Citation Nr: 1808485 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 09-08 375 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected right shoulder impingement syndrome. 2. Entitlement to an initial rating higher than 30 percent for a major depressive disorder, with a mood disorder, for the period from September 1, 2007, to August 26, 2012, and higher than 70 percent thereafter. 3. Entitlement to an initial rating higher than 10 percent for gastroesophageal reflux disease (GERD), with peptic ulcer disease. 4. Entitlement to an initial rating higher than 10 percent for right knee patellofemoral syndrome. 5. Entitlement to an initial rating higher than 10 percent for degenerative changes of the left knee, status post anterior cruciate ligament surgery. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). 7. Entitlement to special monthly compensation (SMC) based on being housebound. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on verified active duty in the Navy from July 1985 to August 2007. He also had an additional six years, ten months, and eight days of prior active duty. This matter is before the Board of Veterans' Appeals (Board) on appeal of a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, that granted service connection and a 30 percent rating for a major depressive disorder, with a mood disorder, effective September 1, 2007; granted service connection and a 10 percent rating for GERD, with peptic ulcer disease, effective September 1, 2007; granted service connection and a 10 percent rating for right knee patellofemoral syndrome, effective September 1, 2007; and granted service connection and a 10 percent rating for degenerative changes of the left knee, status post anterior cruciate ligament surgery, effective September 1, 2007, and denied service connection for a left shoulder disability. The case was later transferred to the St. Petersburg, Florida Regional Office (RO). In May 2011, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. In August 2011, the Board remanded the claims of service connection for a left shoulder disability, to include as secondary to service-connected right shoulder impingement syndrome; to an initial rating higher than 30 percent for a major depressive disorder, with a mood disorder; to an initial rating higher than 10 percent for GERD, with peptic ulcer disease; to an initial rating higher than 10 percent for right knee patellofemoral syndrome; and to an initial rating higher than 10 percent for degenerative changes of the left knee, status post anterior cruciate ligament surgery for further development. An October 2012 RO decision increased the rating for the Veteran's major depressive disorder with a mood disorder to 70 percent, effective August 27, 2012. In February 2013, the Board found that the issue of entitlement to a TDIU was raised during the Veteran's previously appealed increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board also determined that the issue of entitlement to SMC based on being housebound must be considered. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280 (2008). The Board remanded the claims of service connection for a left shoulder disability, to include as secondary to service-connected right shoulder impingement syndrome; to an initial rating higher than 30 percent for a major depressive disorder, with a mood disorder, for the period from September 1, 2007, to August 26, 2012, and higher than 70 percent thereafter; to an initial rating higher than 10 percent for GERD, with peptic ulcer disease; to an initial rating higher than 10 percent for right knee patellofemoral syndrome; and to an initial rating higher than 10 percent for degenerative changes of the left knee, status post anterior cruciate ligament surgery, for further development. In February 2017, the Board requested a Veterans Health Administration (VHA) opinion, as to the issue of entitlement to service connection for a left shoulder disability, to include as secondary to service-connected right shoulder impingement syndrome, and the VHA opinion was obtained in June 2017. In July 2017, the Veteran and his representative were provided with a copy of the June 2017 VHA opinion. In September 2017, the Veteran and his representative, respectively, submitted additional argument in support of his appeal. As noted in the August 2011 and February 2013 Board remands, at a May 2011 Board hearing, the Veteran raised issues of entitlement to service connection for diabetes mellitus and for a liver disorder. Those issues are not before the Board and are referred to the RO for appropriate action. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to an initial rating higher than 30 percent for a major depressive disorder, with a mood disorder, for the period from September 1, 2007, to August 26, 2012, and higher than 70 percent thereafter; entitlement to an initial rating higher than 10 percent for GERD, with peptic ulcer disease; entitlement to an initial rating higher than 10 percent for right knee patellofemoral syndrome; entitlement to an initial rating higher than 10 percent for degenerative changes of the left knee, status post anterior cruciate ligament surgery; entitlement to a TDIU; and entitlement to SMC based on being housebound, are all addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT A left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear, had its onset during service. CONCLUSION OF LAW The criteria for service connection for a left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear, have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Service connection is in effect for right shoulder impingement syndrome, major depressive disorder, with a mood disorder; GERD, with peptic ulcer disease; degenerative disc disease of the lumbar spine; right lower extremity radiculopathy; obstructive sleep apnea; an acquired deviated nasal septum, with sinusitis and allergic rhinitis; migraine headaches; right knee patellofemoral syndrome; degenerative changes of the left knee, status post anterior cruciate ligament surgery; right ankle tendonitis; left ankle tendonitis; bilateral tinnitus; bilateral hearing loss; a deviated nasal septum; status post a bone grafting procedure of the lower lip and chin; right hand arthritis; left hand arthritis; status post a right fibula fracture; bilateral pes planus; hypertension; urinary incontinence; erectile dysfunction; and for a residual surgical scar of the left knee. The Veteran essentially contends that he has a left shoulder disability that is related to service, or, more specifically, that is related to his service-connected right shoulder impingement syndrome. The Veteran specifically maintains that he first hurt his left shoulder in 1986 or 1987 following a Naval SEAL operation with a wetsuit when he slipped and fell while going down a ladder aboard ship. He states that he was provided with a sling at that time. The Veteran reports that he reinjured his left shoulder several times during service as a lead climber in SEAL teams. He indicates that he was treated for his left shoulder several times in the 1990s. The Veteran essentially contends that he suffered left shoulder problems during service and since that time. He also asserts that his left shoulder disability has the same etiology as his service-connected right shoulder impingement. The Veteran's service treatment records show treatment for left shoulder complaints. A January 1991 treatment entry notes that the Veteran complained of left sternal and left clavicular pain secondary to falling down a ladder in a ship and having his kit bag land on top of him. The examiner reported that the Veteran was tender to palpation at the midshaft of the left clavicle and tender at the left clavicular insertion to the sternum. The assessment was sternal pain and blunt clavicular trauma. On a medical history form at the time of a June 1993 examination, the Veteran checked that he had a painful or trick shoulder or elbow. The examiner referred to recurrent low back pain since 1986, but did not refer to a left shoulder problem at that time. Post-service treatment records, including VA examination reports, show treatment for variously diagnosed left shoulder disabilities, to include chronic pain in the shoulders; acromioclavicular joint arthritis of the left shoulder; impingement syndrome of the left shoulder; a rotator cuff disorder of the left shoulder; and a left rotator cuff tear. For example, an August 2008 treatment entry, within one year of the Veteran's separation from service, from the Naval Hospital in Pensacola, Florida indicates that he had chronic pain in the back, shoulders, knees, and ankles. The assessment included chronic pain. A September 2008 treatment entry from the Naval Hospital in Pensacola, Florida notes that the Veteran had chronic pain involving the lower back, right buttock sciatic nerve area, knees, shoulders, and hands. The assessment included chronic pain, especially in the back, but also in the shoulders, fingers, knees, and ankles. A July 2012 VA shoulder and arm conditions examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that the onset of his left shoulder problems began in approximately 1985 to 1989. He stated that he injured his left shoulder during service after he returned from a mission, while wet, and slipped on a ship's ladder. He reported that he struck his left shoulder and that he was conservatively treated with a sling at that time. The Veteran indicated that his left shoulder got better, but that it continued to bother him. He maintained that he was uncertain whether he sought medical care from 1989 and his discharge in 2007. The diagnoses were left shoulder impingement syndrome and left shoulder acromioclavicular arthritis, osteoarthritis/degenerative joint disease. The examiner indicated that the Veteran's left shoulder acromioclavicular joint degenerative joint disease, with impingement syndrome, was not caused by or related to his military service or to the Veteran's report of in-service trauma. The examiner stated that the Veteran's service treatment records, including his July 2007 separation examination report, were silent for any left shoulder condition. An October 2015 VA shoulder and arm conditions examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he first hurt his left shoulder in approximately 1986 or 1987 when he came off an operation in a wetsuit and slipped and fell aboard a ship. He stated that a corpsman treated him on-site with a sling and that he did some physical therapy at a clinic for his left shoulder. He indicated that he was a lead climber and that he reinjured his left shoulder several times during service, but that he never received treatment. The Veteran also maintained that he was treated for his left shoulder several times in the 1990s and that he listed his left shoulder at the time of a 2007 separation examination. The diagnoses were left shoulder impingement; a left rotator cuff tear; and left acromioclavicular joint osteoarthritis. In a February 2016 addendum to the October 2015 VA shoulder and arm conditions examination report, the examiner indicated that the Veteran's left shoulder condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner opined it was less likely than not that the left shoulder condition was related to, or had its onset during service and that it was not otherwise attributable to any aspect of service, including his right shoulder impingement syndrome. The examiner stated that the service treatment records, including a July 2007 VA general medical examination report, were silent for a left shoulder condition or any residuals. The examiner stated that there was no clinical correlation-nexus between the left shoulder condition and the right shoulder impingement syndrome as those were contralateral shoulder joints and that one did not cause or aggravate the other. A VHA opinion, received in November 2017, was provided by an orthopedic surgeon. The VHA expert indicated that the Veteran's medical records were reviewed and that they indicate that he had mild left shoulder acromioclavicular joint arthrosis, which was confirmed by examination and x-rays, as well as left shoulder impingement syndrome. The expert stated that there was no imaging to confirm rotator cuff pathology as to the Veteran's left shoulder. The expert indicated that after a thorough review of the records, including a January 1991 service treatment record, it was unlikely that any complaints about the left shoulder were related to service. The expert reported that the January 1991 service treatment record indicates an injury to the left sterno-clavicular joint. The expert stated that the sterno-clavicular joint was in an anatomically different location to the left shoulder. The expert maintained that, therefore, the January 1991 service treatment record was unrelated to any current left shoulder symptoms. The expert stated that the Veteran's records show that there had been no further complaints of left shoulder problems after the January 1991 service treatment record to his retirement physical in July 2007. The expert reported that the July 2007 retirement physical did not mention any left shoulder problems. The expert indicated that a September 2008 military note states that the Veteran had chronic pain, especially in the back, but also the shoulders, knees, and ankles. The expert related that the same note does not have a physical examination of the left shoulder and that the Veteran was released without limitations. It was noted that a March 2009 psychiatric examination note documents a normal left shoulder examination, and that a July 2009 general medical examination report did not have any mention of the Veteran's left shoulder. The expert commented that it was unlikely that the Veteran's left shoulder complaints were related to, or aggravated by, the service-connected right shoulder condition or any other service-related conditions. The expert indicated that the left shoulder and right shoulder conditions were unrelated. The expert maintained that there was no good evidence that overcompensating for one joint injury lead to another joint injury. The probative value of medical opinion evidence "is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators . . ." Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The determination of credibility is the province of the Board. It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board observes that there are opinions of record from VA examiners and a VHA expert that address the etiology of the Veteran's claimed left shoulder disability. The Board observes that an examiner, pursuant to a July 2012 VA shoulder and arm conditions examination report, following a review of the claims file, related diagnoses of left shoulder impingement syndrome and left shoulder acromioclavicular arthritis, osteoarthritis/degenerative joint disease. The examiner indicated that the Veteran's left shoulder acromioclavicular joint degenerative joint disease, with impingement syndrome, was not caused by or related to his military service or to his report of in-service trauma. The examiner stated that the Veteran's service treatment records, including his July 2007 separation examination report, were silent for any left shoulder condition. The Board notes that although the examiner indicated that the Veteran's service treatment records were silent for any left shoulder condition, the Veteran was actually treated for a left, blunt clavicular trauma in January 1991. He also reported that he had a painful or trick shoulder or elbow on a medical history form at the time of a June 1993 examination. Therefore, it is unclear whether the examiner reviewed the Veteran's entire claims file. The Board also observes that the examiner did not address whether the Veteran's service-connected right shoulder impingement syndrome caused or aggravated the diagnosed left shoulder disability. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. The examiner also did not specifically address the Veteran's reports of left shoulder problems during service and since service. The Board observes that the Veteran is competent to report left shoulder problems during service and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Therefore, the Board finds the opinion provided by the examiner, pursuant to the July 2012 VA shoulder and arm conditions examination report, is not very probative in this matter. Additionally, the Board notes that the examiner, pursuant to a October 2015 VA shoulder and arm conditions examination report, following a review of the claims file, related diagnoses of left shoulder impingement; a left rotator cuff tear; and left acromioclavicular joint osteoarthritis. The examiner, in a February 2016 addendum, indicated that the Veteran's left shoulder condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also maintained that it was less likely than not that the Veteran's left shoulder condition was related to, or had its onset during, the Veteran's service, and that it was not otherwise attributable to any aspect of service, including his right shoulder impingement syndrome. The examiner reported that the Veteran's entire service treatment records, including a July 2007 VA general medical examination report, were silent for a left shoulder condition or any residuals. The examiner stated that there was no clinical correlation-nexus between the left shoulder condition and the right shoulder impingement syndrome as those were contralateral shoulder joints and that one did not cause or aggravate the other. The Board observes that although the examiner indicated that the Veteran's service treatment records were silent for any left shoulder condition, he was actually treated for a left, blunt clavicular trauma in January 1991. Thus, it is unclear whether the examiner fully reviewed the Veteran's entire claims file. Additionally, the examiner did not specifically address the Veteran's reports of left shoulder problems during service and since service. See Davidson, 581 F.3d 1313. The examiner was requested to expressly comment on the Veteran's lay assertions regarding the onset and continuity of left shoulder symptomatology since service and his statements relating such symptoms to his service-connected right shoulder impingement syndrome pursuant to a February 2013 Board remand. Therefore, the Board finds that the examiner's opinions, pursuant to the October 2015 VA shoulder and arms conditions examination report, with the February 2016 addendum, are not very probative in this matter. Further, the Board notes that the an expert, pursuant to a June 2017 VHA opinion, indicated that the Veteran's current diagnoses were mild left shoulder acromioclavicular joint arthrosis, which was confirmed by examination and x-rays, as well as left shoulder impingement syndrome. The expert stated that there was no imaging to confirm rotator cuff pathology as to the Veteran's left shoulder. The expert specifically maintained that after a thorough review of the records, including a January 1991 service treatment record, it was unlikely that any complaints about the left shoulder were related to the Veteran's period of military service. The expert reported that the January 1991 service treatment record indicates an injury to the left sterno-clavicular joint and that the sterno-clavicular joint was in an anatomically different location to the left shoulder. The expert maintained that, therefore, the January 1991 service treatment record was unrelated to any current left shoulder symptoms. The expert stated that the Veteran's records show that there had been no further complaints of left shoulder problems after the January 1991 service treatment record to his retirement physical in July 2007. The expert reported that the July 2007 retirement physical did not mention any left shoulder problems. The expert further indicated that a September 2008 military note states that the Veteran had chronic pain, especially in the back, but also the shoulders, knees, and ankles, but that the same note does not have a physical examination of the left shoulder and that the Veteran was released without limitations. The expert also referred to a March 2009 psychiatric examination note and a July 2009 general medical examination report. The examiner further commented that it was unlikely that the Veteran's left shoulder complaints were related to, or aggravated by, the service-connected right shoulder condition or any other service-related conditions, and that the left shoulder and right shoulder conditions were unrelated. The Board observes that the examiner specifically stated that the Veteran's service treatment records show that there were no further complaints of left shoulder problems after a January 1991 record until his retirement physical in July 2007. The Board notes, however, as discussed above, that the Veteran reported that he had a painful or trick shoulder or elbow on a medical history form at the time of a June 1993 examination. Additionally, the expert maintained that a sterno-clavicular joint was in an anatomically different location than the left shoulder. The Board notes that the January 1991 record specifically indicates that the Veteran complained of left sternal and left clavicular pain at that time, and relates an assessment of sternal pain and blunt clavicular trauma. The expert did not specifically explain how left sternal and left clavicular pain was in anatomically different location than the left shoulder area. Additionally, the expert indicated that a September 2008 treatment note states that the Veteran had chronic pain in the shoulders, but found that there was no physical examination. The expert apparently dismissed the significance of the note based on there not being a physical examination without addressing the Veteran's complaints of shoulder pain. Further, the Board notes that the examiner did not address a prior August 2008 treatment entry, within one year of the Veteran's separation from service, from the Naval Hospital in Pensacola, Florida which also indicates that the Veteran had chronic pain in the shoulders and relates an assessment that included chronic pain. Therefore, the Board finds that the VHA expert's opinions are also not very probative in this matter. The Board observes that the Veteran's service treatment records specifically show that he was treated in January 1991 for complaints of left sternal and left clavicular pain, and that the assessment was sternal pain and blunt clavicular trauma. Also, on a medical history form at the time of a June 1993 examination, the Veteran checked that he had a painful or trick shoulder or elbow. The Board notes that an August 2008 treatment entry from the Naval Hospital in Pensacola, Florida, within a year of the Veteran's separation from service, notes that the Veteran had chronic pain in the shoulders and relates an assessment of chronic pain. A September 2008 treatment entry from the same facility relates essentially the same information. The Board observes that the Veteran is competent to report left shoulder problems during service and since service. See Davidson, 581 F.3d at 1313. Additionally, although the opinions by the respective VA examiners, as well as the VHA expert, are negative in this case, the Board has found that those opinions are not very probative in this matter as a result of various deficiencies. The Board notes that the Veteran is currently diagnosed with a left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear. The Board finds the Veteran's reports of left shoulder problems during and since service to be credible. See Jandreau v. Nicholson, 492 F.3d 1372 (2007) (holding that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Resolving any doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise regarding whether the current left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear, commenced during his military service. In light of the evidence, as well as the deficiencies in opinions pursuant to the July 2012 VA shoulder and arm conditions examination report, the October 2015 VA shoulder and arm conditions examination report, with a February 2016 addendum, as well as the opinions provided, pursuant to the June 2017 VHA opinion, the Board cannot conclude that the preponderance of the evidence is against granting service connection for a left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear. Thus, service connection for a left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear, is warranted. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. ORDER Service connection for a left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear, is granted. REMAND The remaining issues on appeal are entitlement to an initial rating higher than 30 percent for a major depressive disorder, with a mood disorder, for the period from September 1, 2007, to August 26, 2012, and higher than 70 percent thereafter; entitlement to an initial rating higher than 10 percent for GERD, with peptic ulcer disease; entitlement to an initial rating higher than 10 percent for right knee patellofemoral syndrome; and entitlement to an initial rating higher than 10 percent for degenerative changes of the left knee, status post anterior cruciate ligament surgery; entitlement to a TDIU; and entitlement to SMC based on being housebound. As to the Veteran's claim for a higher rating for his service-connected major depressive disorder, with a mood disorder, the Board observes that this case was previously remanded in February 2013, partly to issue a supplemental statement of the case (SSOC) that addressed the specific issue of entitlement to an initial higher rating for a major depressive disorder, with a mood disorder, for the period since August 27, 2012. Pursuant to the February 2013 remand, a SSOC was provided to the Veteran in March 2016. The Board notes, however, that the SSOC solely addressed the issue of entitlement to an initial rating higher than 30 percent for a major depressive disorder, with a mood disorder, for the period prior to August 27, 2012. The SSOC did not address the issue of entitlement to an initial higher rating for a major depressive disorder, with a mood disorder, for the period since August 27, 2012, as requested pursuant to the remand instructions. Additionally, the Board notes that the Veteran was last afforded a VA psychiatric examination, as to his service-connected major depressive disorder, with a mood disorder, in August 2012. The diagnosis was a mood disorder, due to a general medical condition. Since that time, in a March 2016 statement, the Veteran reported that his service-connected major depressive disorder, with a mood disorder, controlled every aspect of his life, including his family and friends; his daily activities, and his relationships. He stated that his psychiatric disorder caused him to be in bed for weeks and ruined his ability to be around people. The Board observes that the Veteran has not been afforded a VA examination, as to his service-connected major depressive disorder, with a mood disorder, in over five years. Additionally, the record clearly raises a question as to the current severity of his service-connected disability. As such, the Board finds it necessary to remand this matter to afford him an opportunity to undergo a contemporaneous VA examination. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). As to the Veteran's claim for a higher rating for his service-connected GERD, with peptic ulcer disease, the Board notes that he was last afforded a VA esophageal conditions examination in October 2015. The diagnosis was GERD. Since that time, in a March 2016 statement, the Veteran specifically indicated that his GERD was bad and that it continued to worsen. He stated that he had frequent attacks; constant pressure in his upper chest and left shoulder; severe reflux, with swelling of his throat; and a severely limited diet. The Board observes that the Veteran has not been afforded a VA examination, as to his service-connected GERD, with peptic ulcer disease, in over two years. In light of the Veteran's March 2016 statement, the record raises a question as to the current severity of his service-connected disability. As such, the Board also finds it necessary to remand this matter to afford him an opportunity to undergo a contemporaneous VA examination. See Snuffer, 10 Vet. App. at 400, 403. The Board notes that the Veteran was last afforded a VA knee and lower leg conditions examination report, as to his service-connected right knee patellofemoral syndrome and degenerative changes of the left knee, status post anterior cruciate ligament surgery, in October 2015. The diagnoses were right knee patellofemoral pain syndrome and a left knee anterior cruciate ligament tear. The Board notes that the U.S Court of Appeals for Veteran's Claims (Court) has issued decisions in Correia v. McDonald, 28 Vet. App. 158, 166 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017) concerning the adequacy of VA orthopaedic examinations. The Court in Correia held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In Sharp, the Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must "elicit relevant information as to the veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran's functional loss due to flares based on all the evidence of record, including the veteran's lay information, or explain why she could not do so." In light of these decisions, and as the findings pursuant to the October 2015 VA knee and lower leg conditions examination report, are inadequate, the Board finds that a new VA examination should be provided addressing the Veteran's service-connected left knee disability and right knee disability. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Snuffer, 10 Vet. App. at 400, 403. Finally, as discussed above, the Board has granted service connection for a left shoulder disability, diagnosed as left shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a rotator cuff tear. Given this change in circumstances, and to accord the Veteran due process, the RO must readjudicate the issues of entitlement to a TDIU and entitlement to SMC based on being housebound. Additionally, as those claims are inextricably intertwined with the Veteran's claims for higher ratings for his service-connected major depressive disorder, with a mood disorder; GERD, with peptic ulcer disease; right knee patellofemoral syndrome; and degenerative changes of the left knee, status post anterior cruciate ligament tear surgery, those matters must be addressed together on remand. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following: 1. Ask the Veteran to identify all medical providers who have treated him for his service-connected major depressive disorder, with a mood disorder; GERD, with peptic ulcer disease; right knee patellofemoral syndrome; and degenerative changes of the left knee, status post anterior cruciate ligament surgery, since February 2016. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of the nature, extent, and severity of his service-connected major depressive disorder, with a mood disorder; GERD, with peptic ulcer disease; right knee patellofemoral syndrome; and degenerative changes of the left knee, status post anterior cruciate ligament surgery, and the impact of those condition on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Thereafter, schedule the Veteran for an appropriate VA examination to determine the extent and severity of his service-connected major depressive disorder, with a mood disorder. The entire claim files, including all electronic files, must be reviewed by the examiner. All indicated tests should be conducted and all symptoms associated with the Veteran's service-connected major depressive disorder, with a mood disorder, must be described in detail. 4. Schedule the Veteran for an appropriate VA examination to determine the extent and severity of his service-connected GERD, with peptic ulcer disease. The entire claim files, including all electronic files, must be reviewed by the examiner. All indicated tests should be conducted and all symptoms associated with the Veteran's service-connected GERD, with peptic ulcer disease, must be described in detail. 5. Schedule the Veteran for a VA examination to determine the extent and severity of his service-connected right knee patellofemoral syndrome and degenerative changes of the left knee, status post anterior cruciate ligament surgery. The claims file must be reviewed by the examiner. All indicated tests must be conducted, including x-ray, and all symptoms associated with the Veteran's service-connected right knee patellofemoral syndrome and degenerative changes of the left knee, status post anterior cruciate ligament surgery, must be described in detail. Specifically, the examiner must conduct a thorough orthopedic examination of the Veteran's right knee disability and left knee disability and provide diagnoses of any pathology found. In examining the right knee and left knee, full range of motion testing must be performed where possible. The joints involved must be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joints. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, the examiner should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of motion, and incoordination that is present. The examiner must also state whether the examination is taking place during a period of flare-ups. If not, the examiner must ask the Veteran to describe the flare-ups he experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 6. Then readjudicate the issues on appeal. If any of the benefits sought remain denied, issue a supplemental statement of the case (which specifically addresses the issue of entitlement to an initial rating higher than 30 percent for a major depressive disorder, with a mood disorder, for the period from September 1, 2007, to August 26, 2012, and higher than 70 percent for the period thereafter) and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs