteran had been diagnosed with bilateral metatarsalgia in March 2011, and inflammatory arthritis of both feet in 2011. It was reported that the Veteran began having foot pain, bilaterally, and toe pain in 2011, and which had become more painful in the last 2 years and was now constant. He was diagnosed with inflammatory arthritis at that time. Imaging studies had confirmed inflammatory arthritis of multiple joints of both feet. In addressing whether psoriatic arthritis, rheumatoid arthritis, and metatarsalgia conditions were incurred by injury, event or illness during active service, the examiner reviewed the record, and cited to multiple clinical records. The examiner opined that the Veteran's inflammatory arthritis and metatarsalgia were not caused by or a result of his active duty. The rationale was that based on review of the medical records, medical literature, and the examiner’s clinical experience there was no evidence of a foot condition in service or for many years after separation, and nothing suggesting an inflammatory arthritis (rheumatoid or psoriatic) during active duty. The complaint of joint pain on 5/25/99 was clarified by the Veteran and referred to knee problems. His "electric shock" pain going down his legs was likely radicular from his back and had nothing to do with an inflammatory arthritis or a foot condition. A nexus could not be made for his foot condition as a result of his diagnosed inflammatory arthritis. On VA examination of the Veteran’s elbows and forearms in May 2013 it was noted that the Veteran was diagnosed with a bilateral elbow strain in May 2013. He had begun having elbow pain, bilaterally, in 2010/2011 and he was diagnosed with rheumatoid and psoriatic arthritis. He continued to have intermittent elbow pain, especially in the mornings. In addressing whether bilateral elbow conditions, including any arthritis, were incurred by injury, event or illness during active service, the examiner reviewed the record, and cited to multiple clinical records. The examiner opined that the Veteran's bilateral elbow condition was not caused by or a result of his active duty. The rationale was that based on review of the medical records, medical literature and the examiner’s clinical experience there was no evidence of an elbow condition in service or for many years after separation, and nothing suggesting an inflammatory arthritis (rheumatoid or psoriatic) during active duty. The complaint of joint pain on 5/25/99 was clarified by the Veteran and referred to knee problems. A nexus could not be made for his elbow condition as a result of his diagnosed inflammatory arthritis. On VA examination of the Veteran’s hands and fingers in May 2013 it was noted that the Veteran was diagnosed with synovitis of both hands and inflammatory arthritis of the hand in March 2011. He began having hand pain and swelling in 2010/11 and was diagnosed with inflammatory arthritis. He had significant pain in the morning which decreased throughout the day but never resolved. In addressing whether the claimed conditions, including any arthritis, were incurred by injury, event or illness during active service, the examiner reviewed the record, and cited to multiple clinical records. The examiner opined that the veteran's bilateral hand condition was not caused by or a result of his active duty. Rationale was that based on a review of the medical records, medical literature, and the examiner’s clinical experience there was no evidence of a hand condition in service or for many years after separation, and nothing suggesting an inflammatory arthritis (rheumatoid or psoriatic) while on active duty. The complaint of joint pain on 5/25/99 was clarified by the Veteran and referred to knee problems. A nexus could not be made for his hand condition as a result of his diagnosed inflammatory arthritis. On VA spinal examination in August 2014 the Veteran’s electronic medical records were reviewed. Sensation to light touch was decreased at the lower legs, ankles, feet and toes which it was commented was not in a dermatomal or radicular pattern and not diagnostic of radiculopathy, although it was noted that the Veteran reported that he had been told that he had diabetic peripheral neuropathy. The Veteran’s gait was slow but normal and not obviously antalgic. He was significantly obese. The examiner noted that the Veteran reported referred symptoms of pain and paresthesia into his lower extremities but there was no objective evidence of radiculopathy, with a normal clinical motor and reflex exams. Referred or radiating symptoms were common occurrences in cases of vertebral degenerative disease due to irritation of structures like facet joints, ligaments, annulus, etc. but that did not indicate radiculopathy [nerve root damage] unless there were objective motor and reflex abnormalities in the appropriate dermatomal distribution peripherally, of which there were none on the current clinical examination. Although Veteran was service-connected for bilateral lower extremity radiculopathy, there was no current evidence thereof. Rather, the current clinical examination was negative for bilateral lower extremity radiculopathy. There was no objective evidence of bilateral lower extremity radiculopathy, consistent with the EMG reports of the right lower extremity in 2012 and 2013 from the Mayo Clinic. The examiner further stated that the Veteran reported he thought this current examination was for rheumatoid arthritis which he said was diagnosed in 2011. The examiner stated that rheumatoid arthritis was an auto-immune disease affecting generalized systems of the body. It was not related to the Veteran’s service-connected back condition, it was not the result of the service-connected back condition either proximately or secondarily. Submitted in May 2015 was an article entitled Obstructive Sleep Apnea (OSA) from an internet source, which states that OSA was of insidious onset and could be present for years before a medical referral. Daytime symptoms might include hypertension. Generally, a physical examination was normal except for obesity, an enlarged neck in men, and hypertension. Examination findings could include systemic arterial hypertension which was present in 50 percent of those with OSA, pulmonary hypertension, and diabetes. Also submitted in May 2015 was an article entitled Sleep Disorders and Associated Medical Comorbidities in Active Duty Military Personnel from an internet source, which found that service-related illnesses were prevalent in military personnel who underwent polysomnography with significant associations between posttraumatic stress disorder, pain syndromes, and insomnia. Of record is a March 2016 VA medical opinion a physician who reviewed the record and opined that the Veteran’s diagnosed sleep apnea was less likely than not (less than 50 percent) incurred or caused by the snoring and weight gain during the service. It was stated that the STRs “do [italics added] reveal that the [V]eteran had a sleep study while on active duty that confirmed the diagnosis of obstructive sleep apnea.” The correspondence from Dr. Arraut stating that the Veteran was being treated for OSA that required CPAP treatment shows that this physician opined that the Veteran had sleep apnea which started while he was serving in the military based on the Veteran’s wife statement that his snoring started in 1998 and that he gained 45 pounds from October 1998 to May 1999. However, the opining VA physician stated that there were no sleep studies seen which documented that the Veteran had OSA. It was commented that a diagnosis of OSA had to be confirmed by a sleep study. The written statement that an individual has this condition without the proper verification was without a supported rationale. “When such a study is produced, the case will be reviewed again.” In December 2917 Dr. S. Benham stated after reviewing the Veteran’s claim file and observing that the Veteran was service-connected for low back disability, left knee PFS, radiculopathy of the left lower extremity, and radiculopathy of the right lower extremity and reviewing pertinent medical literature that it was more likely than not that the Veteran’s sleep apnea developed during military service. Alternatively, his sleep apnea could be considered as secondary to his chronic pain syndrome related to his service-connected injuries. That physician observed that OSA was caused by an airway blockage that occurred when the soft tissue in the back of the throat narrowed or closed during sleep. It occurred only during sleep. Also, snoring was the initial presenting symptom on the sleep-related breathing disorder (SRBD) continuum. As the disease progressed, the patient would begin to show sleepiness, due to increased upper airway resistance. As a cited report showed, if untreated, the patient eventually developed OSA with symptoms of snoring, sleepiness, spouse apnea report, and hypoxia. Dr. Benham opined that based on the testimonies of the Veteran’s wife, Dr. H. Arraut, and on the recent medical literature, it was more likely than not that the Veteran’s sleep apnea actually developed during his military service. Since only a sleep apnea study could diagnosis OSA and physical examination and laboratory exams were generally normal, the Veteran, unfortunately, went undiagnosed until finally having a study performed. Dr. Benham also opined that it was more likely than not that the Veteran’s sleep apnea was secondary to his chronic pain syndrome related to his service-connected injuries. The physician cited the previously noted article of sleep disorders and associated medical comorbidities in servicemembers, that servicemembers with diagnosed pain syndromes were more likely to have insomnia; and that insomnia and sleep apnea overlap. Pain caused sleep apnea in a similar manner that PTSD caused sleep apnea; namely by dysregulation of rapid eye movement (REM) sleep. Thus, there was a reciprocal relationship between sleep quality and pain. Dr. Benham concluded stating that after reviewing all of the Veteran’s medical and military records, it was her expert medical opinion that it was more likely than not (50% or more) that his sleep apnea developed during his military service. Alternatively, his sleep apnea could be considered as secondary to his chronic pain, syndrome related to his service-connected injuries. The medical literature highly supported a nexus between OSA and chronic pain. Principles of Service Connection Service connection is warranted for disability incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Not every manifestation of joint pain during service will permit service connection for arthritis first shown as a clear-cut clinical entity at some later date. 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology in service connection claims is limited to the chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). As such, sleep apnea is not a chronic disease listed at 38 C.F.R. § 3.309(a). Certain chronic disease, such as arthritis and hypertension, which are manifested to a compensable degree within one year of discharge from active duty, shall be presumed to have been incurred in service, even though there is no evidence of such a disease during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for (1) a disability that is proximately due to or the result of a service-connected condition; or, (2) any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of service connection condition, and not due the natural progression of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a), (b). This theory of entitlement requires evidence of (1) a current disability; (2) a service-connected disability; and (3) a nexus, or link, between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Service connection for sleep apnea The STRs are negative for sleep apnea and the earliest contemporary evidence thereof does not antedate 2011. Three supporting private medical opinions have been submitted. Dr. Antonio-Miranda and Dr. Arraut rested their favorable opinions on the lay histories provided by the Veteran and his spouse as well as evidence that the Veteran had a weight gain during service, noting that obesity was a factor in potentially causing sleep apnea, as well as a result of sleep apnea. However, the Board notes that there is also evidence that the Veteran’s wife attributed his inservice weight gain to his lack of exercise, apparently as a result of prolonged physical therapy during service for his left knee and low back injuries. In any event, a third favorable medical opinion was rendered, by Dr. Benham, that the Veteran’s sleep apnea was of service origin, or due to chronic pain syndrome related to service-connected disabilities. However, the Veteran is not service-connected for any chronic pain syndrome, or for arthritis due to gout, psoriasis, or rheumatoid arthritis. The Board notes that the opinion of a VA physician was that the Veteran had a sleep study during service. This is clearly a typographical error inasmuch as that physician rendered a negative nexus opinion based on what that physician reported was an absence of any actual sleep study, without with a diagnosis of sleep apnea could not be made. However, in reviewing the evidence, it must be observed that Dr. Antonio-Miranda reported that the Veteran had, in fact, had a sleep study which was conducted on May 30, 2011, and confirmed the presence of sleep apnea. Consequently, the negative VA nexus opinion is without any probative value. In essence, the favorable medical opinions in this case rest primarily, if not solely, upon the history related by the Veteran’s spouse that during and since his military service had had snored loudly and had interruptions of his breathing while sleeping. The Board finds no reason to question the credibility of this history. Inasmuch as the favorable private medical opinions are otherwise consistent, and even if the Veteran’s weight gain is not associated with sleep apnea, the Board finds that the evidence is at least in equipoise and, so, service connection for sleep apnea is granted. Reopening of Prior Final Disallowed Claims – New and Material Evidence The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with the respect the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). VA must review all evidence submitted since the last final disallowance of the claim on any basis to determine whether a claim may be reopened based on new and material evidence. See Hickson v. west, 12 Vet. App. 247, 251 (1999). The credibility of the evidence is presumed for purpose of reopening, unless it is inherently false or untrue or, if it is the nature of a statement or other assertion, it is beyond the scope of the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216 (1995); Justus v. Principi, 3 Vet. App. 247, 251 (1999). Accordingly, and regardless of a determination by the RO as to reopening, the claim may be considered on the merits only if the Board finds that new and material evidence has been received since the prior final adjudication. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). In the reopening context a weighing of the favorable evidence against the unfavorable evidence is generally not undertaken. See Wilkinson v. Brown, 8 Vet. App. 263, 271 (1995). Only in adjudications de novo is the doctrine of the favorable resolution of doubt applicable. In such cases, the Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). 2. The request to reopen the finally disallowed claim of service connection for PFS of the right knee The evidence on file at the time of the final January 2010 rating decision, which denied service connection for PFS of the right knee, included clinical records, from the Mayo Primary Care Center, which contained a history of bilateral knee pain dating back to military service. The additional evidence received since the January 2010 rating decision includes an April 2011 record of the Jacksonville Orthopaedic Institute, reflecting a 2 to 3 year history of right knee pain and X-rays showing rheumatoid arthritis in the Veteran’s knee. The Veteran related at a May 2013 VA examination having had right knee pain in service which had been an intermittent problem since active duty. However, this was essentially the same clinical history which he had previously related and, so, is not new. The evidence also shows that the Veteran was diagnosed with rheumatoid arthritis in 2011 which was affecting multiple joints, including both knees. This would not relate a current right knee disability to military service or to his service-connected left knee disorder. Moreover, at the 2013 VA examiner the Veteran reported having been told that he had a Baker’s cyst in his right knee, just as he had in his left knee; however, the specifically noted that this had not been documented in the records or by the examiner at the time of that examination. Even if this was documented in the last 2 years, which the examiner could not find, it could not be related to active duty since there was no evidence of this during his active duty. After reviewing the record, the examiner opined that the Veteran's right knee DJD was not caused by or a result of active duty. The rationale was that based on review of the medical records, medical literature, and the examiner’s clinical experience, there was no evidence of a chronic right knee condition during service or for many years following separation. Thus, a chronic right knee condition could not be established as starting in service and a nexus could not be made. His leg cramps noted in service were electric shock sensations from his low back down his legs and was not a knee or leg condition but most likely represented radicular symptoms from his lumbosacral spine. The Veteran is competent attest that he puts greater weight on his right leg due to his service-connected left knee disability. However, to go beyond this and conclude that such weight transfer has caused disability of the right knee is outside of the realm of the competence of a layperson and required that application of medical education, knowledge, and expertise which the Veteran does not possess. 38 C.F.R. § 3.159(a)(1)-(2). This additional evidence, when considered with the evidence previously of record is not sufficient to raise a reasonable possibility of allowing the claim and, accordingly, is not sufficient to reopen the claim for service connection for PFS of the right knee. 3. The request to reopen the finally disallowed claim of service connection for hypertension The evidence on file at the time of the prior denial of service connection for hypertension in the January 2010 rating decision, reflects that the Veteran had a single elevated blood pressure reading and reportedly had increased systolic pressure, for which he was to have a 5-day blood pressure check. However, it appears that this was never done, and the evidence in 2010 did not establish that the Veteran had chronic essential hypertension. The additional evidence received since the January 2010 rating decision includes records from the Arthritis & Osteoporosis Treatment Center and Dr. S. Tilak, showing that since 2011 the Veteran has had hypertension and was prescribed medication for hypertension. Records of Dr. Tilak show that the Veteran had chronic pain and that elevated blood pressure could be due to pain. Also submitted was an article from an internet source, which is to the effect that the symptoms of OSA might include hypertension, and that systemic arterial hypertension which was present in 50 percent of those with OSA. In this case, service connection is being granted for OSA. Thus, the additional evidence, when considered with the evidence previously of record, is sufficient to raise a reasonable possibility of allowing the claim and, accordingly, is sufficient to reopen the claim for service connection for hypertension. However, prior to de novo adjudication of entitlement to service connection for hypertension, further evidentiary development is needed and, so de novo adjudication must be deferred pending remand of this claim. 4. Service connection for gout, also claimed as metatarsalgia 5. Service connection for psoriatic arthritis and rheumatoid arthritis, to include the elbows, hands, feet, right knee, and fingers Because of the similarity of the factual background of each of these claims the Board will analyze them jointly. Upon review, the evidence shows that in recent years, beginning in about 2011, the Veteran has developed some form of systemic arthritis, varying described as gout, psoriatic arthritis, spondyloarthritis, and rheumatoid arthritis. The Veteran cites to his inservice complaints of joint pain and swelling in an effort to antedate the onset of his systemic disorder to his military service. However, associated with the service records is the Veteran’s contemporary account which shows that his complaints at that time did not relate to a systemic disorder but to his now service-connected disabilities of the left knee and lumbosacral spine. The VA examinations have yielded opinions that the Veterans multi-joint systemic disorder, however diagnostically classified, is unrelated to his military service because it first developed years after his active duty, was unrelated to his inservice symptoms and complaints, and unrelated to his service-connected low back disability. Accordingly, the Board must find that the preponderance of the evidence is against the claims for service connection for gout, also claimed as metatarsalgia; and for psoriatic arthritis and rheumatoid arthritis, to include the elbows, hands, feet, right knee, and fingers. 6. An increased rating for PFS of the left knee with Baker’s cyst, rated 10 percent disabling Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). If there is a question as to which of two disability evaluations may be applied, the higher may be assigned if the disability more nearly approximates the criteria for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain which is supported by adequate pathology and evidenced by the visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use is regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.59. In evaluating joint disabilities rated on limited motion consideration is given to functional loss due to pain, weakness, excess fatigability, or incoordination, factors not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limited motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any other factors. See id. Together, DC 5003 and 38 C.F.R. § 4.59 provide that painful motion due to arthritis that is established by x-ray is deemed to be limited motion and warrants the minimum compensable rating, even if there is no actual limitation of motion. Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis and must be considered when properly raised. Burton v. Shinseki, 25 Vet. App. 1 (2011). Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2017). Under DC 5257 a 10 percent rating is warranted where there is slight recurrent subluxation or lateral instability; 20 percent rating when moderate; and 30 percent when severe. Under DC 5258 a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Where there is symptomatic removal of semilunar cartilage, a 10 percent rating is warranted under 38 C.F.R. § 4.71a, DC 5259. Under DC 5260, a noncompensable rating is warranted where knee flexion is limited to 60 degrees; 10 percent rating if limited to 45 degrees; 20 percent if limited to 30 degrees; and 30 percent if limited to 15 degrees. Under DC 5261 a noncompensable rating is warranted where knee extension is limited to 5 degrees; 10 percent rating if limited to 10 degrees; 20 percent if limited to 15 degrees; 30 percent if limited to 20 degrees; 40 percent rating if limited to 30 degrees; and 50 percent if limited to 45 degrees. As a preliminary matter, the Board notes that the evidence fails to show that the following diagnostic codes are applicable in the present case: 5256 (ankylosis of the knee); 5262 (impairment of tibia and fibula); and 5263 (genu recurvatum). In this case, the VA examinations in 2010 and 2013 found no ligamentous instability. However, the Veteran reported in 2010 that his left knee disability had become worse since the 2010 examination. However, at the 2013 he still did not need any assistive device to walk, even though the examiner reported that there was dysfunction due to limited and painful motion as well as disturbance of locomotion. In this regard, “DC 5257 doesn't speak to the type of evidence required and, thus, objective medical evidence isn't required to establish lateral knee instability under that DC.” English v. Wilkie, No. 17-2083, slip op. at 1 and 2 (U.S. Vet. App. Nov. 1, 2018) (panel decision). Thus, objective medical or clinical evidence of instability, such as examination findings, are not categorically more probative than lay evidence. Further, as with pain, such symptoms as subluxation and instability are subjectively experienced and lay evidence of such symptoms is by its very nature subjective in nature. Perceptions of subjective sensations, e.g., pain, subluxation, instability, may vary significantly from one person to another as can the description of both the actual symptoms and the subjective perception of the function impact of such symptom(s). Pain alone is not measurable by any clinical standard or clinical test and the impact as well as the perception of pain is by its nature subjective and its production of disablement is not capable of accurate measurement. Many disabilities can be productive of pain, and most are productive of pain. While pain can be disabling, and is a consideration for rating purposes in all cases, the very subjectiveness of it is not the best means of determining the overall dysfunction of a disorder, which may well include factors other than pain. Objective clinical tests, being standardized, provide a better means of determining the overall dysfunction due to a disability. Range of motion testing is one such test, and another is testing of range of motion after repetition of motion. Likewise, instability, is capable to objective measurement, in terms of the range of instability or subluxation as measured in millimeters. For example, a proposed regulatory amendment of 38 C.F.R. § 4.71a, DC 5257 intends to consider the degree of joint translation in establishing three grades of subluxation or instability, with Grade I being defined as 0 – 5 millimeters (mms.), Grade 2 being 6 – 10 mms., and Grade 3 being equal to or greater than 11 mms. See 82 Fed. Reg. 35728 (Aug. 1, 2017). In this case, based on the Veteran’s subjective complaint of giving way of the left knee, and painful motion in flexion, the Board concludes that he has slight instability which is encompassed in the current 10 percent disability rating. However, given the absence of corroborating clinical findings of virtually any instability the Board must find that the Veteran does not have such instability as to equate with moderate instability. The 2010 and 2013 VA examinations also found that the Veteran had full and painless motion in extension and painless flexion to at least 90 and 110 degrees, respectively, both of which are noncompensable. Those examinations did not find that the Veteran had more than minimal functional impairment. Neither examination was conducted during a flare-up. Functional loss, including during flare-ups, can be describe by using findings of any additional limitation of motion after repetitive motion testing. If an examination was not conducted during a flare-up, such additional loss of motion after repetitive motion testing is the closest means of determining additional functional impairment during a flare-up. Here, such repetitive motion testing found no additional limitation of motion after three repetitions of motion. Accordingly, an evaluation in excess of 10 percent for the service-connected left knee disorder is not warranted. REASONS FOR REMAND Further evidentiary development is required prior to de novo adjudication of the claim for service connection for hypertension. Specifically, a medical opinion should be obtained addressing the etiology of the Veteran’s claimed hypertension. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded an examination to determine, if possible, the time of onset and etiology of any chronic essential hypertension which he may now have. The entire record is to be reviewed by the examiner in conjunction with the examination. The examiner should respond to the following: Is it at least as likely as not (a 50-50 chance) that the Veteran’s hypertension began in (or is otherwise related to the Veteran’s military service? In addressing the above question, the examiner is requested to address the significance, if any, of: The elevated blood pressure reading of 180/60 in January 1999; The notation in the May 1999 Medical Board evaluation that he had increased systolic blood pressure and was to have a 5 day blood pressure check. The examiner is also requested to respond to the following: Is it at least as likely as not (a 50-50 chance) that the Veteran’s OSA has either caused or contributed in any way to the onset of hypertension; or has his hypertension progressed at an abnormally high rate due to or as the result of the OSA? The examiner is also requested to respond to the following: Is it at least as likely as not (a 50-50 chance) that any pain from the Veteran’s service-connected left disability or low back disability, or pain from radiculopathy of his lower extremities; or pain from any combination of his service-connected disabilities has caused or contributed in any way to the onset of hypertension; or has caused his hypertension to progress at an abnormally high rate (i.e., aggravation)? The examination report should include the complete rationale for all opinions expressed. 2. Then, review the record, conduct any additional development deemed necessary, and readjudicate the claim. If the claim remains denied, the Veteran should be furnished a supplemental statement of the case, and she should be afforded an opportunity to respond. The case should be returned to the Board, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs