Citation Nr: 18159132 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 17-04 047 DATE: December 18, 2018 ORDER Service connection for a lumbar spine disorder, claimed as secondary to service-connected left foot disorder is granted. Service connection for a left knee disorder, claimed as secondary to service-connected left foot disorder is granted. Service connection for a left ankle disorder, claimed as secondary to service-connected left foot disorder is granted. Service connection for bilateral hearing loss disability is granted. Service connection for tinnitus is granted. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), mood disorder, and depressive disorder is granted. Service connection for sleep apnea is denied. REMANDED The claim of entitlement to a disability rating greater than 10 percent for left foot traumatic arthritis, formerly rated as residual fracture of 2nd metatarsal, 3rd proximal phalanx, and 4th distal phalanx of the left foot is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving all doubt in his favor, the Board finds that the Veteran has current diagnoses of lumbar spine, left knee, and left ankle disorders which have been related to his service-connected left foot disorder. 2. Resolving reasonable doubt in the Veteran’s favor, the Veteran has a current diagnosis of bilateral hearing loss disability which has been etiologically related to noise exposure in service. 3. Resolving reasonable doubt in the Veteran’s favor, the Veteran has tinnitus which began during active service and has been etiologically related to his bilateral hearing loss and/or noise exposure in service. 4. Resolving all doubt in his favor, the Veteran has current diagnoses of PTSD, mood disorder, and depressive disorder, which have been related to his service and have been continually present since that time. 5. The Veteran has a current diagnosis of sleep apnea, but it is not shown to be causally or etiologically related to any disease, injury, or incident in service. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar spine, left knee, and left ankle disorders have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for bilateral hearing loss disability have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for an acquired psychiatric disorder, to include diagnoses of PTSD, mood disorder, and depressive disorder, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1966 to November 1968. This matter comes before the Board of Veterans’ Appeals (Board) from May 2014, July 2015, and February 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Lumbar spine disorder, left knee, and left ankle The Veteran contends that lumbar spine, left knee, and/or left ankle disorders are secondary to his service-connected left foot disability. Specifically, he contends that these disabilities are either secondary to or aggravated by years of an altered gait due to his left foot disability. The Veteran’s service treatment records show that he dropped a 155 shell on his left foot resulting in multiple fractures in his left foot in March 1968. Subsequently, in September 1968, the Veteran complained of pain and instability in his left foot and knee. However, these records are negative for chronic left knee/left ankle conditions and are also negative for complaints regarding the low back. Significantly, the Veteran’s October 1968 separation examination shows a normal spine and lower extremities and in an October 1968 report of medical history, the Veteran denied “’trick’ or locked knee” and “recurrent back pain.” A December 2010 VA treatment record shows complaints of left leg pain of a long duration. The earliest evidence of a chronic lumbar spine disorder is a December 2014 private diagnosis of degenerative joint disease and osteoarthritis of the lumbar spine. The earliest evidence of chronic left knee and left ankle disabilities is June 2015 VA examinations showing arthritis of the left knee and left ankle. In support of the Veteran’s current claim, he submitted a December 2014 statement from Dr. P.J.Y. Dr. P.J.Y. noted that the Veteran is service connected for residuals of a left foot/left knee injury which, according to Dr. P.J.Y. has been improperly combined as one disability by VA. Specifically, Dr. P.J.Y. noted that the Veteran was hit by an ejected shell from a Howitzer artillery weapon and sustained injury to both the left knee and foot. He was treated by a field medic and then taken to a field hospital where he was treated with a cast and medications. He was also awarded a light duty profile. With regard to the left knee and ankle, Dr. P.J.Y. noted that the Veteran has continued to experience left knee and ankle pain and dysfunction since the time of the injury. With regard to the low back, Dr. P.J.Y. noted that, since the Veteran’s in-service injury to the left lower extremity, he has developed degenerative joint disease and osteoarthritis of the lumbar spine. Significantly, Dr. P.J.Y. opined that it was more likely than not that the Veteran’s lumbar spine disorder is directly and causally related to injury to and conditions of the left lower extremity by a process of chronic and constant bio mechanical adaptation and compensation for altered gait and weight shifting. The Veteran was afforded VA examinations of his back, knees, and ankles in June 2015. At that time, the Veteran was diagnosed with multilevel degenerative disc disease of the lumbosacral spine, degenerative arthritis of the knees, and left foot arthritis. With regard to the back, the examiner opined that the Veteran’s lumbar spine disability was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected left foot disability. As rationale for this opinion, the examiner wrote that there was no objective evidence to support causal nexus between the Veteran’s service-connected left foot disability to his back disability. With regard to the left knee, the examiner opined that the Veteran’s left knee disability was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected left foot disability. As rationale for this opinion, the examiner wrote that there was no documentation to support ongoing care and treatment for a left knee condition. While there was a complaint of left knee/leg pain in 1968, there were no continued complaints regarding the left knee. There was also no documentation in the service treatment records regarding a left knee injury. With regard to the left ankle, the examiner wrote that the Veteran did not have a left ankle disability other than age-related chronic degenerative changes with no acute osseous abnormality. As such, the examiner found that a medical opinion regarding secondary service connection was not necessary. An addendum medical opinion was obtained in January 2017. With regard to the left knee, the examiner noted that the earliest post-service treatment for the left knee is dated in July 2011 and noted review of the December 2014 statement from Dr. P.J.Y. The examiner again opined that the Veteran’s left knee disability was less likely than not (less than 50 percent probability) incurred during his service or caused by the Veteran’s service-connected left foot disability. As rationale for this opinion, the examiner noted that there was no objective evidence to support a relationship between the Veteran’s complaint of left knee pain in 1968 to his June 2015 diagnosis of left knee arthritis as his separation examination is silent for a knee disability. The VA examiner noted that Dr. P.J.Y.’s December 2014 statement was given no credence as it was “out of the scope” of a chiropractor and “full of inaccuracies.” However, the VA examiner did not explain the basis for ignoring Dr. P.J.Y.’s opinion. With regard to the back, the examiner again opined that the Veteran’s lumbar spine disability was less likely than not (less than 50 percent probability) incurred during his service or caused by the Veteran’s service-connected left foot disability. As rationale for this opinion, the examiner noted that the Veteran’s service treatment records are negative for complaints regarding the back. The examiner also noted that current medical literature does not support causal nexus between the Veteran’s service-connected left foot disability and his multilevel degenerative disc disease of the lumbosacral spine. Significantly, the examiner noted that there was no objective evidence to support aggravation as no gait disturbances were identified on examination. The VA examiner noted that Dr. P.J.Y.’s December 2014 statement was given no credence as it was “out of the scope” of a chiropractor and “full of inaccuracies.” However, the VA examiner did not explain the basis for ignoring Dr. P.J.Y.’s opinion. With regard to the left ankle, the examiner opined that the Veteran’s left ankle disability was less likely than not (less than 50 percent probability) caused by the Veteran’s service-connected left foot disability. As rationale for this opinion, the examiner noted that July 2011 X-rays of the left foot show mild degenerative changes of the left foot and June 2015 X-rays of the left foot show moderate degenerative changes of the left foot and chronic degenerative changes of the left ankle. The Veteran’s current left ankle arthritis is age-related arthritis. At the time of the November 2015 VA examination, there was no clinical evidence that the age-related left ankle arthritis is caused by, due to, the result of, and/or aggravated beyond its natural progression by the service-connected left foot disability. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for right knee, left hip, and lumbar spine disorders is warranted. As an initial matter, the Board finds that the Veteran has current diagnoses of lumbar spine, left knee, and left ankle disorders. Furthermore, there is medical evidence that such disabilities are related to either the Veteran’s service-connected injury to his left foot and/or secondary to gait disturbances caused by his service-connected left foot disability. Significantly, the December 2014 statement from Dr. P.J.Y. relates the Veteran’s lumbar spine, left knee, and left ankle disorders to an altered gait caused by the Veteran’s service-connected left foot disability. While the June 2015/January 2017 VA examiner opined that the Veteran’s lumbar spine, left knee, and left ankle disorders are not related to the Veteran’s service-connected left knee disability, this examiner did not consider the VA treatment records showing that the Veteran has experienced many falls or almost falls which is indicative of an altered gait. Accordingly, the Board resolves all doubt in favor of the Veteran and finds that lumbar spine, left knee, and left ankle disorders are related to his service-connected left foot disability. Therefore, service connection for lumbar spine, left knee, and left ankle disorders is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 2. Bilateral hearing loss disability and tinnitus The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). 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, 4000 Hertz is 40 decibels 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. The United States Court of Appeals for Veterans Claims (Court) has held that service connection can be granted for a hearing loss where the Veteran can establish a nexus between his current hearing loss and a disability or injury he suffered while he was in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Court has also held that VA regulations do not preclude service connection for a hearing loss which first met VA’s definition of disability after service. Hensley, supra, at 159. The Veteran contends that he was exposed to acoustic trauma during his military service. The Veteran’s service personnel records confirm that the Veteran served in Vietnam during the Vietnam war and in-service noise exposure has been conceded. The Veteran’s service treatment records are negative for hearing loss and/or tinnitus. Significantly, in September 1966 and October 1968 examinations the Veteran’s hearing was assigned a numerical designation of “1” in the PULHES profile, indicating normal hearing. See McKinney v. McDonald, 28 Vet. App. 15, 19-20, n. 4 (2016). Audiometric testing is also negative for hearing loss. Specifically, a September 1966 audiometric test showed the following: 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 0 0 0 0 Left Ear 5 5 5 5 An October 1968 audiometric test showed the following: 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 0 0 0 Left Ear 0 0 0 The Veteran submitted an initial claim for service connection for bilateral hearing loss in January 2014 and was afforded a VA audiometric examination in May 2014. Audiometric testing at that time revealed the following: Puretone Threshold 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 30 60 70 70 Left Ear 30 40 70 75 Puretone Threshold Average Right Ear 58 Left Ear 54 Speech discrimination Right Ear 94% Left Ear 92% Notably, this report shows bilateral hearing loss pursuant to 38 C.F.R. § 3.385. However, the May 2014 VA examiner opined that it was less likely as not that the Veteran’s current bilateral hearing loss is related to his military service. As rationale for this opinion, the examiner conceded in-service noise exposure but noted that the Veteran’s service treatment records were negative for hearing loss and/or a major threshold shift in hearing. The May 2014 VA examiner also diagnosed tinnitus, noting an onset in 1968 (during the Veteran’s military service) when a “155 went off.” However, the examiner opined that the Veteran’s tinnitus was most likely related to the Veteran’s bilateral hearing loss and not related to military noise exposure. In connection with this claim, the Veteran submitted a December 2014 statement from Dr. P.J.Y. wherein it was noted that the Veteran was exposed to acoustic trauma of artillery fire, specifically Howitzer and other weapon fire and that he suffered from progressive bilateral hearing loss and tinnitus. Dr. P.J.Y. opined that it was more likely than not that the Veteran’s bilateral hearing loss and tinnitus are directly and causally related to his military service. The Veteran also submitted a private audiometric examination report dated in December 2014. At that time, the Veteran reported a history of hearing loss which began during military service and had gradually worsened to the point where he required hearing aids three years earlier. Significantly, Dr. A.H.Y. diagnosed sensorineural hearing loss and secondary tinnitus and opined that such disabilities were related to the Veteran’s noise exposure during military service. With regard to the Veteran’s claim for service connection for bilateral hearing loss, in this case, medical evidence shows a current bilateral hearing loss disability for VA compensation purposes pursuant to 38 C.F.R. § 3.385. There is also evidence of an in-service injury. As above, the Veteran alleges military acoustic trauma, specifically weapon noise, and his service personnel records show that the Veteran served in Vietnam during the Vietnam war. As such, the Board presumes the occurrence of the Veteran’s in-service acoustic trauma. Moreover, the evidence also suggests a link between this hearing loss and the Veteran’s military service. Specifically, both Dr. P.J.Y. and Dr. A.H.Y. opined that it was at least as likely as not that the Veteran’s bilateral hearing loss is related to the Veteran’s in-service noise exposure. While the May 2014 VA examiner opined that the Veteran’s current bilateral hearing loss is not related to the Veteran’s military service, the Board finds that this medical opinion is inadequate for many reasons. First, the Board notes that service department audiometric readings prior to October 31, 1967, must be converted from American Standards Association (ASA) units to International Standard Organization (ISO) units and it is unclear whether the March 2015 VA examiner appropriately converted the audiometric findings from ASA to ISO. Second, the May 2014 VA examiner wrote that there was no “major threshold shift” when comparing the September 1966 audiometric findings to the October 1968 audiometric findings but there was a 5 dBL threshold shift in the left ear and at two Hz which does indicate that there was a threshold shift and a worsening of the Veteran’s hearing between 1966 and 1968. As such, while there is conflicting evidence regarding whether the Veteran’s hearing loss was incurred during his military service, the Board finds that the evidence is in equipoise and will resolve reasonable doubt in the Veteran’s favor to find that bilateral hearing loss is related to the Veteran’s military service. Therefore, in light of Veteran’s conceded in-service noise exposure, current bilateral hearing loss, and the December 2014 private medical opinion relating the Veteran’s bilateral hearing loss to his service, the Board will resolve all doubt in his favor and find that service connection for bilateral hearing loss is warranted. With regard to the Veteran’s claim for service connection for tinnitus, the Board notes that tinnitus is a disorder that is readily observable by laypersons and does not require medical expertise to establish its existence. See Charles v. Principi, 16 Vet. App. 370 (2002). Furthermore, while the Veteran’s service treatment records are negative for specific complaints of tinnitus, the Veteran is competent to report a history of tinnitus that began in service. See 38 C.F.R. § 3.159(a)(2); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno. In its capacity as a finder of fact, the Board finds the Veteran is credible as to his reports of the onset and recurrence of tinnitus symptoms. He is also competent to comment on the onset and frequency of his tinnitus. Lay evidence can be competent and sufficient evidence to establish etiology if the layperson is competent to identify the medical condition and lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson; Jandreau. Here, under Charles the Veteran is competent to identify the medical condition of tinnitus and his lay statements describe tinnitus beginning in service supports the later diagnosis by the May 2014 VA examiner. While the May 2014 VA examiner opined that the Veteran’s tinnitus is not related to the Veteran’s in-service noise exposure but is instead related to his bilateral hearing loss, as above, service connection has been granted for bilateral hearing loss. As such, service connection for tinnitus is also warranted. 38 C.F.R. § 3.303(a). 3. Acquired psychiatric disorder A January 2015 private psychiatric evaluation report shows that the Veteran experienced psychiatric problems prior to his military service, but that these problems intensified during his military service and that he treated his symptoms with alcohol and marijuana both during and after his separation from service. The earliest post-service evidence of psychiatric problems is the January 2015 private psychiatric evaluation report showing diagnoses of PTSD and mood disorder. The Veteran submitted a claim for service connection for PTSD in December 2014. In support of this claim, the Veteran submitted the January 2015 private psychiatric evaluation report from Dr. W.J.A. which shows that the Veteran’s father was an alcoholic who was quite abusive to his mother, himself, and his brothers. Significantly, Dr. W.J.A. opined that it was as likely as not that the Veteran met partial criteria for a PTSD diagnosis as a child but that he currently met the criteria for a PTSD diagnosis secondary to his military service in Vietnam. The rationale of this opinion is contained in the very thorough ten-page report noting the Veteran’s stressful in-service experiences and psychiatric history, to include experiences in combat. Dr. W.J.A. also opined that the Veteran’s mood-symptomatology appeared, overall, to be inseparable from his trauma-related symptomatology, particularly with regard to its impact upon his social functioning. In connection with this claim, he was afforded a VA psychiatric examination in June 2015. Significantly, the examiner diagnosed depressive disorder and found that the Veteran did not meet the DSM-5 criteria for a diagnosis of PTSD. While the Veteran endorsed PTSD symptoms to Dr. W.J.A. in January 2015, recent VA screenings for PTSD have been negative. Specifically, the examiner noted that the Veteran experienced occasional hypervigilance symptoms which he related to childhood abuse and his military service but that these symptoms did not appear to be experienced in a recurrent or consistent basis to significantly impact functioning and did not meet clinical threshold for severity. The VA examiner noted that any PTSD problems related to the Veteran’s conceded stressor (fear of hostile military activity) would likely have occurred before this time (some 40 years after his military service). In support of this assertion, the VA examiner noted that a review of relevant medical literature (see “Delayed onset PTSD among war veterans in primary care clinics” The British Journal of Psychiatry, 2009) shows that delayed-onset PTSD (current, sub-threshold or lifetime) is extremely rare one year post-trauma, and that there is no evidence of PTSD symptom onset six or more years after trauma exposure. The examiner also opined that the Veteran’s depressive disorder was not related to his military service and was instead related to the Veteran’s myriad of medical ailments. Unfortunately, the examiner did not consider the Veteran’s history of significant psychiatric problems beginning in service followed by significant substance abuse and did not provide a rationale for the negative nexus opinion. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for an acquired psychiatric disorder is warranted. As an initial matter, the Board finds that the Veteran has current diagnoses of several acquired psychiatric disorders including PTSD, mood disorder, and depressive disorder. While the medical evidence is not in agreement as to what the Veteran’s psychiatric diagnoses are, there is no question that the Veteran does have a current acquired psychiatric disorder. Furthermore, the Veteran is competent to provide lay testimony regarding psychiatric problems he experienced during and immediately following service. The only matter still in question is whether there is a medical link between the Veteran’s current acquired psychiatric disability and his military service. In this case, the record contains both positive and negative nexus opinions. While the June 2015 VA examiner opined that the Veteran’s depressive disorder is not related to the Veteran’s military service, this opinion does not include a rationale and does not consider the Veteran’s competent allegations of continuity of psychiatric symptoms during military service. Alternatively, the January 2015 report from Dr. W.J.A. relates the Veteran’s current psychiatric problems to his military service and considers the Veteran’s allegations of continuity of symptomatology. Furthermore, the continuity of symptomatology evident from the statements from the Veteran and his wife, as well as the positive medical nexus opinions discussed above provide a plausible basis to conclude that the Veteran’s current acquired psychiatric disorders are related to his military service. With resolution of all reasonable doubt in the Veteran’s favor, it is concluded that the evidence supports service connection for an acquired psychiatric disorder. 38 U.S.C. § 5107(b). Accordingly, the Board resolves all doubt in favor of the Veteran and finds that an acquired psychiatric disorder is related to his military service. Therefore, service connection for such disorder is warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 4. Sleep apnea The Veteran contends that service connection is warranted for sleep apnea. Specifically, the Veteran contends that sleep apnea is related to sinusitis, allergies, and chronic fatigue. While the Veteran’s service treatment records do show a history of nose and throat symptoms since prior to the Veteran’s military service, they are negative for any sleep problems or indications of sleep apnea. The earliest evidence of sleep apnea is a July 2012 private sleep study showing a diagnosis of obstructive sleep apnea. The Veteran submitted a claim for service connection for sleep apnea in December 2017. In connection with this claim, he was afforded a VA sleep apnea examination in January 2018. The examiner continued a diagnosis of obstructive sleep apnea but opined that it was less likely than not (less than 50 percent probability) that the Veteran’s sleep apnea is proximately due to or the result of the Veteran’s military service. As rationale for this opinion, the examiner wrote that while the Veteran claimed that his sleep apnea is secondary to sinusitis, allergies, and chronic fatigue, the Veteran is not service connected for any of these conditions. And, even if he were, there is no medical literature that these conditions cause sleep apnea. Based on the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran’s claim that his current sleep apnea was incurred in or is the result of any established event, injury, or disease during active service. First, while the STRs show occasional URIs, they are negative for any indications of chronic bronchitis or sleep apnea. Moreover, the May 1988 separation examination shows normal “lungs and chest.” Moreover, the January 2018 VA sleep apnea examiner opined that the Veteran’s sleep apnea is not related to his military service. Specifically, the examiner indicated that while the Veteran claimed that his sleep apnea is secondary to sinusitis, allergies, and chronic fatigue, the Veteran is not service connected for any of these conditions. And, even if he were, there is no medical literature that these conditions cause sleep apnea. As the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to their opinion. See Nieves-Rodriguez v, 22 Vet. App. at 295; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran contends that his sleep apnea is related to military service, the Board accords his statements regarding the etiology of this disorder little probative value as he is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). In this regard, the question of causation of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is outweighed by that of the medical examiner. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, based on the foregoing, the Board finds that service connection for sleep apnea is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for sleep apnea. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 1. Left foot The Veteran was last afforded a VA foot examination in June 2015. In a December 2018 Informal Hearing Presentation, the Veteran’s representative wrote that, due to length of time which has passed since the June 2015 VA examination, the Veteran’s left foot needed to be re-examined. This suggests that the Veteran’s service-connected left foot disability has increased in severity. Given the suggestion of an increase in severity of the left foot disability, the Veteran should be afforded a new VA examination. 2. TDIU A review of the record shows that the Veteran last worked in 2008 as an automobile mechanic. The Veteran contends that he is unable to work due to his service-connected disabilities. As above, the Board has granted service connection for lumbar spine/left knee/left ankle disorders, bilateral hearing loss, tinnitus, and acquired psychiatric disability but the agency of original jurisdiction (AOJ) has not yet assigned a disability rating for these disabilities. Furthermore, the Board is remanding the issue concerning an increased rating for the Veteran’s service-connected left foot disability. As the disability ratings assigned for these disabilities are relevant to whether a TDIU can be awarded, the Board finds that the TDIU issue is inextricably intertwined with future assignment of ratings for the newly service-connected disabilities as well as the service-connected left foot disability and must first be addressed by the AOJ. Harris v. Derwinski, 1 Vet. App. 180 (1991). Also, given the need to remand for other reasons all outstanding VA treatment records dated since January 2018 should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records dated from January 2018 to the present. 2. Arrange for the Veteran to undergo VA examination for evaluation of his left foot disability. 3. Assign ratings for the newly service-connected lumbar spine/left knee/left ankle disorders, bilateral hearing loss, tinnitus, and acquired psychiatric disability. 4. After conducting any additional development deemed necessary the Veteran’s claims should be readjudicated. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD April Maddox, Counsel