Citation Nr: 20021257 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 19-34 693 DATE: March 25, 2020 ORDER The petition to reopen the previously denied claim for service connection for right shoulder disability is granted. The petition to reopen the previously denied claim for service connection for a nervous disorder is granted. Service connection for right shoulder disability is denied. Service connection for left shoulder disability is denied. Service connection for right hip disability is denied. Service connection for left hip disability is denied. Service connection for right hand disability is denied. Service connection for left hand disability is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to a total disability rating based on individual unemployability due to service- connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. An unappealed August 1975 Board decision denied service connection for a right shoulder disability; subsequently received evidence is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. 2. An unappealed August 1975 Board decision denied service connection for nervous disorder; subsequently received evidence is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. 3. The preponderance of the evidence is against finding that a right shoulder joint disability had its onset during active service; or arthritis manifested to a compensable degree within one year after service or was noted in service with continuity of symptomatology; or that it is otherwise etiologically related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that a left shoulder joint disability had its onset during active service; or arthritis manifested to a compensable degree within one year after service or was noted in service with continuity of symptomatology; or that it is otherwise etiologically related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that the Veteran has had right hip disability or any related disability at any time during or approximate to the pendency of the claim. 6. The preponderance of the evidence is against finding that a chronic left hip disability had its onset in service; or arthritis manifested to a compensable degree within one year after service or was noted in service with continuity of symptomatology; or that a left hip disability is otherwise etiologically related to an in-service injury or disease. 7. The preponderance of the evidence is against finding that a right hand disability had its onset in service; or arthritis manifested to a compensable degree within one year after service or was noted in service with continuity of symptomatology; or that it is otherwise etiologically related to an in-service injury or disease. 8. The preponderance of the evidence is against finding that a left hand disability had its onset in service; or arthritis manifested to a compensable degree within one year after service or was noted in service with continuity of symptomatology; or that it is otherwise etiologically related to an in-service injury or disease CONCLUSIONS OF LAW 1. The August 1975 Board decision denying the claim for service connection for a right shoulder disability is final; and new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.156(a), 20.1103. 2. The August 1975 Board decision denying the claim for service connection for a nervous disorder is final; and new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.156(a), 20.1103. 3. The criteria for service connection for a right shoulder disability are not met. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a left shoulder disability are not met. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for right hip disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for left hip disability are not met. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for right hand disability are not met. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for service connection for left hand disability are not met. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from February 1973 to June 1973. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). 1. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a right shoulder disability. 2. Whether new and material evidence has been received to reopen a previously denied claim for service connection for nervous disorder. Issues 1-2: The Veteran contends that he developed “bad nerves” in service as a result of harsh treatment by his commander and including as a result of his right shoulder disability. See Correspondence (October 1974); Form 9 (April 2015). He claims that his shoulder got worse and he was hospitalized in Jackson after service because he needed a surgery. See Correspondence (May 1975). The Board concludes that an August 1975 Board decision denying service connection for a right shoulder disability and a nervous disorder is final and that new and material evidence has been received to reopen the previously denied claims. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.102, 3.156(a), 20.1103. A claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The 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, the Secretary shall reopen the claim and review the former disposition of the claim. 38 C.F.R. § 3.156(a). Here, the August 1975 Board decision denied service connection for a right shoulder disability and a nervous disorder. The right shoulder disability claim was denied because there was no right shoulder pathology at the time. The acquired psychiatric disorder claim was denied because the-in service diagnosis of passive-aggressive personality was determined to be a personality disorder. VA notified the Veteran of this decision in an August 1975 letter. Therefore, the August 1975 Board decision became final as to those matters. 38 U.S.C. § 7105(b), (c); 38 C.F.R. §§ 3.160(d), 20.201, 20.302, 20.1103. Evidentiary submissions received since the last prior final denial includes new and material evidence. Specifically, a March 2014 VA examination diagnosed right glenohumeral osteoarthritis of the right shoulder and provided its etiology. VA treatment records also show a diagnosis of anxiety. See CAPRI (September 2019). Because this evidence tends to suggest that the Veteran has current diagnoses and that they may be related to service, the evidence is new and material curing a prior evidentiary defect. The credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Further, the language of 38 C.F.R. § 3.156(a) creates a low threshold. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Accordingly, the petitions to reopen the claims are granted. Service Connection Compensation may be awarded for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. Service connection basically means that the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a), (d). Certain chronic diseases, such as arthritis, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Arthritis is a “chronic disease” listed under 38 C.F.R. § 3.309 (a). Therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) apply to the Veteran’s claim for service connection for his shoulder disability, diagnosed as osteoarthritis, and left hip disability diagnosed as left hip degenerative joint disease. 2. Service connection for right shoulder disability 3. Service connection for left shoulder disability The Veteran contends that he has been complaining of bilateral shoulder pain since service. See Correspondence (September 2014). The question for the Board is whether it is as likely as not that the Veteran had a chronic shoulder disability that began during active service, or arthritis manifested to a compensable degree within the initial post separation year, or any currently shown shoulder disability is otherwise etiologically related to an in-service injury or disease. The Board concludes that, while the evidence shows a current disability of the shoulders, the preponderance of the evidence is against finding that a chronic shoulder disability of either shoulder had its onset during active service or that arthritis manifested to a compensable degree within one year after service; or that a chronic shoulder disorder was noted in service with continuity of symptomatology; or that bilateral shoulder disability is otherwise etiologically related to an in-service injury or disease. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. Service treatment records (STRs) reflect no abnormal pathology of either shoulder. A June 1973 STR reflects that the Veteran presented with a “knot” of right side of neck for two days duration with a tender sternoclavicle area. Subjectively, he had a painful clavicle. X-ray was ordered, which showed no abnormality. On follow-up, the Veteran continued to have right clavicle area pain and advised to apply heat. In April 1974, VA received from the Veteran a claim for service connection for pain of the right shoulder and collar bone. An April 1974 hospital summary reflects that the Veteran underwent biopsy of neck mass due to right sternoclavicular joint swelling with sore supraclavicular lymphoid. Three lymph nodes were removed. An October 1974 VA examination showed a healed scar in the right supraclavicular area after an excisional biopsy of a neck mass. There was no limitation of motion or painful motion of the shoulder joint. No current disability was shown on examination. August 2004 VA treatment records reflect that the Veteran presented with complaints of pain with weakness in the left shoulder related to injury 2 months prior (attempting to remove a dead cat from beneath his home). The Veteran reported that he “was using an instrument to try to pull the animal out, and in the process ‘jerked’ his shoulder pretty bad.” He treated it with Tylenol and topical analgesics at home, and reported that pain, but not weakness, had improved. He reported that he “has to manually lift his left arm with his right arm when lifting beyond about 70 degrees.” The assessment was left shoulder pain with possible rotator cuff injury. X-ray showed “Moderate narrowing involving acromio-clavicular joint space and mild narrowing involving glenohumeral joint spaces are noted. There appears to be a cyst in the projection of greater tuberosity of left humerus. No other significant abnormalities are seen and no previous studies are available for comparison.” A February 2013 VA treatment record reflects complaints of right shoulder pain. The Veteran stated that right shoulder pain is chronic, but had increased for 3-4 days after picking up a bucket. He denied a past history of shoulder problem. The assessment was right shoulder sprain. X-ray showed degenerative narrowing in the right glenohumeral joint. A May 2013 VA treatment record reflects findings for left rotator cuff syndrome based on MRI findings for” tears of the supraspinatus tendon, infraspinatus tendon, and biceps tendon as described above. Tendinosis of subscapularis tendon.” The Veteran reported that his left shoulder pain began with injury a few months prior. A March 2014 VA examination showed diagnoses of left shoulder glenohumeral and acromioclavicular osteoarthritis; and right shoulder glenohumeral osteoarthritis (not involving the acromioclavicular joint). Under diagnoses, the examiner noted that the Veteran had a right supraclavicular lymph biopsy, which was not a “shoulder/arm” condition. A complete medical history was noted. The examination report includes a medical opinion that the Veteran’s current right shoulder disability was less likely than not related to service. The opinion explains that a right shoulder joint condition was not shown in service; but rather, the Veteran had right sternoclavicular tenderness with later non-specific biopsies of the supraclavicular nodes obtained in 1974 that did not involve bone. The opinion noted that there was a well-healed supraclavicular scar and no residual disability. It noted that there are no current findings for any adenopathy and examination of the clavicle is totally normal. It reflects that the Veteran had in-service supraclavicular nodes and not abnormal pathology of the shoulder joint/bones. The Veteran is competent to report his symptoms and treatment. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to diagnose himself with arthritis of either shoulder in service or within the initial post separation year. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). This is not susceptible to lay observation and requires imaging studies. Moreover, in-service radiology report of the right shoulder was negative for arthritis. Therefore, the report of in-service arthritis of the right shoulder is not credible. The Veteran has not clearly articulated why he believes service connection is warranted for left shoulder disability, diagnosed as arthritis, inter alia; however, to the extent that the Veteran suggests it began in service, the Board finds that this is not credible in view of his documented complaints for symptoms involving the right sternoclavicular region during service and no mention of any left shoulder complaints coupled with the absence of any left shoulder disability claim on the Veteran’s original VA disability claim in April 1974 and the first documented complaints of left shoulder pain that the Veteran attributed to a recent 2004 injury. It is further not credible in view of records showing that the Veteran held occupations as a laborer post service, including making bricks in June 1997 and as groundskeeper, and played golf in June 1997. See CAPRI at 27 (April 2018); CAPRI at 350 (August 2014). The Board assigns greater probative value to the STRs, VA treatment records, and decades intervening service discharge and the first documented complaints or abnormal findings for the shoulder joints. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006); see also Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom., Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that the Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disorder at issue); Forshey v. West, 12 Vet. App. 71, 74 (1998), aff’d sub nom., Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (finding that the definition of evidence encompasses “negative evidence” which tends to disprove the existence of an alleged fact). This evidence shows no chronic disability of either shoulder in service, or arthritis within one year after service, or that any currently shown disability is etiologically related to in-service injury or disease. STRs include a radiology report (x-ray) showing no abnormal pathology of the right shoulder joint in service, and STRs show no complaints or abnormal pathology of the left shoulder. Many years passed before the Veteran had shoulder joints complaints and there were findings for abnormal pathology of the joints. VA treatment records dated in 2004 reflect, per the Veteran’s own report, that he injured his left shoulder attempting to remove a dead cat from beneath his home. A 2013 VA treatment record reflects that, when presenting for right shoulder joint complaints and symptoms, the Veteran denied history of right shoulder joint problems. This evidence is competent, credible, and weighs against the claim. The Board has considered carefully the STRs showing right sternoclavicular pain and the later biopsy with residual scar. However, there is no indication of any residual disability, to include painful scar, associated with the right supraclavicular lymph node biopsy soon after service. A current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Further, competent, credible evidence has not been presented tending to show that any current disability of either shoulder is linked to the biopsied lymph nodes soon after service or in-service pain symptoms located at the site of lymph nodes. A mere conclusory generalized lay statement that a service event or illness caused a claimant's current condition is insufficient to trigger VA’s duty to obtain a medical examination or opinion. Waters v. Shinseki, 601 F.3d 1274, 1276 (2010). On balance, the weight of the evidence is against the claims. Accordingly, the claims are denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). 4. Service connection for right hip disability 5. Service connection for left hip disability The Veteran contends that he has bilateral hip disability as a result of service. He has provided no further details or explanation. The Board concludes that the Veteran does not have a current right hip disability or related disability, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board further concludes that the preponderance of the evidence is against finding that a chronic left hip disability had its onset during active service, or that arthritis manifested to a compensable degree within one year after service, or that a left hip disability is otherwise etiologically related to an in-service injury or disease. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. STRs reflect no complaints or findings for abnormal pathology of either hip. Left hip pain is first documented in an October 2002 VA treatment record. At the time, the Veteran reported left hip pain shooting down into his foot and some numbness in the foot and toes. He reported a one-week history of symptoms. Objectively, the left hip had normal range of motion without pain. A May 2008 VA treatment note reflects that “films indicate femur head defect.” A May 2008 VA treatment note reflects that the Veteran had just started a job operating a weed-eater with subsequent left hip discomfort. A December 2008 VA treatment note reflects an impression for left hip arthralgia. X-ray showed no acute fracture, dislocation, or degenerative changes. A November 2009 VA treatment note reflects that the Veteran worked as cemetery groundskeeper and had left hip pain for past two weeks, which he thinks may be arthritis. A May 2011 VA treatment note shows that he had presented to emergency room with complaints of left hip pain of eight-months duration. An October 2011 VA treatment note reflects an impression for degenerative joint disease of the left hip. As to the right hip, a March 2014 VA treatment note reflects pain at right hip/groin area that began after increased working and cleaning up around the house. The Veteran denied injury to the area. The impression was myalgia and he was advised to take acetaminophen, rest, and avoid over-exertion. It is noted that the Veteran underwent right inguinal hernia repair in June 2014. The medical evidence of record reflects that left hip disability did not have its onset in service or soon after service. It is first shown decades after service discharge and the Veteran reported it had only recently started when he was first seen for left hip complaints in 2002. As to the right hip, competent, credible evidence of a right his disability has not been presented. While the Veteran is competent to report injury, symptoms, and treatment, he has not actually provided VA with any meaningful insight into his claimed conditions to include why he believes service connection is warranted. To the extent that he suggests onset of left hip disability in service, the Board finds that this is not credible in view of the STRs, VA treatment records, and decades intervening service and the first documented complaints in 2002 which the Veteran reported began only one-week earlier. Therefore, any suggestion of onset of disorder, or ongoing symptoms, since service have no probative value. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board assigns greater probative value to the STRs, VA treatment records, and the decades intervening service discharge and the first documented left hip complaints or findings. See Curry, supra; see also Maxson, supra. Although no VA examination or medical opinion has been obtained in these matters, the Board finds the duty to assist has not been triggered. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). Although McLendon sets a low bar, that bar has not been met here as there is no indication of a link between the Veteran’s left hip disability and his active service apart from the Veteran’s own assertions. The only evidence of a possible connection between the Veteran’s left hip and his service are the Veteran’s own broad and conclusory statements, and such statements are not sufficient to trigger VA’s duty to obtain an examination or opinion. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (holding that conclusory lay assertion of nexus is insufficient to entitle claimant to provision of VA medical examination). As to the right hip, the Board finds that neither the lay nor the medical evidence demonstrates the presence of “disability.” Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018) (pain alone can constitute a “disability” under 38 U.S.C. § 1110 because pain can cause functional impairment). In the absence of proof of a present disability due to disease or injury, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See McClain v. Nicholson, 21 Vet. App. 318, 321 (2007) (The current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim). Here, Veteran has not presented evidence of any functional loss or impairment due to right hip symptoms including pain and the medical evidence shows no indication of functional loss or impairment due to right hip any symptoms. On balance, the weight of the evidence is against the right and left hip claims. Accordingly, the claims are denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). 6. Service connection for right hand disability. 7. Service connection for left hand disability. Correspondence from the Veteran to VA, dated in October 2018, reflects the he reported of right hand problems. A January 2019 rating decision denied service connection for arthritis of the left and right hand. On the Veteran’s notice of disagreement, he indicated that the sought an evaluation for his bilateral hand disability. There was no contentions that the disability began in service, manifested to a compensable degree within one year after service, or is otherwise related to in-service injury or disease. The Board concludes that the preponderance of the evidence is against finding that a right and/or left hand disability had its onset during active service, or that arthritis manifested to a compensable degree within one year after service, or that a hand disability is otherwise etiologically related to an in-service injury or disease. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. STRs reflect no complaints or findings for abnormal pathology of either hand. The Veteran did not claim to have any hand impairment on his original VA claim soon after service discharge or for decades after service discharge. VA treatment records reflect left wrist, not hand, complaints in June 1997 for swelling and pain of two-weeks duration, with a history of making bricks and playing golf, assessed as left wrist strain. Additional, subsequently dated, VA treatment records also show left wrist complaints. The first indication of a hand disorder is in September 2014. VA treatment records dated in September 2014 reflect complaints of bilateral hand joint pains and x-ray revealed moderate osteoarthritis. A March 2017 VA treatment records shows that that the Veteran was evaluated for hand symptoms and that there was a history of rheumatiod arthritis with advanced deformity of both hands. Clinical findings reflect sudden onset of inability to flex the right index finger, MRI of right hand was ordered MRI, and the Veteran was scheduled for surgical repair or tendon graft of finger. The Veteran participated in Occupational Therapy rehabilitation. A June 2016 follow up visit, post tendon graft to right index finger from rupture. The Veteran is followed by the VA hand specialty clinic. VA received the Veteran’s VA claim for compensation for the right hand in 2018. A November 2018 VA Hand and Finger Conditions examination diagnosed bilateral arthritis and the Veteran’s medical history was noted. Here, neither the lay nor the medical evidence reflects onset of hand disability in service. Competent, credible evidence has not been presented showing arthritis within the initial post separation year. Further, neither the lay nor the medical evidence links the findings for bilateral hand arthritis, or any post service findings for abnormal hand pathology, to in-service injury or disease. The Veteran has not contended any relationship between either hand disability and his active service. Therefore, the Board assigns greater probative value to the available STRs, decades intervening service and the first indication of a hand disorder, and the absence of any alleged in-service injury or disease. See Curry, supra; and Maxson, supra. On balance, the weight of the evidence is against the claims. Accordingly, the claims are denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. To ensure that VA has met its duty to assist, remand is necessary to obtain a new VA examination. 38 U.S.C. § 5103A. The Veteran underwent a VA psychiatric examination in March 2014, where the examiner found no diagnosis and noted the Veteran’s reports of vague symptoms including anxiety. However, since that examination, additional VA treatment records from January 2014 to September 2019 have been associated with the file and show a diagnosis of anxiety and depression as well as ongoing VA mental health treatment, including prescription for Zoloft. Therefore, a new medical opinion is necessary to decide the claim. See Nieves-Rodriguez, 22 Vet. App. at 304. 2. Entitlement to a TDIU is remanded. The Board notes that the Veteran is presently not service-connected for any disability. However, the claim for TDIU is inextricably intertwined with the claims for service connection remanded herein. Therefore, the Board must defer consideration of this matter at this time. See Harris v. Derwinski, 1 Vet. App. 181 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records from September 2019 to the Present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hand disability. The examiner must opine on the following: (a.) Whether it is at least as likely as not related to an in-service injury, event, or disease; and (b.) If arthritis is shown, whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disability to include anxiety and depression. The examiner must opine on the following: (a.) Is at least as likely as not related to an in-service injury, event, or disease, including nervous trouble shown in service. (b.) Is it at least as likely as not that any acquired psychiatric disability shown during this appeal (i) began during active service, or (ii) was noted during service with continuity of the same symptomatology since service. 4. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (CONTINUED ON NEXT PAGE) 5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.