Citation Nr: 19123720 Decision Date: 03/29/19 Archive Date: 03/29/19 DOCKET NO. 15-20 740 DATE: March 29, 2019 ORDER The appeal for service connection for gastroesophageal reflux disease (GERD) is dismissed. The appeal for service connection for sinusitis is dismissed. The appeal for service connection for allergic rhinitis is dismissed. The appeal for service connection for a disability manifested by shortening of the right leg is dismissed. The appeal for an initial compensable disability rating for erectile dysfunction is dismissed. The appeal for an initial compensable disability rating for a cornea scar of the right eye is dismissed. Service connection for a cervical spine disability is denied. Service connection for a left shoulder disability is denied. Service connection for a right shoulder disability is denied. Service connection for a right-hand disability is denied. Service connection for tinnitus is granted. The application to reopen the claim for entitlement to service connection for bilateral hearing loss is denied. A compensable disability rating for otitis externa is denied. REMANDED Service connection for a right knee disability, to include as secondary to the service-connected lumbosacral strain, is remanded. Service connection for a left knee disability, to include as secondary to the service-connected lumbosacral strain, is remanded. Service connection for sebaceous cysts is remanded. FINDINGS OF FACT 1. In October 2018, after certification of the claims to the Board and prior to the promulgation of a decision in the appeal, the Veteran and his authorized representative requested that the following claims be withdrawn from appeal: service connection for GERD; service connection for sinusitis; service connection for allergic rhinitis; service connection for a disability manifested by shortening of the right leg; an initial compensable disability rating for erectile dysfunction; and an initial compensable disability rating for a cornea scar of the right eye. 2. A cervical spine disability is not attributable to service and arthritis of cervical spine was not manifest within one year of separation from service. 3. A left shoulder disability is not attributable to service and arthritis of the left shoulder was not manifest within one year of separation from service. 4. A right shoulder disability is not attributable to service and arthritis of the right shoulder was not manifest within one year of separation from service. 5. A right-hand disability is not attributable to service and arthritis of the right hand was not manifest within one year of separation from service. 6. Tinnitus is related to service. 7. A December 2001 rating decision denied the Veteran’s claim for service connection for bilateral hearing loss. There was no material evidence pertinent to the claim received within one year of the issuance of that decision. The Veteran was notified of the decision and apprised of his appellate rights but did not appeal. 8. The evidence received since the December 2001 decision does not relate to an unestablished fact necessary to substantiate the claim of service connection for bilateral hearing loss; it is cumulative of the evidence already of record. 9. Otitis externa is not manifested by swelling and has not required frequent and prolonged treatment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the following claims have been met: service connection for GERD; service connection for sinusitis; service connection for allergic rhinitis; service connection for a disability manifested by shortening of the right leg; an initial compensable disability rating for erectile dysfunction; and an initial compensable disability rating for a cornea scar of the right eye. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 2. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 5. The criteria for service connection for a right-hand disability have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 6. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 7. The December 2001 rating decision denying service connection for bilateral hearing loss is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 8. Evidence received since the December 2001 rating decision is not new and material, and the claim for service connection for bilateral hearing loss is not reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 9. The criteria for a compensable disability rating for otitis externa have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.87, Diagnostic Code (DC) 6210. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1981 to November 2001 in the United States Coast Guard. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified before the undersigned during a videoconference hearing. A transcript of the hearing is included in the electronic claims file. In characterizing the claims involving tinnitus, and the bilateral shoulders, and the right hand, the Board considered the decision of the United States Court of Appeals for the Federal Circuit (Federal Circuit) in Boggs v. Peake, 520 F. 3d 1330 (Fed. Cir. 2008), which provides that a claim premised on a diagnosis not considered in prior decisions is treated as a new claim without the need for new and material evidence. The RO last denied service connection for tinnitus, a right shoulder rotator cuff and shoulder strain, left shoulder acromioclavicular separation, and a right-hand condition with numbness and pain in a December 2001 final rating decision. Since then, a May 2012 VA examination report has documented tinnitus, and a July 2012 VA examination documented degenerative joint disease of the bilateral shoulders. As for the right hand, the United States Court of Appeals for the Federal Circuit (Federal Circuit) recently held that pain, even in the absence of a presently-diagnosed condition, can constitute a disability for VA purposes if it causes functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As the Veteran reports right hand pain with functional impairment, reasonable doubt will be resolved in his favor as to the presence of a current disability. As all of these disabilities were not present when the claims were previously denied, the Board finds that the current claims may be considered without regard to whether new and material evidence has been received. The electronic filing system contains medical records that were submitted by the Veteran, rather than VA, since the RO’s last readjudication of the claims. In the absence of a specific, written request for initial agency of original jurisdiction (AOJ) review of any additional evidence, there is an automatic waiver of AOJ review. See 38 U.S.C. § 7105(e)(1), (2) (2012) (applicable in cases where the substantive appeal is filed on or after Feb. 2, 2013). Withdrawn Claims The Board may dismiss any appeal which fails to allege specific errors of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. During the October 2018 Board hearing, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew his appeal of the following claims: service connection for GERD; service connection for sinusitis; service connection for allergic rhinitis; service connection for a disability manifested by shortening of the right leg; an initial compensable disability rating for erectile dysfunction; and an initial compensable disability rating for a cornea scar of the right eye. See Hearing Transcript, pp. 2, 24. The Veteran was represented by a private attorney at the hearing, and both the attorney and the Veteran participated in the proceeding. See Acree v. O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018). The withdrawals of each particular claim were clarified by the undersigned and confirmed by the attorney. Further, the undersigned and the attorney discussed that the claim involving erectile dysfunction was being withdrawn given the criteria necessary for a higher rating under the applicable diagnostic code, combined with the fact that the Veteran is already receiving special monthly compensation for loss of use of a creative organ. The record thus demonstrates that the consequences of the withdrawals were fully understood. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these claims and they are dismissed. Claims for Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to show a service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). For certain chronic diseases, including arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic diseases, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Here, there was no documentation of arthritis of the cervical spine, shoulders, or right hand during service and characteristic manifestations of the disease processes were not identified. Additionally, arthritis affecting these areas was not found within one year of discharge. Accordingly, § 3.303(b) is not applicable. Cervical Spine, Bilateral Shoulders, & Right Hand The Veteran has a current cervical spine strain, bilateral shoulder strain with DJD, and status-post right hand and thumb laceration with pain and functional impairment, documented on VA examination in July 2012. With specific regard to the right hand, the Veteran has already been granted service connection for the scar associated with his in-service laceration. As such, the scar will not be considered in the discussion below. On a November 1980 enlistment examination and pre-training examination in November 1981, no abnormalities of cervical spine, shoulders, or right hand were found, and the Veteran raised no pertinent complaints on the accompanying Report of Medical History as to the cervical spine, left shoulder, or right hand. As for the right shoulder, the Veteran reported a prior separation of the right shoulder, with no current problems or residuals. As noted, the examining physician found no relevant abnormalities on the entrance examination report, and there is otherwise no evidence indicating a preexisting right shoulder disability. A history of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b). Given all of this, legal analysis of the right shoulder claim as a “preexisting condition” is not applicable. Service treatment records (STRs) show that the Veteran was diagnosed with a mild cervical strain in January 1994. A few days later in February 1994, he again reported pain. An examination showed no pain on palpation, no swelling, and no muscle spasms. He was advised to take Motrin for the pain. As for the shoulders, a right rotator cuff/shoulder strain was documented in January 1984. A left trapezius strain was documented in July 1992. A mild left shoulder strain was documented in May 1997. On his Report of Medical History on separation, the Veteran reported a painful trick shoulder or elbow. The physician noted a history of shoulder pain occurring every now and then. As for the right hand, the Veteran’s palm was lacerated by a tool in August 1993. The wound was sutured. In March 1996, there was soft tissue swelling around the proximal interphalangeal joint of the middle finger. X-rays revealed no fracture; the diagnosis was a possible residual from an old trauma or a congenital anomaly of the ulnar styloid process. In August 2000, the Veteran reported a sensation of numbness around the right thumb area with hand cramping. On examination, there was no tenderness on palpation. The Veteran displayed a strong grip. A diagnosis was not rendered. On his November 2001 separation examination, the Veteran did not report problems relating to the cervical spine. As for the shoulders, he reported his 1997 injury but denied present problems. As for his right hand, he reported a history of numbness. He stated he was given a brace during service but was not currently using it. On examination, he had a full range of motion of the neck and no abnormalities were found. Muscle strength and deep tendon reflexes were normal in the upper extremities. A neurological examination was normal. The examiner did not render any diagnosis pertaining to the cervical spine or hand. He was diagnosed with a history of a separated acromioclavicular joint, which was resolved. On VA examination in July 2012, the examiner documented the Veteran’s reports of his in-service injuries, and reviewed the claims file. He opined that the current disabilities of the cervical spine, shoulders, and right hand were less likely than not related to service. As rationale, he stated that the in-service injuries were acute and transitory events and the subsequent record did not document chronicity of the injuries. At the October 2018 hearing, the Veteran testified that he served as a damage controlman and was at sea for much of his career in the military. He testified, and submitted records to support, that he worked in tight quarters on rough seas nearly continuously. He testified regarding the general rigors of working in these conditions, and the overall strain involved with constantly lifting, bending, and carrying while being thrown around onboard the ship. He and his attorney argued that the bilateral shoulder disability and right-hand disability may be secondary to his cervical spine disability. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the claims. The probative evidence does not show that the Veteran’s cervical spine, bilateral shoulder, or right-hand disabilities are related to his active military service, including to his in-service injuries. The examination at service separation in 2001 found no pertinent disabilities. A chronic disability was not documented in service, and the fact that he sought treatment for other conditions after service, but not a cervical spine, bilateral shoulder, or right-hand disability, weighs against the credibility of any statement that the disorders persisted since discharge. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013). The medical opinion evidence is also persuasive. The July 2012 VA examiner addressed the contentions of direct service connection, but opined that in-service injuries represented acute and transitory events, and the Veteran’s disabilities were not related to military service. The examiner based his conclusions on an examination of the claims file, including STRs, post-service treatment records, and diagnostic reports. He reviewed the reported history and symptoms in rendering the opinion and provided a rationale for the conclusions reached. The only evidence to the contrary is the lay evidence. The Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of medically complex disabilities such as cervical spine strain, bilateral shoulder strain with DJD, and status-post right hand and thumb laceration. See, e.g., Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). To the extent the Veteran seeks secondary service connection for his bilateral shoulder disability and right-hand disability, this is not possible as service connection is not being granted for the cervical spine disability. In reaching these decisions the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. Tinnitus The Veteran has a current diagnosis of tinnitus, documented on VA examination in May 2012. He has consistently reported that tinnitus began during military service and has persisted ever since. He reports that the condition began as intermittent, but now it is constant in both ears. Tinnitus is a condition capable of lay observation and diagnosis. See Charles v. Principi, 16 Vet. App. 370, 374 (observing that “ringing in the ears is capable of lay observation.”) During service, the Veteran served as a damage controlman, working in a loud engine room with grinding, hammering, and welding noise. He has denied post-service recreational or occupational noise exposure. His military occupational specialty (MOS) of damage controlman is one associated with a high probability of exposure to hazardous noise. Moreover, an undated Occupational Health Surveillance Questionnaire documented his exposure to excessive noise. On his service separation examination in November 2001, the examiner noted that he had been exposed to high noise levels during service with poor ear protection. The Board thus finds the Veteran was exposed to acoustic trauma in service and had tinnitus during service. On the question of whether the Veteran’s in-service noise exposure is etiologically related to his current tinnitus, the May 2012 VA examiner stated she could not provide such an opinion without resorting to speculation due to the fact that she had not been provided with the claims file for review. While the claim could be remanded for a further opinion, the Board finds this is avoidable. Throughout the appeal, the Veteran has consistently indicated an in-service onset of tinnitus. He is competent to report experiencing tinnitus during service, and his lay assertions are found believable for the purpose of linking the onset of his tinnitus to the exposure to excessive noise levels during active service. The evidence is thus in relative equipoise in showing that the current tinnitus as likely as not had its clinical onset in service due to the Veteran's exposure to harmful noise as a damage controlman. Furthermore, resolving any doubt in the Veteran's favor, the record shows that symptoms of tinnitus were continuous since service separation under 38 C.F.R. § 3.303(b); Fountain v. McDonald, 27 Vet. App. 258 (2015). Thus, in resolving all reasonable doubt in the Veteran’s favor, service connection is warranted. Application to Reopen Generally, a claim that has been denied in a final, unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In a rating decision of December 2001, the RO denied service connection for bilateral hearing loss. The evidence consisted of statements from the Veteran, STRs, service personnel records, and a November 2001 separation examination report. The claim was denied because the record did not contain any audiometric findings meeting the criteria for hearing loss for VA purposes under 38 C.F.R. § 3.385. In this regard, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. There was no material evidence received within one year of the issuance of the December 2001 decision. The Veteran was notified of that decision and of his appellate rights, but he did not appeal. The December 2001 decision is therefore final as to the evidence then of record and is not subject to revision on the same factual basis. Evidence received since the last final April 2012 rating decision includes statements from the Veteran, VA treatment records, private treatment records, and VA examination reports. The basis for the prior denial was a lack of a diagnosis of hearing loss for VA purposes. The records received since December 2001 do not raise any reasonable possibility of substantiating this element of the claim. To the contrary, hearing loss for VA purposes was not shown on VA audiological examination in May 2012, and an August 2014 private treatment record documenting right ear pain also documented no hearing loss. The Veteran’s statements, while both admissible and believable, are repetitive of those made prior to December 2001. Moreover, a finding of hearing loss for VA purposes requires a mechanical application of the applicable law and regulations to the numeric designations from audiometric test results. 38 U.S.C. § 7104(c); 38 C.F.R. § 20.101(a); Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The prior evidentiary defect has not been cured, nor has it triggered VA’s duty to provide further assistance. The evidence is cumulative and redundant of that already of record when the claim was denied in December 2001. It does not relate to an unestablished fact necessary to substantiate the claim, nor does it raise a reasonable possibility of substantiating the claim. The benefit-of-the-doubt doctrine is not for application. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). The claim for service connection for bilateral hearing loss is not reopened. Claim for Higher Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disability specified is considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. In an unappealed December 2001 rating decision, the RO granted service connection for otitis externa and assigned a noncompensable (0%) disability rating under 38 C.F.R. § 4.87, DC 6210. The noncompensable rating was continued in a June 2005 rating decision, and the November 2013 rating decision on appeal. Under DC 6210, a maximum rating of 10 percent is assigned where there is chronic otitis externa manifested by swelling, dry and scaly or serous discharge, and itching requiring frequent and prolonged treatment. The probative evidence includes a VA examination report of July 2012, and the Veteran’s October 2018 hearing testimony. His VA and private treatment records were considered, but do not contain information sufficient for rating the disability under the applicable rating criteria. On VA examination in July 2012, the Veteran reported bouts of otitis externa occurring twice per year since military discharge. The examiner found the external ear canal was dry and scaly but did not find the otitis externa required frequent or prolonged treatment. The tympanic membrane was normal. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. While the examiner also noted the Veteran experienced tinnitus and vertigo, these are disabilities separate from the present claim. Service connection for tinnitus is on appeal and has been granted above. Service connection for a disability manifested by vertigo was denied in the November 2013 rating decision and not appealed. At the October 2018 hearing, the Veteran testified that he experienced otitis externa in service. After discharge, he experienced ear infections, which he self-treated with peroxide and apple cider vinegar. On occasions in which the infections were more severe, he would seek treatment from his doctor. Considering the pertinent evidence in light of the governing legal authority, the Board finds the preponderance of the evidence is the assignment of a compensable rating. The Veteran does not have a history of otitis externa requiring frequent and prolonged treatment, and the record does not demonstrate any swelling. As the criteria contemplated by a 10 percent rating are not shown, the preponderance of the evidence is against the claim. The Board can point to no other diagnostic code that would provide a basis for the assignment of a compensable rating for the Veteran’s otitis externa. The July 2012 ear examination did not reveal any ear disability other than otitis externa, and tinnitus and vertigo as discussed above. Moreover, the symptomatology contemplated by other diagnostic codes pertaining to the ear is not raised by the medical record. To the extent the Veteran’s attorney argued at the October 2018 hearing that the criteria for otitis media should be applied, the Board will address the argument. Chronic suppurative otitis media, mastoiditis, or cholesteatoma (or any combination) is contemplated by DC 6200 and a compensable rating is applied during suppuration or where there are aural polyps. The July 2012 examiner found the Veteran did not have chronic suppurative otitis media or aural polyps. Chronic nonsuppurative otitis media with effusion (serous otitis media) is contemplated by DC 6201 and is rated based on hearing impairment. As discussed above, the Veteran does not have hearing impairment for VA purposes. As such, a higher disability rating is not available under the codes pertaining to otitis media. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for otitis externa. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. REASONS FOR REMAND Knees The Veteran seeks service connection for his current bilateral knee strain as secondary to his service-connected lumbosacral strain. The only opinion obtained in this regard is that of a July 2012 VA examiner, who provided a negative opinion on the matter of secondary causation. However, as the examiner did not address the matter of secondary aggravation, a further opinion is required. See e.g. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Sebaceous Cysts Service treatment records document the presence of sebaceous cysts on multiple occasions, including, but not limited to, February 1984, November 1984, September 1986, August 1987, February 1990, July 1990, February 1991, June 1996, and February 2000. Sebaceous cysts were documented shortly after discharge, including in September 2002, August 2004, and December 2004. The Veteran reports he has experienced reoccurring cysts ever since, and this contention appears supported by the post-service medical record. On VA examination in July 2012, the examiner diagnosed current sebaceous cysts and provided a negative nexus opinion based on the fact that there were no records indicating chronicity. It does not appear from the Medical History section of the report, however, that the examiner was cognizant of the numerous service records and post-service records documenting the cysts as none of these records were mentioned. A further opinion should be obtained. Barr, 21 Vet. App. at 311; Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to obtain an opinion addressing the nature and etiology of his bilateral knee disability. A complete explanation should be provided for all opinions rendered. The examiner must opine as to whether it is at least as likely as not that any knee disability (a.) began during active service or is related to an in-service injury, event, or disease; or (b.) was caused OR aggravated (chronically worsened) by the service-connected lumbosacral strain. In rendering these opinions, the examiner must consider: • April 1994 and January 2003 service treatment records documenting right knee complaints and treatment • July 2012 VA examination report 2. Schedule the Veteran for a VA examination to obtain an opinion addressing the nature and etiology of his sebaceous cysts. A complete explanation should be provided for all opinions rendered. The examiner must opine as to whether it is at least as likely as not that the sebaceous cysts began during active service or are related to an in-service injury, event, or disease. In doing so, the examiner must consider: • February 1984, November 1984, September 1986, August 1987, February 1990, July 1990, February 1991, June 1996, and February 2000 service treatment records documenting sebaceous cysts • September 2002, August 2004, and December 2004 records generated shortly after discharge documenting sebaceous cysts, and Veteran’s report of experiencing recurring cysts ever since • July 2012 VA examination report M. Tenner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith, Counsel