Citation Nr: 18152734 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 17-49 963 DATE: November 27, 2018 ORDER New and material evidence has been presented, and the claim for service connection for a left knee disability is reopened. New and material evidence has been presented, and the claim for service connection for a right knee disability, to include as secondary to the service-connected left knee disability, is reopened; the appeal is granted to this extent only. New and material evidence has been presented, and the claim for service connection for a left ankle disability, to include as secondary to the service-connected left knee disability, is reopened; the appeal is granted to this extent only. New and material evidence has been presented, and the claim for service connection for a right ankle disability, to include as secondary to the service-connected left knee disability, is reopened; the appeal is granted to this extent only. Service connection for a left knee disability is granted. FINDINGS OF FACT 1. In an unappealed rating decision issued in September 2015, the RO denied the Veteran's claim for service connection for a left knee disability. 2. The evidence associated with the claims file subsequent to the September 2015 denial includes evidence that relates to an unestablished fact necessary to substantiate the claim for service connection, is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for a left knee disability. 3. In an unappealed rating decision issued in September 2015, the RO denied the Veteran's claim for service connection for a right knee disability. 4. The evidence associated with the claims file subsequent to the September 2015 denial includes evidence that relates to an unestablished fact necessary to substantiate the claim for service connection, is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for a right knee disability. 5. In an unappealed rating decision issued in September 2015, the RO denied the Veteran's claim for service connection for a left ankle disability. 6. The evidence associated with the claims file subsequent to the September 2015 denial includes evidence that relates to an unestablished fact necessary to substantiate the claim for service connection, is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for a left ankle disability. 7. In an unappealed rating decision issued in September 2015, the RO denied the Veteran's claim for service connection for a right ankle disability. 8. The evidence associated with the claims file subsequent to the September 2015 denial includes evidence that relates to an unestablished fact necessary to substantiate the claim for service connection, is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for a right ankle disability. 9. The currently diagnosed left knee degenerative arthritis is related to active service. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen a claim for service connection for a left knee disability. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2018). 2. New and material evidence has been received to reopen a claim for service connection for a right knee disability, to include as secondary to the service-connected left knee disability. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2018). 3. New and material evidence has been received to reopen a claim for service connection for a left ankle disability, to include as secondary to the service-connected left knee disability. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2018). 4. New and material evidence has been received to reopen a claim for service connection for a right ankle disability, to include as secondary to the service-connected left knee disability. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2018). 5. The currently diagnosed left knee degenerative arthritis was incurred in active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1966 to April 1968. In a September 2015 rating decision, service connection for a left hip strain was denied. The Veteran has not appealed the denial of service connection for the left hip. As such, the issue is not currently on appeal before the Board. Claims to Reopen As a general rule, a previously denied claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. When a claimant seeks to reopen a final decision, the first inquiry is whether the evidence obtained after the last disallowance is "new and material." Under 38 C.F.R. § 3.156 (a), new evidence means evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The submission of "new and material" evidence is a jurisdictional prerequisite to the Board's review of such an attempt to reopen a claim. Absent the submission of evidence that is sufficient to reopen the claim, the Board's analysis must cease. See Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996); McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). The United States Court of Appeals for Veterans Claims has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim, in the final sentence of 38 C.F.R. § 3.156 (a), does not create a third element in the reopening process, but is a component of the question of what is new and material evidence, rather than a separate determination to be made if evidence is new and material. See Shade v. Shinseki, 24 Vet. App.110, 117 (2010) (noting that 38 U.S.C. § 5108 requires only new and material evidence to reopen). Shade further holds that 38 C.F.R. § 3.156 "suggests a standard that would require reopening if newly submitted evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim[.]" Id. Further, the Board should not focus solely on whether the evidence remedies the principal reason for denial in the last prior decision, and regulations do not require new and material evidence as to each previously unproven element of a claim. Id. Rather, the Board should focus on whether the evidence, taken together, could at least trigger the duty to assist by providing a medical opinion. Id. See also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Simply stated, the standard is low, but it is a standard that needs to be met. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510 (1992). If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). Once evidence is deemed new and material, the Board can proceed to review the claim based on the merits and the entire evidence of record. 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a left knee disability, and if so, whether the reopened claim should be granted In a November 2004 rating decision, the RO denied service connection for a chronic condition to account for left knee pain, based on a finding that there was no medical evidence of a relationship between the Veteran’s knee pain beginning in 2002 and his in-service left knee injury, and no evidence of treatment for the left knee for years after his discharge. The Veteran did not file an appeal and the decision became final. In January 2011, the Veteran filed another claim for service connection for a left knee disability. In a June 2011 rating decision, the RO denied service connection for a chronic condition to account for left knee pain again, because no new evidence had been submitted in support of the Veteran’s claim and there was no evidence of any current treatment for the left knee. The Veteran did not file an appeal and the decision became final. In May 2015, the Veteran filed another petition to reopen his claim for service connection for a left knee disability. In a September 2015 rating decision, the RO denied service connection for patellofemoral syndrome of left knee claimed as chronic condition to account for left knee pain because it found a VA examiner’s opinion more persuasive than a private medical opinion submitted by the Veteran. See September 2015 rating decision. In December 2016, the Veteran filed a petition to reopen his claim for service connection for a left knee disability. Pertinent evidence added to the record since the September 2015 denial includes private medical records, dated in 2011 and 2013, but received in February 2017, which includes an opinion from the Veteran’s private physician that his currently diagnosed left knee disability is related to an in-service left knee injury. The evidence also includes a December 2016 statement from the Veteran’s friend who knew him before and after his military service, indicating that the Veteran was in good health and active in sports and other outdoor activities prior to service, but since his discharge from the military, he has complained of knee, ankle and back pain. The Board finds that the private medical records and the December 2016 lay statement from the Veteran’s friend are new and not cumulative or redundant of evidence already of record. Furthermore, this evidence relates to a fact necessary to substantiate the claim, i.e. whether the Veteran's currently diagnosed left knee disability was incurred during active service, and raises a reasonable possibility of substantiating the claim. The private medical records and the December 2016 statement thereby satisfy the low threshold requirement for new and material evidence; and, the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disability In May 2015, the Veteran filed a claim for secondary service connection for a right knee disability. In a September 2015 rating decision, the RO denied service connection for right knee patellofemoral syndrome because there was no evidence showing that the left knee disability was related to service, and no evidence showing that the currently diagnosed right knee disability was incurred in or aggravated by military service. The Veteran did not file an appeal and the decision became final. In December 2016, the Veteran filed a petition to reopen his claim for service connection for a right knee disability. Pertinent evidence added to the record since the September 2015 denial includes a December 2016 statement from the Veteran, indicating that his right knee disability, as well as all his other claimed disabilities, was incurred during active duty. The evidence also includes a December 2016 statement from the Veteran’s friend who knew him before and after his military service, indicating that the Veteran was in good health and active in sports and other outdoor activities prior to service, but since his discharge from the military, he has complained of knee, ankle and back pain. The Board finds that the December 2016 statement from the Veteran is new because he had never claimed direct service connection for the right knee before. The Board also finds that the December 2016 lay statement from the Veteran’s friend is new and not cumulative or redundant of evidence already of record. Furthermore, the December 2016 statements relate to a fact necessary to substantiate the claim, i.e. whether the Veteran's currently diagnosed right knee disability was incurred during active service, and together, with service treatment records showing knee injuries in service and other private medical evidence of record indicating that the currently diagnosed right knee disability is related to an in-service knee injury (see April 2013 and April 2015 statements from private physician, F. M., MD) , raises a reasonable possibility of substantiating the claim. The December 2016 statements thereby satisfy the low threshold requirement for new and material evidence; and, the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The additional evidence demonstrates that further development is required before the claim may be considered on the merits. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a left ankle disability In a June 2011 rating decision, the RO denied service connection for a left ankle condition, based on a finding that the evidence did not show a left ankle condition occurred in or was caused by service. The Veteran did not file an appeal and the decision became final. In May 2015, the Veteran filed a petition to reopen his claim for service connection for a left ankle disability. In a September 2015 rating decision, the RO denied service connection for chronic left ankle sprain because the evidence did not show a causal relationship between the Veteran’s left knee disability and his left ankle disability, and there was no evidence showing a left ankle condition was incurred in or aggravated by military service. The Veteran did not file an appeal and the decision became final. In December 2016, the Veteran filed a petition to reopen his claim for service connection for a left ankle disability. Pertinent evidence added to the record since the September 2015 denial includes a December 2016 statement from the Veteran’s friend who knew him before and after his military service, indicating that the Veteran was in good health and active in sports and other outdoor activities prior to service, but since his discharge from the military, he has complained of knee, ankle and back pain. The Board finds that the December 2016 lay statement from the Veteran’s friend is new and not cumulative or redundant of evidence already of record. Furthermore, the December 2016 statement relates to a fact necessary to substantiate the claim, i.e. whether the Veteran's currently diagnosed left ankle disability was incurred during active service, and together, with other private medical evidence of record indicating that the currently diagnosed left ankle disability is related to in-service injuries (see April 2015 statements from private physician, F. M., MD), raises a reasonable possibility of substantiating the claim. The December 2016 statement thereby satisfies the low threshold requirement for new and material evidence; and, the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The additional evidence demonstrates that further development is required before the claim may be considered on the merits. 4. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right ankle disability In a June 2011 rating decision, the RO denied service connection for right ankle posterior tibial tendonitis with heel spur, based on a finding that although there was treatment in service for a right ankle sprain, no permanent residual or chronic disability subject to service connection was shown in the service treatment records or post-service medical records. The Veteran did not file an appeal and the decision became final. In May 2015, the Veteran filed a petition to reopen his claim for service connection for a right ankle disability. In a September 2015 rating decision, the RO denied service connection for right ankle posterior tibial tendonitis with heel spur because the evidence did not show a causal relationship between the Veteran’s left knee disability and his right ankle disability, and there was no evidence showing a right ankle condition was incurred in or aggravated by military service. The Veteran did not file an appeal and the decision became final. In December 2016, the Veteran filed a petition to reopen his claim for service connection for a right ankle disability. Pertinent evidence added to the record since the September 2015 denial includes a December 2016 statement from the Veteran’s friend who knew him before and after his military service, indicating that the Veteran was in good health and active in sports and other outdoor activities prior to service, but since his discharge from the military, he has complained of knee, ankle and back pain. The Board finds that the December 2016 lay statement from the Veteran’s friend is new and not cumulative or redundant of evidence already of record. Furthermore, the December 2016 statement relates to a fact necessary to substantiate the claim, i.e. whether the Veteran's currently diagnosed right ankle disability was incurred during active service, and together, with other private medical evidence of record indicating that the currently diagnosed right ankle disability is related to in-service injuries (see April 2015 statements from private physician, F. M., MD), raises a reasonable possibility of substantiating the claim. The December 2016 statement thereby satisfies the low threshold requirement for new and material evidence; and, the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The additional evidence demonstrates that further development is required before the claim may be considered on the merits.   Service Connection 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. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In relevant part, 38 U.S.C. 1154 (a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must then determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (2018); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2018); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. At 54. Entitlement to service connection for a left knee disability Service treatment records show the Veteran was treated for a left knee injury in 1967. Post-service treatment records show treatment for left knee pain and evidence of degenerative arthritis of the left knee. In subsequently received April 2013 and April 2015 statements, the same private physician opined that the Veteran’s in-service knee injuries contributed to his current bilateral knee condition. He did not provide a rationale for the April 2013 and April 2015 opinions and as such, they are inadequate by themselves, for evaluation purposes. However, May 2011 private treatment records show the Veteran’s private physician opined that, based on his review of the Veteran’s service treatment records and post-service medical records, it is a “high probability” that the Veteran’s in-service twisting injury to his left knee, including possible torn ligaments, could “definitely” be the cause of the problem he is having with the left knee at this time. A September 2015 VA examiner opined that the current degenerative arthritis of the left knee was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was that there was no ongoing left knee condition or complaint at the time of the 1968 separation examination, indicating that there was no sequela to the in-service left knee injury. The examiner essentially opined that, as there was no evidence of a chronic left knee disability in service, or for years thereafter, the Veteran's currently diagnosed left knee disability is not related to the left knee problems in service. However, the Board's inquiry does not end there. Service connection is possible for diseases first identified after service. 38 C.F.R. § 3.303 (d) (2018). The September 2015 examiner did not provide an opinion as to whether the left knee disability identified after service is related to a disease or injury in service or to the Veteran's reports of continuous symptoms since service. In fact, the examiner did not adequately consider the Veteran's lay statements of continuity. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (finding a medical examination inadequate where the examiner impermissibly ignored the appellant's lay assertions regarding onset of symptoms or injury during service). As such, the Board finds the September 2015 VA opinion inadequate for evaluation purposes. The medical evidence documents a current left knee disability, currently left knee degenerative arthritis. The service treatment records document treatment in service for a left knee injury. The Board also notes that the Veteran has reported in statements, including the December 2016 statement noted above, and during VA examination, that he had left knee pain during active military service, and that he has had continuing problems with his left knee since that time. These statements provide competent and credible evidence of a left knee injury during active duty and a continuity of symptoms since. They are also buttressed by the opinion of his private physician, F. M., MD. There is evidence against the claim, inasmuch as the contemporaneous record does not document a left knee disability for many years after service. Furthermore, the September 2015 VA examiner opined that the Veteran's current left knee disability is not related to his active military service. However, the Board finds the September 2015 opinion inadequate for the reasons stated above. Furthermore, as there is also competent medical evidence of record that is favorable to the Veteran, the May 2011 opinion of F. M., MD, the Board finds that the evidence is in at least equipoise. Resolving reasonable doubt in the Veteran's favor, service connection for left knee degenerative arthritis is warranted. 38 U.S.C. § 5107 (b) (2012).   REMANDED Entitlement to service connection for lumbar spine disability is remanded. The reopened claim for service connection for a right knee disability, to include as secondary to the service-connected left knee disability, is remanded. The reopened claim for service connection for a left ankle disability, to include as secondary to the service-connected left knee disability, is remanded. The reopened claim for service connection for a right ankle disability, to include as secondary to the service-connected left knee disability, is remanded. REASONS FOR REMAND 1. Entitlement to service connection for lumbar spine disability is remanded. Service treatment records are negative for any evidence of a low back disability during active duty or at discharge. However, the Veteran has reported that he worked on tanks during active duty and his DD-214 shows that he had a military occupational specialty (MOS) of Armor Intelligence Specialist. The Board also notes that the Veteran’s friend who knew him before and after service, reported in a December 2016 statement that prior to going into the military, the Veteran was in good health and very active in sports and outdoor activities, but after service, he complained of knee, ankle and back pain, which continues to this day. Based on this evidence, the Board finds that the Veteran’s reports of injuring his back during active duty are credible and a low back injury in service is conceded. VA treatment records show the Veteran has complained of low back pain and that he was diagnosed with a muscle strain in the right lower back in March 2014. The Veteran is competent to report that he injured his low back during active service and that he has continued to experience low back pain since his separation from active service. The Veteran's reports provide evidence that a current low back disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). No medical opinion currently of record addresses the etiology of any currently diagnosed back disability. As such, the Board finds that a remand for a VA examination and medical opinion as to the etiology of any current low back disability is necessary. See 38 C.F.R. § 4.2 (2018). 2. Entitlement to service connection for a right knee disability is remanded. Service treatment records are negative for any evidence of a right knee disability in service or at discharge. However, as noted above, the Veteran’s MOS of Armor Intelligence Specialist and the December 2016 lay statement from his friend show that his reports of musculoskeletal injuries, including a right knee injury, in service are credible and a right knee injury in service is conceded. Post-service treatment records show treatment for right knee pain and evidence of degenerative arthritis of the right knee. The Veteran’s private physician opined in April 2013 and pril 2015 statements that the Veteran’s in-service injuries contributed to his current bilateral knee conditions. He did not provide a rationale for the opinions or indicate that he had reviewed the claims file prior to rendering the opinions. As such, the Board finds both the April 2013 and April 2015 opinions inadequate for evaluation purposes. The Veteran was afforded a VA examination and opinion for the right knee in September 2015. The examiner opined that the Veteran’s right knee disability was less likely than not proximately due to or the result of his left knee disability, which was not service-connected at the time of the examination. The examiner did not give an opinion as to whether the right knee disability is directly related to service. The Board notes further that the examiner’s only rationale for finding that the Veteran’s right knee disability was not secondary to the now service-connected left knee disability was essentially, that the right and left knee disabilities were both incurred in 1967. The Board finds that this reasoning does not adequately explain why the currently diagnosed right knee disability has not been aggravated by the now service-connected left knee disability. For these reasons, the Board find that the opinion is incomplete and therefore, inadequate for evaluation purposes. As such, the Board finds that a remand for another medical opinion as to the etiology of any current right knee disability is necessary. Barr v. Nicholson, 21 Vet. App. 303 (2007). See also 38 C.F.R. § 4.2 (2018). 3. Entitlement to service connection for a left ankle disability is remanded. Service treatment records are negative for any evidence of a left ankle disability during service or at discharge. However, as noted above, the Veteran’s MOS of Armor Intelligence Specialist and the December 2016 lay statement from his friend show that his reports of musculoskeletal injuries, including a left ankle injury, in service are credible and a left ankle injury in service is conceded. Post-service treatment records show the Veteran has been treated for chronic ankle pain and diagnosed with a chronic left ankle sprain. The Veteran’s private physician opined in an April 2015 statement that the Veteran’s in-service injuries contributed to his current bilateral knee and ankle conditions. He did not provide a rationale for the opinion or indicate that he had reviewed the claims file prior to rendering the opinion. As such, the Board finds the opinion in adequate for evaluation purposes. A September 2015 VA examiner opined that the currently diagnosed chronic left ankle sprain is less likely than not proximately due to or the result of the Veteran’s service-connected left knee disability. The rationale was that there is no documentation in the records, nor a compelling line of medical reasoning that suggests a causal relationship between the Veteran’s left knee condition and his currently diagnosed left ankle condition. The Board finds that the rationale is lacking in specificity. Furthermore, the examiner did not give an opinion as to whether the Veteran’s left ankle disability is directly related to his active military service, as he has also asserted. See December 2016 statement from the Veteran. As such, the Board finds the September 2015 opinion to be incomplete and therefore, inadequate for evaluation purposes. As such, the Board finds that a remand for another medical opinion as to the etiology of any current left ankle disability is necessary. Barr v. Nicholson, 21 Vet. App. 303 (2007). See also 38 C.F.R. § 4.2 (2018). 4. Entitlement to service connection for a right ankle disability is remanded. Service treatment records show the Veteran was treated for a right ankle sprain in October 1967. Treatment included having the ankle placed in a Gelocast until later that month. There was no further treatment documented for the right ankle during service and no right ankle disability was noted at discharge. Post-service treatment records show the Veteran has been treated for chronic ankle pain and diagnosed with a chronic right ankle sprain. A June 2011 VA examiner diagnosed right ankle posterior tibial tendonitis with heel spur, and opined that it was less likely than not that the current right ankle tendonitis is a continuation of the symptoms shown during military service because there was no follow-up treatment for right ankle complaints after October 1967 through the end of service, nor were there comments of on-going ankle pain or joint problems on the separation examination or evidence of continued complaints regarding the right ankle from military discharge to the present. As noted above, the Veteran’s private physician opined in an April 2015 statement that the Veteran’s in-service injuries contributed to his current bilateral knee and ankle conditions. He did not provide a rationale for the opinion or indicate that he had reviewed the claims file prior to rendering the opinion. As such, the Board finds the opinion in adequate for evaluation purposes. A September 2015 VA examiner opined that the currently diagnosed chronic right ankle sprain was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was that at the time of his separation examination in 1968, the Veteran indicated no ongoing ankle problems, and there is no documentation in the VA medical records that indicate ongoing ankle problems between 1967 and 2015. The examiner essentially opined that, as there was no evidence of a chronic right ankle disability in service, or for years thereafter, the Veteran's currently diagnosed right ankle disability is not related to the right ankle problems in service. However, the Board's inquiry does not end there. Service connection is possible for diseases first identified after service. 38 C.F.R. § 3.303 (d) (2018). The September 2015 examiner did not provide an opinion as to whether the right ankle disability identified after service is related to a disease or injury in service or to the Veteran's reports of continuous symptoms since service. In fact, the examiner did not adequately consider the Veteran's lay statements of continuity. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (finding a medical examination inadequate where the examiner impermissibly ignored the appellant's lay assertions regarding onset of symptoms or injury during service). The examiner also opined that the current right ankle disability was less likely than not proximately due to or the result of the Veteran’s service-connected left knee disability. The rationale was that there is no documentation in the medical records, nor a compelling line of medical reasoning that suggests a causal relationship between the left knee condition and the currently diagnosed right ankle condition. In addition, the Veteran’s stated history is that his ankle condition began in 1967, the same year as his knee condition. Furthermore, at the time of his separation examination, the Veteran denied ongoing ankle problems, and there is no documentation found in the medical records that indicate subsequent ankle problems until years later. The Board finds that the examiner’s rationale lacks specificity, and does not adequately explain why the currently diagnosed right ankle disability has not been aggravated by the now service-connected left knee disability. For these reasons, the Board find that the opinion is incomplete and therefore, inadequate for evaluation purposes. As such, the Board finds that a remand for another medical opinion as to the etiology of any current right ankle disability is necessary. Barr v. Nicholson, 21 Vet. App. 303 (2007). See also 38 C.F.R. § 4.2 (2018).   REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Following completion of the above, schedule the Veteran with an appropriate clinician for a VA examination to determine the nature and etiology of any currently diagnosed low back disability. The examiner should review the claims folder and acknowledge such review in the examination report or in an addendum, and any indicated studies should be performed. The examiner should diagnose all low back disabilities found. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed low back disability, is etiologically related, in whole or in part, to the Veteran's active service, including his conceded back injury in service. The examiner is advised that the Veteran is competent to report injuries as well as symptoms, and that his reports must be considered in formulating the requested opinion. The examiner is also advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. The examiner should provide a rationale for all opinions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 3. Schedule the Veteran with an appropriate clinician for a VA examination to determine the nature and etiology of any currently diagnosed right knee disability. The examiner should review the claims folder and acknowledge such review in the examination report or in an addendum, and any indicated studies should be performed. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed right knee disability, is etiologically related, in whole or in part, to the Veteran's active service, including his conceded right knee injury in service. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current right knee disability was/is aggravated (increased in severity beyond the natural progress of the disorder) by the now service-connected left knee disability. The examiner is advised that the Veteran is competent to report injuries as well as symptoms, and that his reports must be considered in formulating the requested opinion. The examiner is also advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. The examiner should provide a rationale for all opinions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 4. Schedule the Veteran with an appropriate clinician for a VA examination to determine the nature and etiology of any currently diagnosed left ankle disability. The examiner should review the claims folder and acknowledge such review in the examination report or in an addendum, and any indicated studies should be performed. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed left ankle disability, is etiologically related, in whole or in part, to the Veteran's active service, including his conceded left ankle injury in service. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current left ankle disability was/is aggravated (increased in severity beyond the natural progress of the disorder) by the now service-connected left knee disability. The examiner is advised that the Veteran is competent to report injuries as well as symptoms, and that his reports must be considered in formulating the requested opinion. The examiner is also advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. The examiner should provide a rationale for all opinions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 5. Schedule the Veteran with an appropriate clinician for a VA examination to determine the nature and etiology of any currently diagnosed right ankle disability. The examiner should review the claims folder and acknowledge such review in the examination report or in an addendum, and any indicated studies should be performed. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed right ankle disability, is etiologically related, in whole or in part, to the Veteran's active service, including his noted right ankle injury in service. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current right ankle disability was/is aggravated (increased in severity beyond the natural progress of the disorder) by the now service-connected left knee disability. The examiner is advised that the Veteran is competent to report injuries as well as symptoms, and that his reports must be considered in formulating the requested opinion. The examiner is also advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. The examiner should provide a rationale for all opinions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. (Continued on the next page)   6. After completing the above, and any other development deemed necessary, readjudicate the Veteran's remaining claims for service connection, based on the entirety of the evidence. If any benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided with a SSOC. An appropriate period of time should be allowed for response. The case should then be returned to the Board, if otherwise in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD F. Yankey, Counsel