Citation Nr: 20021316 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 18-22 819 DATE: March 25, 2020 ORDER Service connection for obstructive sleep apnea (OSA) is denied. Service connection for headaches is denied. Service connection for right thigh paresthesias is denied. Service connection for left thigh paresthesias is denied. REMANDED The issue of service connection for hypothyroidism is remanded. The issue of service connection for a right knee disorder is remanded. FINDINGS OF FACT 1. OSA first manifested many years after the Veteran’s military service and is unrelated thereto and is not proximately due to or the result of service-connected psychiatric disability. 2. The record evidence shows the Veteran’s headaches are not of service origin and are not related to any inservice injury, event or disease. 3. A current neurological disability of either thigh is not demonstrated by the record. CONCLUSIONS OF LAW 1. The criteria for service connection for OSA are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 2. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 3. The criteria for service connection for paresthesia of the right thigh are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 4. The criteria for service connection for paresthesia of the left thigh are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran had active service from June 1990 to July 2010. This appeal comes before the Board of Veterans’ Appeals (Board) from rating decisions in March 2017 and April 2017 of a Department of Veterans Affairs (VA) Regional Office (RO). A March 2017 rating decision denied service connection for hypothyroidism, headaches, a right knee disorder, for paresthesia of the right thigh, for paresthesia of the left thigh, and bilateral pes planus. In September 2017, the Veteran filed a Notice of Disagreement (NOD), and after a Statement of the Case (SOC) was issued in April 2018 addressing these issues, the appeal was perfected by filing VA Form 9, Appeal to the Board, in May 2018. An April 2017 rating decision denied service connection for sleep apnea. In September 2017, the Veteran filed a NOD, and the appeal was perfected by filing VA Form 9 on April 12, 2018 Subsequently, an August 2018 rating decision confirmed and continued a 70 percent disability evaluation for the Veteran’s service-connected posttraumatic stress disorder (PTSD) with dysthymic disorder. Principles of Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all 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 competent evidence of (1) a current disability; (2) 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection can be granted for certain chronic diseases, including arthritis, organic diseases of the nervous system, and endocrinopathies, if the evidence established that such disease manifested to a compensable degree within one year after the Veteran was discharged from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.307, 3.309(a). Service connection for chronic diseases can be established through a showing of continuity of symptomatology since service, as an alternative to the nexus requirement. 38 C.F.R. § 3.303(b). The option is limited to the chronic diseases listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection will be granted on a secondary basis for disability that is proximately due to or the result of, or permanently aggravated by, an already service-connected condition. 38 C.F.R. § 3.310(a) and (b). This requires (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence establishing a nexus between the service-connected disability and the claimed disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for OSA Background In VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD, the Veteran reported that during service he had visited a combat stress team because he could not sleep and was given Ambien. On VA psychiatric examination in May 2013 the diagnoses were that the Veteran had PTSD and a dysthymic disorder. He reported that while serving in Afghanistan he had gone to a mental health clinic because he was unable to sleep and was given Ambien which he took throughout his deployment. He reported that this was not effective, and he went to work being tired all the time. He reported that he had been receiving Prozac and Ambien since the spring of 2012. It was reported that as he became depressed, he had problems with sleep. He had difficulty falling asleep because his mind would not stop, and he had both terminal and intermittent insomnia. When asked about insomnia, he reported that he was unable to sleep without medication. Generally, he used Ambien but occasionally used Benadryl for his sleeping problems. He had had sleep difficulty throughout his deployment which continued after service discharge and remained to the current time. He denied having sleep problems or using medication to sleep, prior to his deployment. Rather, he first used sleep medication when deployed to Turkey. The examiner reported that the symptoms which applied to the Veteran’s diagnosed psychiatric disorders included chronic sleep impairment. On VA examination in March 2017 for evaluation of sleep apnea, the Veteran’s records were reviewed. The service treatment records reflected that he had been seen on February 1, 2009, for not being able to get a good night's sleep. He was diagnosed with insomnia and instructed to get 7 to 8 hours of sleep and, if not, he was given Ambien to use as needed for sleep. A follow-up note dated February 10, 2009, stated that he was currently taking Ambien for insomnia and doing well on that medication. In December 2009, a web-based health assessment noted inadequate sleep of a number of days duration. It was also noted that he was having problems with unrestful sleep, as well as difficult falling asleep and staying asleep during the night or waking too early. He got less than 5 hours of sleep on three or more consecutive nights. The examiner further observed that there were no other inservice clinical notes about sleep issues. At the time of post-deployment evaluations from both Iraq and Afghanistan, the Veteran had not made any mention of sleep issues. The Veteran did not seek any referral for his sleep issues until May 12, 2016, when he discussed with sleep problems with a clinical provider. At that time a sleep study was ordered, and he was diagnosed with moderate obstructive sleep apnea on August 7, 2016. The Veteran was placed on the use of a CPAP machine in October 2016, and he had not had any further follow-up. A psychiatry note dated December 22, 2016, reflected that he was sleeping well with the use of Zolpidem. The Veteran now continuously used medication for control of a sleep disorder, which was Zolpidem. The examiner opined that the claimed OSA was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that upon review of the Veteran’s records, his service records showed that he was seen for sleep issues in 2009 and treated with Ambien which was noted to help his sleep issues. A clinical record in December 2009 noted sleep issues. There were no other records found with reference to a sleep problems. Post deployment evaluations from both Iraq and Afghanistan did not mention a sleep issue. The Veteran was not seen for sleep issues after discharge from the military until 2016, about 7 years after his sleep issues in military. Although the Veteran stated, in support of claim, that he had problems while in Afghanistan and was seen by mental health and given Ambien - which was documented - there were no further records showing the Veteran sought help for any further sleep issues. It was the examiner’s opinion that the Veteran's sleep apnea was less likely than not (less than 50% probability) incurred during service. In VA Form 21-4138, Statement in Support of Claim, in April 2018, the Veteran’s wife reported that they had been together since May 2010 and he had had trouble sleeping ever since she had known him. Many nights he would gasp for air, and his had awful snoring. When he did sleep well, he had to medicate to get a good nights’ sleep. He had been given a CPAP machine after VA did a sleep study in August 2016. The Veteran had told her that he had had trouble sleeping during his deployment and for many years. She believed that he had had apnea for the years that his was in military service. Received in November 2018 was an article entitled “PTSD severity linked to Higher Risk of Sleep Apnea in Veterans.” That article states in sleep apnea breathing frequently stopped and started. Veterans with PTSD were at higher risk for OSA and the risk rose with an increase in PTSD symptom severity. Thus, those with PTSD should be screened for OSA. However, it was also stated that “[t]he link between sleep apnea and PTSD in veterans is not clear. Possible factors that may connect the two disorders included combat-related sleep disturbance, chronic stress from PTSD, [and] poor sleep caused by sleep apnea.” Also submitted was a copy of a prior Board decision granting service connection for OSA as secondary to service-connected PTSD. In that decision it was not argued that PTSD caused OSA but that PTSD aggravated OSA and, in that case, private medical opinions were submitted which supported this, and one private medical opinion was that the PTSD had caused OSA. Contrary negative VA medical opinions were not as thorough as a private psychologist’s opinion. VAOPT records show that in October 2019 the Veteran reported having had a sleep study which showed he did not have OSA and they felt his sleep problems related more to PTSD, and he was given medication. He was on Ambien, but he felt it was not working as well as he would like. The assessment was insomnia, and he was advised to follow-up with mental health treatment sources because a sleep study was interpreted as demonstrating that sleep disturbance was related more to PTSD and anxiety versus OSA. Analysis The Veteran may believe that the claimed OSA began during active service and he has reported having had sleep disturbance since his military service. A statement from his wife was to the same effect. However, for the reasons explained, while this history is credible, the Veteran and his spouse lacks the competence to establish that mere sleep disturbance is necessarily due to OSA, as opposed to being symptomatic of his service-connected PTSD with dysthymic disorder. The evidence of record as a whole demonstrates that OSA, as a distinct and separate clinical entity, first manifested many years after the Veteran’s military service and is unrelated in any manner to his service-connected psychiatric disorder. As to this, a layperson may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. See Jandreau, Id. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran being untrained and uneducated in medicine is not competent to address etiology in the present case. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (a claimant is not competent to provide evidence as to more complex medical questions). In this regard, the credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). VA may rely on an absence of an entry in a record as evidence that the event did not occur, if the matter is of the kind that ordinarily would have been recorded. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) ("[E]vidence of a prolonged period without medical complaint can be considered") and Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009) (taking into account the lack of treatment or complaints of the condition for an extensive period of time); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 305 (2008) (more probative weight to VA opinions which relied, inter alia, on a record showing disability symptoms did not begin until decades after service). Here, the Veteran has been receiving treatment for sleep apnea only in relative recent years, and at a point in time which is many years after his last period of military service. There is no clinical evidence of sleep apnea prior thereto, as opposed to his previously related histories of sleeping problems related to sleep interference from psychiatric disability. To the extent that the Veteran seeks to establish a nexus between his military service and his current OSA by attributing the latter to having incurred a psychiatric disorder as a result of his military service or being aggravated by a psychiatric disorder, establishing such a nexus is beyond the capabilities a layperson. Rather, it requires medical knowledge. In other words, the determination of medical etiology requires competent medical evidence. See 38 U.S.C. § 1153(a); 38 C.F.R. §§ 3.303, 3.156(a) (a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). This is particularly true in circumstances, as in this case, in which other types of sleep disturbance may be confused by laypersons as being a manifestation of OSA. For example, to the extent that the Veteran may have difficulty getting to sleep as well as awakening due to nightmares, these are not manifestations of OSA; rather, they are manifestations of his service-connected psychiatric disorder. In this connection, under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, chronic sleep impairment is a criterion for consideration in evaluating service connection psychiatric disabilities. Specifically, it is listed as a criterion for a 30 percent disability rating. Thus, even though the Veteran has some sleep disturbance due to a psychiatric disorder, it would not in itself be proof that that at some point in time he had OSA, much less that OSA originated during service or originated or increased in severity due to any psychiatric disorder(s). Consequently, to the extent that the evidence demonstrates that the Veteran now has sleep disturbance due to OSA, it does not establish that OSA is due to or aggravated by the Veteran’s now service-connected psychiatric disorder or is due to his military service. The Board finds the negative 2017 VA medical opinion to be particularly persuasive. This is because it was rendered after an extensive review of the evidence and set forth rationales for the opinion which is both logical and consistent with the other evidence of record. For these reasons the 2017 VA physician’s opinions must be given greater probative value. The Board finds in the instant case that the combination of the treatment for sleep disturbance during service which improved with the administration of Ambien, a psychotropic medication, during service; not having sought treatment or disability compensation for sleep apnea immediately after service; and the fact that his post-service clinical records are negative for any findings of sleep apnea for many years after service discharge, to be persuasive evidence against the claim. In reaching this determination the Board has considered the article submitted in support of the claim indicating a higher prevalence of OSA in those with PTSD. However, that article speculated as to possible causes and conceded that a causative nexus between PTSD and OSA was not known. Significantly, evidence of a correlation is not proof of causation. “A mutual relationship or some degree of correspondence that is not based on causation or aggravation is not sufficient to meet the requirements of [38 C.F.R.] § 3.310.” Harvey v. Shulkin, No. 16-1515, slip op. at 13 (U.S. Vet. App., Feb. 7, 2018) (panel decision) (addressing an article suggesting a correlation between sleep apnea and psychiatric disorders). Likewise, consideration has been given to the prior Board decision, a copy of which was submitted, granting service connection for OSA on the basis of a medical opinion that OSA was aggravated by service-connected PTSD. Here, however, there is no favorable medication opinion as to either causation or aggravation. Moreover, the prior Board decision referenced by the Veteran has no precedential effect in this case. 38 C.F.R. § 20.1303. Granted, both cases involved claimants who sought service connection for OSA and both had PTSD but neither the facts in each case nor the medical evidence are not demonstrated to be identical. Therefore, the Board finds that the preponderance of the evidence establishes that the Veteran's OSA was first manifested decades after active service, and it is not related to any disease, injury, or incident of military service, or caused or aggravated by a service-connected disorder. Thus, the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Entitlement to service connection for headaches Background On VA examination for headaches in February 2018 the Veteran’s claim file was reviewed. This revealed that during service, in December 2007 he was evaluated for severe debilitating headaches. An MRI of his brain in December 2007 had been normal. There were no other indications that he was seen for headaches. Headaches had not been mentioned at the March 2010 separation examination. VA records from 2015 to 2017 headaches were not discussed or mentioned. The Veteran reported that his headaches had begun in 2002. He reported now having headaches twice monthly, accompanied by photophobia, nausea, and vomiting, as well as blurred vision and vertigo. He treated his headaches by lying down in a quiet dark room. The examiner reported that the Veteran had characteristic prostrating attacks of headaches. The diagnosis was “[h]eadaches, likely migraine.” Following the VA examinations in February 2018 medical opinions were rendered by the examiner that conducted those examinations. As to headaches, the examiner opined that the claimed headaches were less likely than not incurred in or caused by inservice injury, event or illness. The rationale was that although the Veteran was evaluated for headaches in late 2007, there was no other mention of headache pain in the service treatment records. Also, there was no documentation that he was seen for headaches after service separation which would indicate a lack of continuity or persistence of his headaches. Analysis In the February 2020 Informal Hearing Presentation, the Veteran’s service representative argued that the 2018 VA examination was inadequate because in rendering an opinion the examiner had dismissed the Veteran’s history. In other words, it is argued that the VA examiner did not find the Veteran’s report of continuity of symptomatology to be persuasive. However, an assessment of the Veteran’s reports and statements of continuity of symptomatology are ultimately within the province of VA adjudicators, and not VA examiners. It is true that the 2018 VA examiner gave greater weight to the absence of continuity of treatment as compared to the Veteran’s reports of continuity of symptomatology. See generally Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). On the other hand, as stated earlier, VA may rely on an absence of an entry in a record as evidence that the event did not occur, if the matter is of the kind that ordinarily would have been recorded. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) ("[E]vidence of a prolonged period without medical complaint can be considered") and Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009) (taking into account the lack of treatment or complaints of the condition for an extensive period of time); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 305 (2008) (more probative weight to VA opinions which relied, inter alia, on a record showing disability symptoms did not begin until decades after service). Here, the VA examiner explicitly noted that lapse of a number of years between the Veteran’s inservice complaint of headaches in 2007 and his lack of reported headaches at service discharge in 2010 and even for a number of years thereafter. Given the severity of the symptoms which he related having at the 2018 examination, which included photophobia, nausea, vomiting, blurred vision, and vertigo it would reasonable be expected that if he had actually had such symptoms that he would have sought continued treatment during service or soon thereafter. However, he did not, and this diminishes the credibility of this reported continuity of symptomatology. This supports the rationale of the VA examiner, who additionally emphasized the lack of continuity of treatment. Thus, the Board finds that the opinion of the VA examiner is adequate and provides for a basis to reach a fully informed decision in this case. Also, for the reasons explained, the Board finds that the opinion of the VA examiner is of greater probative value than the Veteran’s reports of continuity of symptomatology. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for headaches and, as such, there is no doubt to be resolved in favor of the Veteran. Entitlement to service connection for paresthesia of the right thigh Entitlement to service connection for paresthesia of the left thigh Background During service, in May 2010, the Veteran related having tingling of the outer aspect of both thighs. However, he had no such complaints when he retired from military service. On VA thoracolumbar spinal examination on May 7, 2013, the Veteran’s claim file was reviewed. The diagnosis was mild degenerative changes of the thoracic spine. He reported that his low back pain had begun in 1998 and continued throughout his military service. He denied having any radiation of low back pain. On physical examination strength in his lower extremities was normal at 5/5 and there was no muscle atrophy. Deep tendon reflexes were normal at 2+ at both knees and both ankles. Sensation to light touch was normal throughout the lower extremities. He did not have any radicular pain or other signs or symptoms of radiculopathy. He did not have intervertebral disc syndrome (IVDS). On VA peripheral nerve examination in May 2013 the Veteran’s claim file was reviewed. The diagnosis was bilateral carpal tunnel syndrome (CTS). On physical examination the Veteran had no symptoms attributable to any peripheral nerve conditions in the lower extremities, including no pain, paresthesias or dysesthesias, or numbness. Strength was normal in extension of both knees, and plantar flexion and dorsiflexion were normal in both ankles, and there was no muscle atrophy of the lower extremities. Deep tendon reflexes were normal at 2+ at both knees and both ankles. Sensation to light touch was normal throughout the lower extremities. There were no trophic changes of his extremities. The examiner reported that the Veteran did not have any peripheral nerve condition or peripheral neuropathy which impacted his ability to work. VAOPT records show that in October 2019 the Veteran reported that he had had some numbness in his left anterior thigh for greater than 5 years with numbness in the third and fourth left toes. However, he had not had ann treatment for it. He had low back pain as well but there were not sciatica type symptoms. The assessments included paresthesias upper and lower extremities, and he was to be referred to neurology. Analysis There is no competent evidence that the Veteran has ever had symptoms of chronic disability which was manifested by paresthesia of either or both thighs. Rather, the service records indicate that his isolated complaint of tingling of the outer aspects of his thighs was no more than acute and transitory. In sum, the Veteran’s lay testimony alone is insufficient to establish that he also now has or has ever had additional disability of any kind from this isolated episode of inservice neurologic complaints of tingling of his thighs. Service connection cannot be granted “[i]n the absence of proof of a present disability.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement is satisfied when the claimant has a disability at the time the claim is filed or during the pendency of the appeal even though the disability may resolve prior to adjudication. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In sum, the Veteran’s statements as to his belief that he has chronic residual disability from paresthesia of his thighs is, in substance, actually a medical opinion in the guise of lay evidence and, as such, is not competent because the Veteran does not have the education, training or expertise to render a medical opinion. 38 C.F.R. § 3.159(a)(1) and (2); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994); and Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). With respect to any indication that the Veteran has pain of the thighs, in Saunders v. Wilkie, 2017-1466, slip op. at 7 and 8 (Fed. Cir., Apr. 3, 2018) the United States Court of Appeals for the Federal Circuit addressed “the legal issue [of] whether pain without an accompanying pathology can constitute a “disability” under [38 U.S.C.] § 1110.” The Federal Circuit held that the Veterans Court erred “as a matter of law in holding that pain alone, without an accompanying diagnosis or identifiable condition, cannot constitute a ‘disability’ under [38 U.S.C.] § 1110, because pain in the absence of a presently-diagnosed condition can cause functional impairment.” Saunders v. Wilkie, 2017-1466, slip op. at 21 (Fed. Cir., Apr. 3, 2018) (overruling the Veterans Court’s holding in Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999)). Further, the Federal Circuit held that “[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain—to establish a disability, the veteran’s pain must amount to a functional impairment. To establish the presence of a disability, a veteran will need to show that [] pain reaches the level of a functional impairment of earning capacity.” Saunders v. Wilkie, 2017-1466, slip op. at 21 (Fed. Cir., Apr. 3, 2018). Here, there is no evidence, medical or lay, that any pain of the Veteran’s thighs, even assuming without conceding that it is somehow related to his military service, now rises, or at any time has risen, to the level of being productive of any functional impairment of earning capacity. Rather, the VA neurology examinations in 2013 found no neurologic disorder of the Veteran’s thighs and the peripheral nerve examination in 2013 specifically found that he had no peripheral nerve disorder which impacted his ability to work. Thus, even assuming he did have a neurologic disorder which caused paresthesia of his thighs, and even further assuming that such was of service origin, there is no evidence that any such disorder causes pain, or any other neurologic symptom(s), which reaches a level such as to cause functional impairment of earning capacity. Accordingly, service connection for paresthesia of the right and the left thigh is not warranted. REASONS FOR REMAND Issue of entitlement to service connection for hypothyroidism In VA Form 21-4138, Statement in Support of Claim, in October 2019 the Veteran reported that although his claim for service connection for hypothyroidism had been denied because he had no current diagnosis, he stated that he was recently diagnosed with hypothyroidism at a VA facility in Fargo, and was put on medication, i.e., Levothroxine. Also, his service record showed that he had this condition during service. VAOPT records show that in October 2019 the Veteran was assessed as having hypothyroidism and started on Levothyroxin. VA outpatient treatment (VAOPT) records include a December 10, 2019, record showing that the Veteran was requesting more thyroid medication. Another record of that date states that his continued use of Levothroxine was appropriate. In the February 2020 Informal Hearing Presentation, the Veteran’s service representative requested that the Veteran be afforded a VA nexus examination. The Board finds that such a VA nexus examination would be helpful in this case. Issue of entitlement to service connection for a right knee disorder On VA examination of the Veteran’s knees and lower legs in February 2018 the Veteran’s claim file was reviewed. The diagnosis was “left” patellar tendonitis. It was noted that the Veteran now worked as a locomotive engineer. A review of the service records revealed that the Veteran had been seem for an orthopedic evaluation in 1991 after reporting that he had right knee pain below the patella since November 1991. He had been walking when the pain started but he had been running 3 miles per day previously. He was diagnosed with patellar tendinitis secondary to running and excessive foot supination. Quadriceps strengthening and icing of the infrapatellar area were recommended. He was fitted with bilateral orthotics to correct the supination of his feet. Also, the examiner reported that the Veteran had been seen during service on January 28, 1992, for an aching pain of the lateral aspect of the right knee. X-rays at that time had been normal, but lateral meniscus problems had been suspected and he had been referred for an orthopedic evaluation. An MRI on April 4, 1992 had revealed that there was no meniscal tear, but he was referred for physical therapy and his return in 4 weeks was recommended. There were no other service records of inservice treatment documenting assessment and treatment for a right knee condition. There was no mention of right knee pain during his separation examination in March 2010. The Veteran reported that he had not sought evaluation or treatment for a right knee condition since his discharge from service, but he did report having had right knee pain since the early 1990s. He now had no right knee pain at rest but had right knee pain when he walked or ran farther than one block, which he rated as 1 to 2 on a scale of 10 (1 -2/10). He stated that he consciously pronated his feet (which historically had had a tendency to supinate) which prevented knee pain when he walked up stairs. On physical examination the Veteran had full right knee extension, but flexion was to only 130 degrees, but this loss of 10 degrees of flexion did not contribute to functional loss. Also, pain was noted on examination in flexion, but the examiner reported that the pain did not result in or cause functional loss. There was no pain on weight-bearing. There was mild tenderness to palpation over the medial aspect of the right knee joint. Strength was normal in flexion and extension of each knee, and there was no muscle atrophy. There was no ligamentous instability or recurrent subluxation of either knee. He did not have and had never had a meniscal condition. It was reported that imaging studies had documented arthritis of the right knee. A January 1992 right knee X-ray had revealed an osseous projection extending from the medial cortex of the proximal right tibia, which was fairly, closely apposed to the bone. The joint spaces were well maintained. The impression was that the osseous lesion of the proximal right tibia, medially, probably represented a small osteochondroma. An April 1992 MRI had revealed no evidence of a meniscal tear. X-rays in February 2018 of the right knee revealed a minute spur on the medial tibial plateau and one slightly larger on the patella, and the current impression was minimal degenerative changes. Following the VA examinations in February 2018 medical opinions were rendered by the examiner that conducted those examinations. As to the right knee, the examiner opined that the claimed right knee disability was less likely than not incurred in or caused by inservice injury, event or illness. The rationale was that the Veteran had been diagnosed as having right patellar tendinitis in 1991 and was prescribed orthotics for this (for supination of his feet) and when seen at a podiatric examination on July 7, 1998, it was noted that the use of orthotics, prescribed at the Orthopedic appointment in 1991, had resolved his knee complaints. Additionally, there was no record that he was seen again for a knee condition during service after 1992 and no record that he was seen for these complaints after his separation from service. Thus, the claimed right knee condition was less likely than not incurred in or caused by inservice injury, event or illness. In the February 2020 Informal Hearing Presentation, the Veteran’s service representative argued that the 2018 VA examination was inadequate because the examiner’s opinion was based primarily on the Veteran’s not having complained of knee pain when discharged from service. The Board believes that the assessment of “left” patellar tendinitis on VA examination was actually a clerical error because that examination was for assessment of right, and not left, knee disability. Also, given the similarity of (a) the inservice and post service diagnoses of patellar tendinitis of the right knee, (b) his inservice treatment with orthotics to prevent supination of his feet and his post service report of consciously pronating his feet to prevent knee pain, and (c) the similarity of the radiological findings during service in 1992 and after service in 2018, that further development of this claim would be helpful. The matters are REMANDED for the following action: 1. Afford the Veteran an examination for the purpose of determining, if possible, whether the Veteran now has any form of endocrinopathy and, if so, the etiology thereof or the date of onset thereof, or both. The examiner should have access to the Veteran’s VA electronic claim file. The examiner should review the Veteran’s service treatment records and note any clinical history which he reports. Then, after any necessary physical examination, the examiner is requested to render an opinion as to the following: Is it as likely as not that the Veteran now has a form of endocrinopathy which affects or involves his thyroid? In this regard, the examiner is requested to comment on the significance, if any, of the Veteran’s having been prescribed Levothyroxin (or Levothyroxine). If he does, is it as likely as not that any form of endocrinopathy which affects or involves his thyroid either (a) had its’ onset during his active service from June 1990 to July 2010; or (b) first manifested within one year after his discharge from active service in July 2010? In reaching any such opinions the examiner is requested to explain the significance, if any, of any inservice complaints, signs, symptoms, findings, evaluations laboratory findings as to circulating thyroid hormone levels, or any treatment during the Veteran’s active service. 2. Afford the Veteran an examination for the purpose of determining, if possible, the etiology or the date of onset, or both, of any disability of his right knee. The examiner should have access to the Veteran’s VA electronic claim file. The examiner should review the Veteran’s service treatment records and note any clinical history which the Veteran reports. Then, after any necessary physical examination, the examiner is requested to render an opinion as to the following: What is the significance, if any, of the Veteran’s inservice treatment with orthotics to prevent supination of his feet in order to avoid knee pain and his post service report of consciously pronating his feet to prevent knee pain? What is the significance, if any, of the similarity of the radiological findings during service in 1992 an at the time of the February 2018 VA examination, and particularly the osseous projections or spurring of the right tibia? What is the significance, if any, of the inservice diagnosis of patellar tendinitis in November 1991 and the post service diagnoses of patellar tendinitis of the right knee on VA examination in February 2018? Does the Veteran now have any pathology of the right knee, either patellar tendinitis or arthritis, or any other pathology, which is as likely as not of service origin. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fussell, Counsel 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.