Citation Nr: 18154348 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 15-06 663A DATE: November 29, 2018 ORDER The rating reduction from 20 percent to 10 percent for right carpal tunnel syndrome, status post release effective August 15, 2014 was improper, and the 20 percent rating is restored. Prior to May 25, 2018, a disability rating of 20 percent, but no higher, for right shoulder, tendinopathy, tear, rotator cuff syndrome, and degenerative joint disease and impingement syndrome (hereinafter right shoulder disability) is granted. From July 1, 2018, a disability rating in excess of 20 percent for right shoulder disability is denied. REMANDED The issue of entitlement to service connection for bilateral hearing loss is remanded. The issue of entitlement to service connection for tinnitus is remanded. The issue of entitlement to service connection for a left knee disability is remanded. The issue of entitlement to service connection for a right knee disability is remanded. FINDINGS OF FACT 1. In an August 2014 rating decision, the Regional Office (RO) reduced the rating for right carpal tunnel syndrome, status post release from 20 percent to 10 percent, effective August 15, 2014; at the time of the reduction, the 20 percent rating had been in effect more than five years; the evidence of record does not show sustained material improvement of the right carpal tunnel syndrome that represents improvement under the ordinary conditions of life. 2. Prior to May 25, 2018 and after July 1, 2018, the Veteran’s right shoulder disability was primarily productive of functional loss due to pain at shoulder level; limitation of motion worse than shoulder level, ankylosis and impairment of the humerus, clavicle and scapula were not shown. CONCLUSIONS OF LAW 1. The reduction of the rating for right carpal tunnel syndrome, status post release from 20 percent to 10 percent, effective August 15, 2014, was improper, and the 20 percent rating is restored. 38 U.S.C. §§ 1155, 5107, 5112; 38 C.F.R. §§ 3.105, 4.1, 4.124a, Diagnostic Code 8515. 2. Prior to May 25, 2018, the criteria for a rating of 20 percent for right shoulder disability were met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5003, 5200-5203. 3. At no time during the appeal period, to include prior to May 25, 2018 or after July 1, 2018, have the criteria for a rating in excess of 20 percent for right shoulder disability been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5200-5203. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1973 to November 1994. In March 2018, the Veteran testified at a video conference hearing before the undersigned Veterans’ Law Judge. A transcript of the proceeding is associated with the electronic claims file. In May 2018, the Veteran’s attorney submitted a motion to correct portions of the hearing transcript. The Board has reviewed the transcript and agrees with the Veteran’s attorney as to all suggested changes; thus, the motion is granted. I. Rating Reduction Generally, VA must abide by specific procedural protections that apply when a veteran’s rating is reduced. 38 C.F.R. § 3.105(e). In this case, the Board is restoring the 20 percent disability rating for right carpal tunnel syndrome, status post release, effective August 15, 2014, the date the reduction was implemented. As such, any discussion as to compliance with the procedural requirements of 38 C.F.R. § 3.105(e) is rendered moot. In this case, the 20 percent disability rating for right carpal tunnel syndrome was in effect from May 12, 2009 to August 15, 2014, a period of more than five years. Accordingly, the provisions of 38 C.F.R. § 3.344(a) and (b) apply, which prescribe that only evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, can justify a reduction. Where a rating has been in effect for five years or more, as in this case, the rating may be reduced only if the examination on which the reduction is based is at least as full and complete as that used to establish the higher rating. Ratings for disease subject to temporary or episodic improvement will not be reduced based on any one examination, except in those instances where the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, though material improvement in the physical condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). The burden of proof is on VA to establish that a reduction is warranted by the weight of the evidence. Kitchens v. Brown, 7 Vet. App. 320 (1995). In determining whether a reduction was proper, the Board must focus upon evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the condition actually improved. Cf. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-282 (1992). However, post-reduction evidence may not be used to justify an improper reduction. In this case, prior to the August 15, 2014 rating reduction, the Veteran’s right carpal tunnel syndrome was rated under Diagnostic Code (DC) 8514, which contemplates impairment of the musculospiral (radial) nerve. The evidence reflects that the Veteran is right-handed; accordingly, his right upper extremity is his major (dominant) extremity. For the major (dominant) extremity, 20, 30, and 50 percent ratings are warranted for mild, moderate, or severe incomplete paralysis. A 70 percent rating for the major extremity is warranted for complete paralysis of the radial nerve. 38 C.F.R. § 4.124a. Since August 15, 2014, the Veteran’s right carpal tunnel syndrome has been rated under DC 8515, which rates paralysis of the median nerve. Pursuant to DC 8515, 10, 20 and 30 percent ratings are warranted for mild, moderate, or severe incomplete paralysis. A 70 percent rating is warranted for complete paralysis of the median nerve with the hand inclined to the ulnar side, the index and idle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Turning to the evidence, the Veteran filed a claim for an increased rating for his right wrist condition in May 2009. At that time, he was in receipt of a noncompensable rating. In August 2009, the Veteran underwent a VA examination. He reported flare-ups aggravated by lifting that caused increased weakness, numbness and fatigue. These flare-ups were noted to occur a couple times a week and be moderate in severity. He reported tingling of the skin and weakness in the upper arm and forearm area since his carpal tunnel surgery. Sensory testing showed decreased pinprick sensation in a radial nerve pattern. Vibratory sense and two-point discrimination were also decreased. In an October 2009 rating decision, the RO increased the rating to 20 percent under DC 8514 for incomplete paralysis of hand movements which was mild based on findings of decreased vibratory sense, pinprick sense, and two-point discrimination. In October 2010, the Veteran filed another claim for an increased rating. At a February 2011 VA examination, the Veteran complained of tingling and burning of the skin during flare-ups that led to increased pain caused by increased activity and aggravated by hand use. The severity of the flare-ups was described as moderate. Numbness and tingling were noted in the right hand and the pinprick test indicated diminished sensation over the thumb and index finger toward the wrist along the radial aspect of the hand. Vibratory sense was also diminished over the thumb and index finger toward the wrist along the radial aspect of the hand. It was noted the right medial nerve was the most likely involved peripheral nerve for sensory impairment. Painful motion of the right wrist was noted. Pain, tenderness, fatigue, lack of endurance and incoordination were noted after range of motion testing. It was noted the diagnosis had progressed to right carpal tunnel syndrome, status post release with residual scar, right wrist decreased range of motion with pain, and mild entrapment of the right medial nerve. In a June 2011 rating decision, the RO continued the 20 percent rating under DC 8514. In June 2013, the Veteran filed another increased rating claim. At an August 2014 VA examination, he indicated carpal tunnel was interfering with his occupation and he had to stop about every 30 minutes because of hand numbness and cramping. Mild pain, paresthesias and/or dysesthesias and numbness were noted. Phalen’s sign and Tinel’s sign were positive. Mild incomplete paralysis of the median nerve on the right was identified. EMG studies indicated impairment to the median motor and sensory nerves in both wrists consistent with a diagnosis of moderate to severe bilateral carpal tunnel syndrome (left worse than right). In an August 2014 rating decision, the RO decreased the rating for right carpal tunnel syndrome by changing the diagnostic code under which it was rated to DC 8515 which allows for a 10 percent rating for mild incomplete paralysis instead of a 20 percent rating for mild incomplete paralysis as under DC 8514. In March 2018, the Veteran testified at a hearing before the Board. He stated that over time his carpal tunnel syndrome had basically stayed the same and every now and then would get “a little worse.” He indicated intermittent pain, tingling and numbness in all the fingers except the index. He clarified that between the time he was rated in 2009 and the 2014 reduction in rating, his condition was getting worse and continued to worsen prior to surgery on his elbow in 2018. He stated that if the 20 percent rating were restored, he would be satisfied with such rating. The Board finds that although the Veteran may not satisfy the criteria for a 20 percent rating under DC 8515, the reduction in rating was improper because actual improvement in the Veteran’s carpal tunnel syndrome was not demonstrated between when the 20 percent rating was assigned in 2009 and when it was reduced in 2014. The assignment of a particular DC is “completely dependent on the facts of a particular case.” Butts v Brown, 5 Vet. App. 532, 538 (1993). One DC may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis and demonstrated symptomatology. Here, the central question is not whether the change in DC was appropriate, but whether actual improvement in the Veteran’s disability occurred. Congress has provided that a veteran’s disability rating will not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. Looking at the evidence in the light most favorable to the Veteran, the Board cannot conclude that the weight of the evidence shows a material improvement in the Veteran’s carpal tunnel syndrome that is reasonably certain to be maintained under the ordinary conditions of life. See 38 C.F.R. § 3.344; Brown v. Brown, 5 Vet. App. 413 (1993). In 2014, he was still experiencing pain, tingling and numbness in his fingers and the impact on his daily life, to include his occupation, was still present. The severity of his carpal tunnel had not improved. Accordingly, the Board finds that the rating reduction was improper and that the Veteran is entitled to restoration of the 20 percent rating for right carpal tunnel syndrome, status post release effective the date of the reduction, August 15, 2014. As noted earlier, this satisfies the Veteran’s appeal regarding his right carpal tunnel syndrome. II. Rating for Right Shoulder Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. The United States Court of Appeals for Veterans Claims (Court) clarified that although pain may be a cause or manifestation of functional loss, limitation of 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). The Veteran’s right shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003-5201. See 38 C.F.R. §§ 4.27 (explaining hyphenated diagnostic codes). DC 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate DC for the specific joint or joints involved. If limitation of motion is noncompensable under the appropriate DC, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 38 C.F.R. § 4.71a; DC 5003. In the absence of limited motion, a 10 percent rating is assigned when X-ray evidence shows two or more major joints or two or more minor joint groups. A higher 20 percent rating is assigned when X-ray evidence shows involvement of two or more major joints or minor joint groups, with accompanying occasional incapacitating exacerbations. Id. Diagnostic Codes 5200 through 5203 address disability ratings for the shoulder and arm. In this case, the record reflects that the Veteran is right hand dominant and his right arm is thus the major extremity when considering the proper ratings. DC 5200 provides for the evaluation of a shoulder or arm disability if there is ankylosis of the scapulohumeral articulation. 38 C.F.R. § 4.71a. DC 5201 provides that limitation of motion of the major arm at shoulder level warrants a 20 percent rating; limitation of motion of the major arm to midway between the side and shoulder level warrants a 30 percent rating; and limitation of motion of the major arm to 25 degrees from the side warrants a 40 percent rating. 38 C.F.R. § 4.71a, DC 5201. With respect to the major arm, DC 5202 provides that impairment of the humerus is rated as 20 percent with recurrent dislocation of the scapulohumeral joint with infrequent episodes and guarding of movement only at shoulder level; impairment of the humerus is rated as 30 percent with recurrent dislocation of the scapulohumeral joint with frequent episodes and guarding of all arm movements; impairment of the humerus is rated as 50 percent with fibrous union; impairment of the humerus is rated as 60 percent with nonunion (false flail joint); and impairment of the humerus is rated as 80 percent with loss of head (flail shoulder). 38 C.F.R. § 4.71a, DC 5202. Also under this code with respect to the major extremity, a 20 percent rating is warranted for malunion of the humerus with moderate deformity and a 30 percent rating is warranted for malunion of the humerus with marked deformity. Id. Under DC 5203, a 20 percent evaluation, the maximum available under this section, is assignable for dislocation of the clavicle or scapula, or nonunion with loose movement. This code also allows that alternatively, the disability may be rated on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, DC 5203. Normal flexion of the shoulder is from 0 to 180 degrees and normal abduction is 0 to 180 degrees. 38 C.F.R. § 4.71a, Plate I. Normal external rotation of the shoulder is from 0 to 90 degrees and normal internal rotation is 0 to 90 degrees. Turning to the evidence, the Veteran filed a claim for an increased rating in June 2013. At that time, he was in receipt of a noncompensable rating under DC 5201-5019 which rates for bursitis based on limitation of motion of the arm. Treatment records dated in February 2014 indicated the Veteran was experiencing severe pain in his shoulder upon movement. Flexion was to 160 degrees, abduction to 160 degrees and external rotation to 50 degrees. MRI showed a full thickness rotator cuff tear along with joint osteoarthritic changes. In July 2014, the Veteran underwent a VA examination. The Veteran described flare-ups of his shoulder condition that prevented him from doing anything overhead. Range of motion testing revealed flexion to 130 degrees, abduction to 140 degrees, external rotation to 50 degrees and internal rotation to 60 degrees with evidence of painful motion. Weakened movement, less movement than normal and pain on movement were noted in the right shoulder after repetitive use. The examiner also commented that contributing factors of pain, weakness, fatigability and incoordination were present during flare-ups or repeated use over time. The examiner indicated that the degree of range of motion loss during pain on use or flare-ups was approximately 5 degrees in flexion, abduction, external and internal rotation. Ankylosis was not present and dislocation was not indicated. Rotator cuff pathology was identified. Tests for clavicle, scapula, acromioclavicular (AC) joint, and sternoclavicular joint conditions were negative. The functional impact of the Veteran’s condition was that he could not work overhead and/or lift things overhead during a flare-up. Rotator cuff syndrome and impingement of right shoulder were added to the Veteran’s diagnoses. In the August 2014 rating decision, the RO increased the Veteran’s right shoulder rating to 10 percent based on limited motion of the arm above shoulder level and painful motion of the shoulder pursuant to DC 5003 and 38 C.F.R. § 4.59. At his hearing before the Board in March 2018, the Veteran indicated his shoulder started to hurt when he moved his arm a quarter of the way out to his side, although he could raise his arm all the way up, which he demonstrated at the hearing. He indicated being able to hear it snap, crackle, pop and grind and that it really hurt to reach across his body from shoulder to shoulder. He indicated his shoulder was getting worse and he was considering surgery. On May 25, 2018, the Veteran underwent a right shoulder arthroscopic massive rotator cuff repair. Following application for a temporary total rating in June 2018, the RO granted a 100 percent rating for the right shoulder between May 25, 2018 and July 1, 2018. Since July 1, 2018, the Veteran has been in receipt of a 20 percent rating for painful motion of the arm at the shoulder under DC 5201 and 38 C.F.R. § 4.59. On review of the record, Board finds that any doubt can be resolved in the Veteran’s favor and a rating of 20 percent, but no higher, is warranted for the right shoulder prior to May 25, 2018 based on evidence of painful motion of the arm at the shoulder under DC 5201 and 38 C.F.R. § 4.59. The Board recognizes that the Veteran’s range of motion at the July 2014 VA examination was noncompensable and under DC 5003, he would merit only a 10 percent rating. However, the record is clear that throughout the appeal period, the Veteran has experienced painful motion of the arm at shoulder level or worse, especially during flare-ups. It is the intention of the regulations to recognize actually painful joints, due to healed injury, as entitled to at least the “minimum compensable rating for the joint.” 38 C.F.R. § 4.59. In this case, the minimum compensable rating for the shoulder under DC 5201 is 20 percent for the dominant or non-dominant arm. 38 C.F.R. § 4.71a. Thus, the appropriate rating is for the right shoulder is 20 percent from the date of claim, here, June 20, 2013. The Board also finds that entitlement to a disability rating in excess of 20 percent either prior to May 25, 2018 or after July 1, 2018 is not demonstrated. To warrant a rating in excess of 20 percent, the evidence would need to indicate the presence of ankylosis (DC 5200), limitation of motion midway between side and shoulder level or worse (DC 5201) and/or recurrent dislocation or impairment of the humerus (DC 5202). The lay and medical evidence of record does not demonstrate the Veteran has ankylosis in his shoulder, impairment of the humerus or limitation of motion to the extent necessary for a higher rating to include during a flare-up or after repetitive use. Instead the evidence reflects a painful shoulder with range of motion to shoulder level or better with an inability to work overhead and/or lift things overhead during a flare-up. In coming to the above conclusions, the Board has considered the benefit of doubt doctrine. 38 U.S.C. § 5107. REASONS FOR REMAND I. Service connection for hearing loss and tinnitus The Board finds remand is necessary to schedule a new VA examination and obtain an additional medical opinion regarding whether any current hearing loss at least as likely as not had onset in service or is otherwise related thereto given conceded in-service exposure to hazardous noise and evidence of decreased hearing specifically in the Veteran’s left ear at separation from service. A grant of service connection for hearing loss requires that a Veteran have hearing loss as defined for VA purposes. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (db) or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In this case, following his claim for service connection filed in June 2013, the Veteran underwent a VA examination in October 2014. An audiogram reflected pure tone decibels as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 20 35 LEFT 10 10 5 10 25 This audiogram did not demonstrate a current hearing loss disability as defined by VA at that time in either ear. The examiner considered the Veteran had been a roofer prior to joining the military, that during the military he was an aircraft structural mechanic with a high probably of hazardous noise exposure and that he also had civilian noise exposure following service while driving a forklift from 1997 to 2011 and working as an aircraft mechanic again beginning in 2011. She specifically noted review of a July 1990 audiogram which demonstrated that as of July 1990, the Veteran did not have a recognized hearing loss disability. The July 1990 audiogram reflected pure tone decibels as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 20 10 LEFT -5 10 10 5 15 Notably, however, the examiner did not have available for review an audiogram dated in May 1994, closer in time to the Veteran’s separation from service, that showed hearing loss in the left ear and a worsening in hearing in relation to July 1990. The May 1994 audiogram reflected pure tone decibels as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 5 15 15 LEFT 15 30 25 30 30 However, the record does not currently show a hearing loss disability in the left ear. For example, the August 2017 audiogram performed by the Veteran’s current employer reflects the following pure tone decibels and shows hearing loss for VA purposes in the right ear but not in the left ear: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 15 25 45 LEFT 5 5 5 0 30 Given that the Veteran has a conceded in-service injury, specifically exposure to hazardous noise, and there is no medical opinion that takes into account the threshold shift apparent between July 1990 and May 1994, the Board finds that a new VA examination is warranted to determine the current severity of any hearing loss present and to obtain an etiology opinion that considers both in-service audiograms. Regarding the Veteran’s claim for service connection for tinnitus, the October 2014 VA examiner indicated that tinnitus was related to the Veteran’s hearing loss. As such, the claim for service connection for tinnitus is inextricably intertwined with the claim for service connection for hearing loss and must be remanded also. II. Service connection for right and left knee disabilities The Board finds that remand is necessary to schedule the Veteran for a VA examination. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran filed a claim for service connection for bilateral knee pain in June 2013. The RO denied claims for service connection for a right knee condition and a left knee condition in an August 2014 rating decision based on the lack of complaints, treatment or diagnosis regarding the knees in the Veteran’s service treatment records (STRs) and the lack of evidence of a link between his current knee disabilities and service. A VA examination was not provided prior to the denial. At his March 2018 hearing before the Board, the Veteran testified that during a football game in the mid-1970s, his right kneecap moved and the coach slid it back in place. He indicated it would swell up from time to time and it currently hurt every day. Regarding his left knee, he stated he did not recall a specific injury, but attributed his current condition to wear and tear from the 40-50,000 miles he jogged in the Marine Corps over the course of 20 years. He indicated he was told prior to separation from service that he had arthritis in his knees due to feeling grinding when his knees moved, although he declined to have a scope to clean them out at that time. The Veteran’s representative pointed out that a 2010 MRI indicated that the medial collateral ligaments of both knees appeared intact but were thickened “possibly related to old injury.” The Veteran testified he never sustained additional injury to his knees after separation from service. In addition, he indicated having an x-ray of his knees in 1995, a year after separation from service, showing arthritis. An examination is necessary because there is evidence of current disability in both knees, evidence suggesting injury to the knees in the form of wear and tear during 20 years of service and insufficient evidence to decide the case in the absence of an etiology opinion provided by a medical professional. See McLendon, 20 Vet. App. 79. Additional records should be sought on remand, to include any x-rays dated in 1995 regarding the knees. The matters are REMANDED for the following action: 1. Associate all VA treatment records from May 2018 to the present with the electronic claims file. 2. With appropriate authorization from the Veteran, obtain and associate with the claims file all pertinent private treatment records that have not already been obtained, to include any x-rays of the knees dated in 1995. All requests and responses, positive and negative, must be documented in the claims file. If the requested records are unavailable, the Veteran should be so notified so he can provide those records himself, if possible. 3. Schedule the Veteran for a VA audiological examination to determine the current severity of any hearing loss present and to obtain an opinion regarding whether the Veteran’s hearing loss and/or tinnitus are at least as likely as not (50 percent or greater probability) related to service, to include conceded exposure to hazardous noise as an aircraft mechanic. In rendering this opinion, the examiner should consider the threshold shift apparent between the July 1990 and May 1994 audiograms in the Veteran’s service treatment records. The examiner should explain why the Veteran’s current bilateral hearing loss is or is not a delayed response to in-service noise exposure. The examiner should explain the reasoning for any opinion provided. The medical significance of any findings should be addressed as the Board is precluded from making medical findings. 4. Schedule the Veteran for a VA examination to determine the nature of any current knee disabilities and to obtain an opinion as to whether a disability in the right or the left knee is at least as likely as not (50 percent or greater probability) related to service, to include wear and tear over the course of 20 years. The claims file should be reviewed by the examiner. All necessary tests should be conducted and the results reported. The examiner should elicit a full history from the Veteran and consider the lay statements of record. It is noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (Continued on the next page)   A rationale for all opinions expressed should be provided as the Board is precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Boyd Iwanowski, Counsel