Citation Nr: 18158899 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 16-51 726 DATE: December 19, 2018 ORDER The petition to reopen the claim of entitlement to service connection for a right hip disability is granted. The petition to reopen the claim of entitlement to service connection for a right knee disability is granted. The petition to reopen the claim of entitlement to service connection for a left knee disability is granted. The petition to reopen the claim of entitlement to service connection for a right shoulder disability is granted. The petition to reopen the claim of entitlement to service connection for a left shoulder disability is granted. The petition to reopen the claim of entitlement to service connection for a heart disability, claimed as enlarged heart, is granted. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. REMANDED The claim of entitlement to a rating in excess of 50 percent for anxiety disorder not otherwise specified (also claimed as posttraumatic stress disorder (PTSD)) is remanded. The claim of entitlement to a rating in excess of 20 percent for degenerative disc disease L4-5 and L5-S1 is remanded. The claim of entitlement to a rating in excess of 10 percent for hypertension is remanded. The claim of entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy is remanded. The claim of entitlement to a compensable rating for bilateral hearing loss is remanded. The claim of entitlement to a compensable rating for hallux valgus right foot is remanded. The claim of entitlement to a compensable rating for hallux valgus left foot is remanded. The claim of entitlement to a compensable rating for right calcaneal spur is remanded. The claim of entitlement to service connection for a right hip disability is remanded. The claim of entitlement to service connection for a right knee disability is remanded. The claim of entitlement to service connection for a left knee disability is remanded. The claim of entitlement to service connection for a right shoulder disability is remanded. The claim of entitlement to service connection for a left shoulder disability is remanded. The claim of entitlement to service connection for residuals of a traumatic brain injury (TBI), to include headaches, vertigo, and mental functioning deficits, is remanded. The claim of entitlement to service connection for a heart disability, claimed as enlarged heart, is remanded. The claim of entitlement to service connection for erectile dysfunction is remanded. FINDINGS OF FACT 1. The Veteran’s claim of entitlement to service connection for a right hip disability was denied by a January 2002 RO rating decision; the Veteran did not appeal the denial of this claim, and VA did not receive new and material evidence on the matter within one year following the rating decision. 2. Evidence submitted since the January 2002 RO rating decision pertaining to the issue of entitlement to service connection for a right hip disability includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 3. The Veteran’s claim of entitlement to service connection for a right knee disability was denied by a January 2002 RO rating decision; the Veteran did not appeal the denial of this claim, and VA did not receive new and material evidence on the matter within one year following the rating decision. 4. Evidence submitted since the January 2002 RO rating decision pertaining to the issue of entitlement to service connection for a right knee disability includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 5. The Veteran’s claim of entitlement to service connection for a left knee disability was denied by a January 2002 RO rating decision; the Veteran did not appeal the denial of this claim, and VA did not receive new and material evidence on the matter within one year following the rating decision. 6. Evidence submitted since the January 2002 RO rating decision pertaining to the issue of entitlement to service connection for a left knee disability includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 7. The Veteran’s claim of entitlement to service connection for a right shoulder disability was denied by a January 2002 RO rating decision; the Veteran did not appeal the denial of this claim, and VA did not receive new and material evidence on the matter within one year following the rating decision. 8. Evidence submitted since the January 2002 RO rating decision pertaining to the issue of entitlement to service connection for a right shoulder disability includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 9. The Veteran’s claim of entitlement to service connection for a left shoulder disability was denied by a January 2002 RO rating decision; the Veteran did not appeal the denial of this claim, and VA did not receive new and material evidence on the matter within one year following the rating decision. 10. Evidence submitted since the January 2002 RO rating decision pertaining to the issue of entitlement to service connection for a left shoulder disability includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 11. The Veteran’s claim of entitlement to service connection for a heart disability, claimed as enlarged heart, was denied by a January 2002 RO rating decision; the Veteran did not appeal the denial of this claim, and VA did not receive new and material evidence on the matter within one year following the rating decision. 12. Evidence submitted since the January 2002 RO rating decision pertaining to the issue of entitlement to service connection for a heart disability, claimed as enlarged heart, includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 13. The Veteran’s tinnitus is assigned a single 10 percent rating, which is the maximum evaluation authorized under Diagnostic Code 6260. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for a right hip disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 2. The criteria for reopening the claim of entitlement to service connection for a right knee disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 3. The criteria for reopening the claim of entitlement to service connection for a left knee disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 4. The criteria for reopening the claim of entitlement to service connection for a right shoulder disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 5. The criteria for reopening the claim of entitlement to service connection for a left shoulder disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 6. The criteria for reopening the claim of entitlement to service connection for a heart disability, claimed as enlarged heart, have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 7. The criteria for an increased rating for tinnitus have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.87, DC 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1977 to November 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2012 and February 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Petitions to Reopen Service Connection Claims Subject to Prior Final Denials 1. The petition to reopen the claim of entitlement to service connection for a right hip disability is granted. 2. The petition to reopen the claim of entitlement to service connection for a right knee disability is granted. 3. The petition to reopen the claim of entitlement to service connection for a left knee disability is granted. 4. The petition to reopen the claim of entitlement to service connection for a right shoulder disability is granted. 5. The petition to reopen the claim of entitlement to service connection for a left shoulder disability is granted. 6. The petition to reopen the claim of entitlement to service connection for a heart disability, claimed as enlarged heart, is granted. As to the matters of whether new and material evidence has been received to reopen the claims of (1) entitlement to service connection for a right hip disability, (2) entitlement to service connection for a right knee disability, (3) entitlement to service connection for a left knee disability, (4) entitlement to service connection for a right shoulder disability, (5) entitlement to service connection for a left shoulder disability, and (6) entitlement to service connection for a heart disability, the Board is required to consider the question of whether new and material evidence has been received to reopen the claims, without regard to the RO’s determinations, in order to establish the Board’s jurisdiction to address the underlying claims and to adjudicate them on a de novo basis. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). A January 2002 RO rating decision denied the Veteran’s claims of entitlement to service connection for (1) a right hip disability, (2) a right knee disability, (3) a left knee disability, (4) a right shoulder disability, (5) a left shoulder disability, and (6) a heart disability. No new and material evidence was submitted within a year following the January 2002 denial of these claims. 38 C.F.R. § 3.156(b). The Veteran did not appeal the January 2002 RO rating decision. The January 2002 RO rating decision denying these claims is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104(a), 20.302. The Veteran petitioned to reopen the claims in November 2010. The prior final decision denying service connection for the six pertinent claimed disabilities was based upon the RO’s findings that (1) “[t]here is no record of … hip disability showing a chronic disability subject to service connection,” (2 & 3) “[a]lthough there is a record of treatment in service for bilateral knee pain, no permanent or chronic disability subject to service connection is shown by service medical records or demonstrated by evidence following service,” (4 & 5) “[a]lthough there is a record of treatment in service for bilateral shoulder pain, no permanent or chronic disability subject to service connection is shown by service medical records or demonstrated by evidence following service,” and (6) “[w]e do not find any … medical records which show the existence of an enlarged heart during the veteran’s active service or from his discharge from service to the present date. There is no record of enlarged heart showing a chronic disability subject to service connection.” The Board finds that new and material evidence has been presented sufficient to reopen these claims. An October 2010 report from a private chiropractor, serving as a diagnostic consultant to the Veteran, presents medical opinions supporting each claim with assertions tending to establish previously unestablished facts pertinent to the prior final denials. With regard to right hip disability, the October 2010 opinion concludes that the Veteran has a diagnosed right hip disability that is likely etiologically linked to his service-connected right calcaneal spur and also “directly and causally related to [the Veteran]’s military service.” With regard to right knee disability, the October 2010 opinion concludes that the Veteran has a diagnosed right knee disability “directly and causally related to [the Veteran]’s military service.” With regard to left knee disability, the October 2010 opinion concludes that the Veteran has “developed substantial pain in his left knee which is more likely than not directly and causally related to chronic compensation for deficits of his right lower extremity (hip, knee, and foot) over time.” (The Board notes that in addition to pending claims of entitlement to service connection for right hip and knee disabilities, the Veteran has already established service-connected status for disabilities of the right foot.) With regard to right shoulder disability, the October 2010 opinion concludes that the Veteran has a diagnosed right shoulder disability that is “more likely than not...directly and causally related to [the Veteran]’s military service.” With regard to left shoulder disability, the October 2010 opinion concludes that the Veteran has a diagnosed left shoulder disability that is “more likely than not...directly and causally related to [the Veteran]’s military service.” With regard to the issue concerning enlarged heart, the October 2010 opinion concludes that the Veteran’s “cardiogram interpretation would also include ventricular strain secondary to long standing hypertension…. [I]t is more likely than not that his cardiac disease chest pain, his hypertension, his erectile dysfunction and his enlarged heart are all inter related.” The report presents the finding that “it is more likely than not that the enlarged heart (left ventricular hypertrophy) is directly and causally related to his military service as discussed.” The October 2010 report includes the authoring chiropractor’s assertion that “[s]aid practitioner has full diagnostic authority” to provide the diagnostic impressions offered, and that “[a]ll diagnostic opinions are rendered legally by a practitioner experienced in whole body pathology and diagnostic procedures appropriate to same.” To the extent necessary to meet the low threshold to reopen a claim, these statements reasonably tend to indicate that the Veteran suffers from each of the claimed disabilities and that each is causally / etiologically linked to his military service or to a service-connected disability. The Board finds that new and material evidence has been submitted on these claims of entitlement to service connection following the prior final denial of these claims. Accordingly, the Board has reopened the claims of entitlement to service connection for (1) a right hip disability, (2) a right knee disability, (3) a left knee disability, (4) a right shoulder disability, (5) a left shoulder disability, and (6) a heart disability for consideration on the merits at this time.   Increased Ratings 7. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. Disability ratings are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran’s tinnitus is rated under Diagnostic Code (DC) 6260. The highest possible schedular rating for tinnitus is 10 percent; it is not possible for the Veteran to receive a higher rating under DC 6260. In addition, only a single rating is warranted for tinnitus regardless of whether the tinnitus is unilateral or bilateral. 38 C.F.R. § 4.87, DC 6260, Note (2). As the Veteran is already receiving the maximum schedular disability rating for tinnitus, his claim is denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). Neither the Veteran nor his representative has raised any other issues concerning his tinnitus, nor have any other issues concerning tinnitus been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. The claim of entitlement to a rating in excess of 50 percent for anxiety disorder not otherwise specified (also claimed as PTSD) is remanded. 2. The claim of entitlement to a rating in excess of 20 percent for degenerative disc disease L4-5 and L5-S1 is remanded. 3. The claim of entitlement to a rating in excess of 10 percent for hypertension is remanded. 4. The claim of entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy is remanded. 5. The claim of entitlement to a compensable rating for bilateral hearing loss is remanded. 6. The claim of entitlement to a compensable rating for hallux valgus right foot is remanded. 7. The claim of entitlement to a compensable rating for hallux valgus left foot is remanded. 8. The claim of entitlement to a compensable rating for right calcaneal spur is remanded. The Veteran was last provided VA examinations for the purpose of assessing the severity of his disabilities on appeal for rating purposes in August 2011 (examinations concerning psychiatric health, hearing loss, hypertension, and disabilities of the back, shoulders, hip, and knees) and December 2012 (hearing loss). The most recent evidence adequate for rating purposes for most of the rating issues on appeal is therefore from more than 7 years ago, with only the rating examination for hearing loss from 6 years ago being more recent. The Veteran should be provided an opportunity to report for new VA examinations to ascertain the current severity and manifestations of his disabilities on appeal. In addition, most particular with regard to the back disability rating issue, the Board notes that a new VA examination shall have the opportunity to provide the findings necessary to satisfy the requirements of the holdings of the United States Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016) and in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Additionally, the Board observes that in 2012 to RO received medical records from ongoing medical treatment the Veteran was receiving at a service department / government medical facility. During the processing of this remand, the RO shall have the opportunity to obtain any more recent pertinent medical treatment records that may be within VA’s constructive possession. See Bell v. Derwinski, 2 Vet. App. 611 (1992). (Such records may additionally contain information pertinent to the Veteran’s service connection claims that are also being remanded by the Board at this time.) 9. The claim of entitlement to service connection for a right hip disability is remanded. The Veteran’s service treatment records document complaints of right hip pain in 1993, near the conclusion of his active duty military service. The August 2011 VA examination report with medical opinion addressing the Veteran’s claimed right hip disability acknowledged the in-service symptoms, but the medical opinion weighed against service connection and cited that “The patient’s right hip exam was totally normal today. There is no record of any treatment of any right hip disorder from the time of discharge to the present day.” The VA examiner also found that the Veteran demonstrated a normal gait. However, contrary to the August 2011 VA medical opinion’s discussion, the October 2010 private medical report from the Veteran’s chiropractor / diagnostic consultant shows “strongly positive Patrick’s test of the right hip, and an area of trochanteric bursitis” with “crepatus [sic],” leading to a diagnosis of “Post traumatic residual degenerative joint disease of the right hip.” The October 2010 private medical report includes the opinion that the described right hip disability is likely “due to long term adaptation to altered gait secondary to known and service connected calcaneal spur,” and the opinion also attributes right hip disability to an in-service injury. The August 2011 VA examination report does not appear to have reviewed and considered the October 2010 private medical report (which appears to have been added to the claims-file in November 2010). The VA examiner indicated that the Veteran had no abnormalities of the right hip nor any post-service indications of right hip problems, but without making any discussion or acknowledgment of the October 2010 private medical report presenting clinically noted abnormalities of the right hip with a diagnosis. The August 2011 VA examination report’s discussion of factual history, clinical findings, diagnosis, and medical etiology is in significant conflict with the assertions of the October 2010 private medical report without any discussion of, or attempt to reconcile, the significantly conflicting indications. Moreover, a key element of the August 2011 VA examination report’s conclusion regarding the right hip is a finding that the right hip was clinically normal at that time, but this reliance upon the clinical status of the Veteran’s right hip more than 7 years ago (amongst significantly conflicting indications around that time) does not clearly provide an adequate factual predicate to conclude that the Veteran does not have a current right hip disability. The Board finds that a remand is warranted to afford the Veteran a new VA examination with (1) current findings clarifying whether the Veteran has a right hip disability (including discussion of the conflicting findings presented by the October 2010 private chiropractor’s report and the August 2011 VA examination report), (2) an adequate medical opinion that acknowledges and discusses the findings and opinions of the October 2010 private chiropractor’s report submitted in support of the Veteran’s claim, and (3) a medical opinion addressing the secondary theory of service connection raised by the October 2010 private medical report asserting that the Veteran’s right hip disability is causally linked to service-connected right foot disabilities (and other disabilities for which service connection claims are pending). 10. The claim of entitlement to service connection for a right knee disability is remanded. 11. The claim of entitlement to service connection for a left knee disability is remanded. The Veteran’s service treatment records document complaints of knee pain, including bilateral knee pain in 1992 and 1993 near the conclusion of his active duty military service. The service treatment records include a diagnosis of bilateral patellofemoral pain syndrome in 1993 following more than a year of complaints of pain, soreness, and swelling. The August 2011 VA examination report with medical opinion addressing the Veteran’s claimed right and left knee disabilities acknowledged the in-service symptoms, but the medical opinion weighed against service connection and cited: “While there is a complaint of bilateral knee pains in his service medical records, the injury appeared temporary and mild. From that time on, there is no medical record documentation of any knee complaints.” The VA examiner also found that the Veteran demonstrated a normal gait and had no functional impairment of either knee. The VA examiner found no significant current clinical abnormality or diagnosis for either knee. However, dramatically contrary to the August 2011 VA medical opinion’s discussion, the October 2010 private medical report from the Veteran’s chiropractor / diagnostic consultant states: “On examination he has visible medial compartment swelling, and 45 degrees of flexion. There is marked crepatus [sic], and grinding of the right knee as it travels through available motion. [The Veteran] demonstrates medical necessity for orthopedic surgical consultation for consideration of total knee joint replacement.” The October 2010 private medical report includes a diagnosis of “Post traumatic residual well advanced degenerative joint disease and osteoarthritis of the right knee,” and the report includes the comment that “[i]t is obvious that his right knee can not be rehabilitated.” With regard to the right knee, the October 2011 private medical report finds that the diagnosed disability is “more likely than not … directly and causally related to [the Veteran]’s military service.” With regard to the left knee, the October 2011 private medical report describes “substantial pain in his left knee which is more likely than not directly and causally related to chronic compensation for deficits of his right lower extremity (hip, knee, and foot) over time.” The August 2011 VA examination report does not appear to have reviewed and considered the October 2010 private medical report (which appears to have been added to the claims-file in November 2010). The VA examiner indicated that the Veteran had no abnormalities of the knees nor any post-service indications of knee problems, but without making any discussion or acknowledgment of the October 2010 private medical report documenting significant knee symptom complaints along with clinically noted abnormalities and diagnosis. The August 2011 VA examination report’s discussion of factual history, clinical findings, diagnosis, and medical etiology is in significant conflict with the assertions of the October 2010 private medical report without any discussion of, or attempt to reconcile, the significantly conflicting indications. Moreover, a key element of the August 2011 VA examination report’s conclusion regarding the knees is a finding that the knees were clinically normal at that time, but this reliance upon the clinical status of the Veteran’s knees more than 7 years ago (amongst significantly conflicting indications around that time) does not clearly provide an adequate factual predicate to conclude that the Veteran does not have a current knee disability. The Board finds that a remand is warranted to afford the Veteran a new VA examination with (1) current findings clarifying whether the Veteran has a disability of either knee (including discussion of the conflicting findings presented by the October 2010 private chiropractor’s report and the August 2011 VA examination report), (2) an adequate medical opinion that acknowledges and discusses the findings and opinions of the October 2010 private chiropractor’s report submitted in support of the Veteran’s claims, and (3) a medical opinion addressing the secondary theory of service connection raised by the October 2010 private medical report asserting that the Veteran’s left knee pain is causally linked to service-connected right foot disabilities (and other disabilities for which service connection claims are pending). 12. The claim of entitlement to service connection for a right shoulder disability is remanded. 13. The claim of entitlement to service connection for a left shoulder disability is remanded. The Veteran’s service treatment records document a right shoulder weight-lifting injury in October 1983, and bilateral shoulder problems in 1994 with a January 1994 notation of “crepitus” and “symptomatic B[ilateral] shoulders [with] degenerative arthritis symptoms.” The 1994 notations occurred near the conclusion of his active duty military service. The August 2011 VA examination report with medical opinion addressing the Veteran’s claimed right and left shoulder disabilities acknowledged one (but not all) of his documented instances of in-service symptoms. However, the medical opinion weighed against service connection, citing: “The patient has one complaint of right shoulder pain sustained while on active duty due to weight lifting. Since his discharge from active duty, there is no medical evidence of any treatment or evaluation of his right shoulder. His exam today was unremarkable.” The VA examiner also found that the Veteran had no functional impairment of either shoulder. The VA examiner found no significant current clinical abnormality or diagnosis for either shoulder. However, contrary to the August 2011 VA medical opinion’s discussion, the October 2010 private medical report from the Veteran’s chiropractor / diagnostic consultant states: “On examination he has a markedly positive Apley’s test” for both the right and left shoulders, with elevation limited to 80 degrees for the left. For both shoulders: “There is crepatus [sic] on palpation of the [right and left] glenohumeral joint through motion.” The October 2010 private medical report includes a diagnosis of “Post traumatic residual degenerative joint disease” for both shoulders. The October 2010 private medical report presents the author’s opinion that it is “more likely than not that same is directly and causally related to [the Veteran]’s military service.” The Board observes that medical evidence featuring a more recent March 2016 private medical report documents further treatment for shoulder problems. The August 2011 VA examination report does not appear to have reviewed and considered the October 2010 private medical report (which appears to have been added to the claims-file in November 2010). The VA examiner indicated that the Veteran had no abnormalities of the shoulders nor any post-service indications of shoulder problems without making any discussion or acknowledgment of the October 2010 private medical report documenting significant shoulder complaints along with clinically noted abnormalities and diagnosis. The August 2011 VA examination report’s discussion of factual history, clinical findings, diagnosis, and medical etiology is in significant conflict with the assertions of the October 2010 private report without any discussion of, or attempt to reconcile, the significantly conflicting indications. Additionally, the August 2011 VA examination report does not appear to have been prepared with awareness of the Veteran’s documented bilateral shoulder “arthritis symptoms” noted at the end of his military service. Moreover, a key element of the August 2011 VA examination report’s conclusion regarding the shoulders is a finding that the shoulders were clinically normal at that time, but this reliance upon the clinical status of the Veteran’s shoulders more than 7 years ago (amongst significantly conflicting indications around that time) does not clearly provide an adequate factual predicate to conclude that the Veteran does not have a current shoulder disability. The Board finds that a remand is warranted to afford the Veteran a new VA examination with (1) current findings clarifying whether the Veteran has a disability of either shoulder (including discussion of the conflicting findings presented by the October 2010 private chiropractor’s report and the August 2011 VA examination report), and (2) an adequate medical opinion that acknowledges and discusses the findings and opinions of the October 2010 private chiropractor’s report submitted in support of the Veteran’s claims. 14. The claim of entitlement to service connection for residuals of a TBI, to include headaches, vertigo, and mental functioning deficits, is remanded. The October 2010 private chiropractor / diagnostic consultant’s report notes that the Veteran described that he was “involved in a motor vehicle accident with head trauma in 1985 at Camp Humphreys. He received sutures to his facial region, and was treated for concussion.” A September 2010 private psychological evaluation report notes that the Veteran described being in a motor vehicle accident at age 21 (suggesting 1971 or 1972, prior to his military service) and that he was involved in an incident of driving under the influence of alcohol (DUI) in 1984, during service, when he was “convicted of DUI in Korea.” The Veteran went on to describe an incident in “1985” (during his military service) in which the Veteran’s friend was killed in an accident for which the Veteran does not appear to have been present, but the Veteran also “reported that he had additionally been involved in an automobile accident, which he was unable to recall.” With regard to this automobile accident, the report notes that the Veteran’s wife described: “that her husband was covered with blood, and he repeatedly stated that the steering wheel was ‘dented.’ She stated that the First Sergeant had taken him to the couple’s home, rather than to the hospital, at [the Veteran]’s own insistence. [The Veteran’s wife] stated that her husband was suspected of having a concussion at the time.” The psychologist authoring the September 2010 report noted pertinent deficits in the Veteran’s mental functioning and made a diagnostic note of “R/O Postconcussional Disorder.” The Board notes that an August 1986 medical history questionnaire form amongst the Veteran’s service treatment records shows that the Veteran specifically denied any history of head injury as of that time. The Veteran’s statement documented in the October 2010 private chiropractor’s report indicates that he believed that his claimed TBI occurred in 1985, and that statement appears to be contradicted by the Veteran’s August 1986 denial of any history of head injury. However, the Board has considered that the September 2010 psychological report shows that the Veteran himself is actually “unable to recall” the automobile accident from around 1985 that appears to be the basis of his TBI claim. Rather, the only details obtained regarding the pertinent in-service head injury was provided from the Veteran’s wife’s recollection of the event. The information of record suggests that the claimed TBI would have occurred in Korea (the location of Camp Humphreys, and where the Veteran was stationed throughout the middle of the 1980s), most likely during his second period serving in Korea, spanning from February 1984 to September 1987. The Board sympathetically notes that the nature of the alleged injury, featuring a claimed brain injury associated with concussion, plausibly may have impaired the Veteran’s recall of details of the event. Accordingly, the Board will not view the identification of “1985” in the October 2010 private chiropractor’s report (which does not appear to reflect any clear contribution from the Veteran’s wife’s recollections) as indicating that 1985 is precisely the only year in which the claimed injury may have happened. The Board also notes that the statements of record suggest that the Veteran may have avoided attention at the time of the accident, perhaps due to concerns associated with his existing prior DUI conviction at the time. To afford every consideration to the Veteran’s claim, and to establish a basis for informed appellate review, the Board believes that additional development seeking evidence from additional sources is warranted. First, it appears that the Veteran’s wife may have significantly more recollection of the details and timing of the claimed in-service TBI event than does the Veteran. Most of the information regarding the event that she provided to the private psychologist in September 2010 was focused upon describing what she recalled of the nature of the injury rather than the specific timing. The Board finds that development action is warranted to send a letter to the Veteran and his wife requesting that they identify the timing of the claimed in-service TBI associated with a motor vehicle accident, in addition to providing any other pertinent information that may assist in efforts to corroborate / verify the incident. Second, after soliciting the pertinent information from the Veteran and his wife, appropriate action should be taken to determine whether any service department resources may have records of the pertinent claimed motor vehicle accident. Finally, after all appropriate development action regarding the claimed in-service TBI has been completed, the Veteran should be afforded a VA TBI examination to determine whether the Veteran has a TBI that may be linked to his military service. The Board notes that the September 2010 private psychologist’s report notes mental functioning deficits associated with a noted recommendation for evaluation of a possible TBI. The Board also notes that the October 2010 report of the Veteran’s private diagnostic consultant noted: “On examination both the left and the right consensual reflexes are absent. Pupils constrict with light, however the left more slowly than the right,” with a diagnosis of “Residual TBI … directly and causally related to head trauma received in the motor vehicle accident….” The consultant advised that “[t]his diagnosis should be furthered by the examination and further testing of a Board Certified medical neurologist.” Contrary to such findings, an August 2011 VA mental health examination report indicates that the Veteran had no diagnosis of a TBI; however, this examination report was not prepared with focused attention upon the issue of the claimed TBI, and it does not appear that the examiner was aware of the Veteran’s complete medical history, including the pertinent September 2010 and October 2010 private reports. The Board observes that the Veteran’s service treatment records contain notation of symptom complaints of headaches and vertigo during service, though attributed to flu or viral syndrome episodes at the time. To the extent that the Veteran’s claim essentially includes claims of entitlement to service connection for his impairments associated with headache and vertigo complaints, however diagnosed, the medical opinion associated with the new VA examination shall have the opportunity to address the question of whether the Veteran’s claimed current impairments are causally / etiologically linked to his military service. 15. The claim of entitlement to service connection for a heart disability, claimed as enlarged heart, is remanded. A December 2012 VA heart examination report presents medical impressions featuring the examiner’s understanding that “No,” the Veteran has not “ever been diagnosed with a heart condition.” The VA examiner noted that there was “no mitral valve stenosis or mitral valve regurgitation.” The Board observes that the October 2010 report of the Veteran’s private diagnostic consultant / chiropractor refers to a “cardiogram interpretation” that was described as “demonstrating probable ischemic disease” and “also include[s] ventricular strain secondary to long standing hypertension.” This section of the report concludes that the Veteran’s “enlarged heart (left ventricular hypertrophy) is directly and causally related to his military service ….” Perhaps more significantly, a January 2016 private medical treatment report shows medical diagnostic assessments of “Aortic stenosis,” “Hypertensive heart disease,” “Aortic regurgitation,” and “Mitral regurgitation.” The evidence of record clearly indicates that the Veteran’s heart health has significantly changed compared to the understanding of the Veteran’s heart health relied upon by the December 2012 VA examiner. Additionally, the December 2012 VA examiner’s assertion that the Veteran had never been diagnosed with a heart condition appears to overlook the prior October 2010 private diagnostic consultant’s report which, although authored by a chiropractor, asserts that the author “has full diagnostic authority” to provide the diagnostic impressions offered, and that “[a]ll diagnostic opinions are rendered legally by a practitioner experienced in whole body pathology and diagnostic procedures appropriate to same.” The Board further notes that the October 2010 private diagnostic consultant’s report asserts that the Veteran’s heart health has been diminished by his service-connected hypertension, and the January 2016 private medical report includes reference to the Veteran’s diagnosis of hypertensive heart disease. The evidence raises a theory of entitlement to service connection for a heart disability secondary to the service-connected hypertension, and this theory can be addressed during the needed development actions accomplished in the processing of this remand. The Board finds that a remand is warranted to afford the Veteran a new VA examination with (1) current findings clarifying whether the Veteran has a heart disability (including discussion of the findings presented by the October 2010 private diagnostic consultant’s report and the January 2016 private medical report, contrasting to the findings in the December 2012 VA examination report), (2) an adequate medical opinion that acknowledges and discusses the findings and opinions of the October 2010 private diagnostic consultant’s report submitted in support of the Veteran’s claims, and (3) a medical opinion addressing the secondary theory of service connection raised by the medical evidence indicating that the Veteran may have one or more heart disability diagnoses causally / etiologically linked to his service-connected hypertension. 16. The claim of entitlement to service connection for erectile dysfunction is remanded. Medical evidence of record, featuring the October 2010 private diagnostic consultant’s report, indicates that the Veteran’s erectile dysfunction may be etiologically linked to his claimed heart disease: “erectile dysfunction which more likely than not is directly and causally related to his cardiac disease….” The Court has held that two issues are inextricably intertwined when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Thus, the Board must defer final adjudication of the claim seeking service connection for erectile dysfunction until the separate issue regarding the Veteran’s claimed entitlement to service connection for a heart disability has been fully developed and prepared for informed appellate review. A remand of the claim for service connection for erectile dysfunction is required. The matters are REMANDED for the following action: 1. Associate with the claims-file any outstanding pertinent treatment records, including any additional treatment records from VA, service department facilities, or private providers (such as those that may have been created since the last such update of the claims-file). This should include attention to the fact that the Veteran appears to have been receiving ongoing treatment at a service department medical facility (“45th Medical Group”) when records were last obtained in 2012. Ask the Veteran to complete a VA Form 21-4142 for any new outstanding records from providers of pertinent medical treatment that the Veteran may wish VA to assist in obtaining for the record. 2. Send a letter to the Veteran to request more specific information detailing the timing of the Veteran’s claimed in-service TBI / motor vehicle accident. The information may be provided by the Veteran, his wife, or any other witness or informed party. The September 2010 private psychologist’s report suggests that the Veteran’s wife has significantly more detailed recollection of pertinent details, and the Veteran should be informed that testimony from his wife in this regard may be of assistance in VA’s efforts to corroborate alleged events in connection with this TBI claim on appeal. The Veteran (and his wife) should be asked to identify as specifically as possible when and where the claimed in-service TBI / motor vehicle accident occurred, and to also provide any other details of the event that may assist in obtaining record documentation of the event or otherwise corroborating its occurrence. 3. After requesting from the Veteran (and his wife) any needed additional information (as directed above), all available information regarding the alleged in-service TBI / motor vehicle accident should be forwarded to the Joint Services Records Research Center (JSRRC), or other appropriate source, with a request for that organization to attempt to verify the event. If the information provided by the Veteran is insufficient, he must be so notified and offered opportunity to supplement the information. If the claimed in-service TBI / motor vehicle accident cannot be verified, the file must be so annotated, and the Veteran must be so notified. 4. After completion of the above, schedule the Veteran for a VA TBI protocol examination to ascertain whether he currently suffers from symptomatic manifestations of a traumatic brain injury (TBI) and, if so, to identify the current residuals of such brain injury. The claims-file must be reviewed by the examiner. Any indicated tests or studies should be completed. The examiner must review the Veteran’s STRs and post-service medical records (including prior examination reports and consultation/evaluation reports discussing possible residuals of a TBI such as headaches, vertigo, mental functioning / cognitive impairments, etc.). The examiner must specifically address each of the Veteran’s subjective complaints alleged to be related to an incident when he may have suffered injury to the brain (including headaches, vertigo, and mental functioning / cognitive impairments). The examiner must indicate the presence or absence of each claimed symptom, and for each symptom the examiner is asked to opine upon the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the symptom is related to a head injury? Please specifically address each claimed symptom, including headaches, vertigo, and mental / cognitive functioning difficulties. In answering the question, please specifically discuss the clinical findings noted in the September 2010 private psychologist’s report (featuring mental functioning deficits) and in the October 2010 diagnostic consultant’s report (featuring possible neurological deficits) that were presented as potentially suggestive of residual impairment from a TBI. (b) Is it at least as likely as not (a 50 percent or greater probability) that the symptom is a manifestation of a disability (whether a TBI or another pathology) that was incurred during or is otherwise causally / etiologically linked to the Veteran’s military service? The examiner must explain the rationale for all opinions. If an opinion sought cannot be offered without resort to mere speculation, the examiner must explain whether that is so because the facts presented are lacking (if so, identify the facts needed, but not shown); because the state of medical knowledge is inadequate to address the question; or because the examiner lacks the requisite training. 5. After the record is determined to be complete, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any right hip disability. The Veteran’s claims-file should be made available for review by the examiner. The examiner should review the file, and this fact should be noted in the accompanying medical report. The examiner should diagnose any current disability and must opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any such disability began during or is otherwise related to his military service. The examiner must discuss, as necessary, documentation of pertinent symptom complaints in the Veteran’s service treatment records. The examiner must also opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any right hip disability has been caused by any service-connected disability, specifically including any gait alteration associated with the Veteran’s service-connected right foot disabilities. The examiner must also opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any right hip disability has been aggravated (increased in severity) by any service-connected disability, specifically including any gait alteration associated with the Veteran’s service-connected right foot disabilities. In providing these opinions, the examiner must specifically discuss and account for, as necessary, the October 2010 private chiropractor’s report that presents clinical findings and a diagnosis indicative of a right hip disability and presents opinions linking such disability to service and/or to service-connected disabilities. The examiner should also discuss, as necessary, the contrary findings presented in the August 2011 VA examination report. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 6. After the record is determined to be complete, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any right and left knee disabilities. The Veteran’s claims-file should be made available for review by the examiner. The examiner should review the file, and this fact should be noted in the accompanying medical report. The examiner should diagnose any current disability and must opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any such disability began during or is otherwise related to his military service. The examiner must discuss, as necessary, documentation of pertinent symptom complaints in the Veteran’s service treatment records. The examiner must also opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any right and/or left knee disability has been caused by any service-connected disability, specifically including any gait alteration associated with the Veteran’s service-connected right foot disabilities. The examiner must also opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any right and/or left knee disability has been aggravated (increased in severity) by any service-connected disability, specifically including any gait alteration associated with the Veteran’s service-connected right foot disabilities. In providing these opinions, the examiner must specifically discuss and account for, as necessary, the October 2010 private chiropractor’s report that presents clinical findings and a diagnosis indicative of knee disability and presents opinions linking such disability to service and/or to service-connected disabilities. The examiner should also discuss, as necessary, the contrary findings presented in the August 2011 VA examination report. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 7. After the record is determined to be complete, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any right and left shoulder disabilities. The Veteran’s claims-file should be made available for review by the examiner. The examiner should review the file, and this fact should be noted in the accompanying medical report. The examiner should diagnose any current disability and must opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any such disability began during or is otherwise related to his military service. The examiner must discuss, as necessary, documentation of pertinent symptom complaints in the Veteran’s service treatment records. In providing these opinions, the examiner must specifically discuss and account for, as necessary, the October 2010 private chiropractor’s report that presents clinical findings and a diagnosis indicative of shoulder disability and presents opinions linking such disability to service and/or to service-connected disabilities. The examiner should also discuss, as necessary, the contrary findings presented in the August 2011 VA examination report. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 8. After the record is determined to be complete, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any heart disability. The Veteran’s claims-file should be made available for review by the examiner. The examiner should review the file, and this fact should be noted in the accompanying medical report. The examiner should diagnose any current disability and must opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any such disability began during or is otherwise related to his military service. The examiner must discuss, as necessary, documentation of pertinent symptom complaints in the Veteran’s service treatment records. The examiner must also opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any heart disability (including hypertensive heart disease) has been caused by any service-connected disability, specifically including hypertension. The examiner must also opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any heart disability has been aggravated (increased in severity) by any service-connected disability, specifically including hypertension. In providing these opinions, the examiner must specifically discuss and account for, as necessary, the October 2010 private diagnostic consultant / chiropractor’s report and the January 2016 private medical report that presents clinical findings and a diagnoses indicative of a heart disability and suggesting such disability is linked to service and/or to service-connected disabilities. The examiner should also discuss, as necessary, the contrary findings presented in the December 2012 VA examination report. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 9. Schedule the Veteran for a VA examination to determine the current severity of his service-connected psychiatric disorder including anxiety disorder not otherwise specified. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran’s claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 10. After the record is determined to be complete, schedule the Veteran for an examination of the severity of his service-connected back disability. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examination report must include findings detailing the severity of all lower extremity radiculopathy associated with the back disability. The examiner should identify and completely describe all current symptomatology. (a) The examiner must test the Veteran’s ranges of motion on active motion, passive motion, and with weight-bearing and without weight-bearing (including testing for pain). If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (b) The examiner should also render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies active motion, passive motion, pain with weight-bearing and without weight-bearing (to the extent medically appropriate) at each time the back disability was previously examined with documented range of motion testing for VA rating purposes. (c) The VA examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. The VA examiner should assess or estimate the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If an opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. A rationale should be provided for each medical opinion presented. 11. Schedule the Veteran for a VA examination to determine the current severity of his hypertension. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran’s claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 12. Schedule the Veteran for a VA examination to determine the current severity of his bilateral hearing loss. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran’s claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 13. Schedule the Veteran for a VA examination to determine the current severity of his foot disabilities featuring right and left hallux valgus and right calcaneal spur. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran’s claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 14. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to service connection for a heart disability and entitlement to service connection for erectile dysfunction (including as secondary to heart disability). If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Barone, Counsel