Citation Nr: 20041994 Decision Date: 06/19/20 Archive Date: 06/19/20 DOCKET NO. 18-36 356 DATE: June 19, 2020 ORDER Service connection for an acquired psychiatric disorder, to include as secondary to service-connected disabilities, is denied. Service connection for a right wrist disorder, to include as secondary to service-connected residuals of burn, right forearm, is denied. REMANDED Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for a right hip disorder, to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for a right thigh disorder, to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for an impairment of the left lower leg (claimed as left calf disorder), to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for an impairment of the right lower leg (claimed as right calf disorder), to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for a left foot disorder, to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for a right foot disorder, to include as secondary to service-connected right knee disability, is remanded. FINDINGS OF FACT 1. The preponderance of the competent and credible evidence indicates that the Veteran’s acquired psychiatric disorder did not have its onset during active service, is not proximately caused or aggravated by service-connected disabilities, and is not otherwise related to service. 2. The preponderance of the competent and credible evidence indicates that the Veteran’s right wrist disorder did not have its onset during active service, is not proximately caused or aggravated by his service-connected residuals of burn, right forearm, and is not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310 (2018). 2. The criteria for service connection for a right wrist disorder, to include as secondary to service-connected residuals of burn, right forearm, have not been met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1982 to June 1985. These matters were previously before the Board in August 2019 at which time they were remanded for further evidentiary development. The Board also remanded the issue of entitlement to service connection for a left hip disorder, to include as secondary to service-connected right knee disability, for the limited purpose of issuing a Statement of the Case (SOC) pertaining to the issue. See 38 C.F.R. § 20.200 (2018); Manlincon v. West, 12 Vet. App. 238, 240-241 (1991). The Agency of Original Jurisdiction (AOJ) issued the SOC in February 2020, however, the Veteran did not perfect an appeal. See 38 C.F.R. § 20.202 (2018). As such, that claim is not currently before the Board. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove 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). Service connection for certain chronic disorders may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury, or for an additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). 1. Acquired Psychiatric Disorder The Veteran has claimed entitlement to an acquired psychiatric disorder as a direct result of his military service in Korea, Turkey, and Germany. See November 2007 Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD). The record also raised a possible relationship between the Veteran’s psychiatric symptoms and his military service and raised a secondary theory of entitlement due to pain from his service-connected disabilities. There are additional requirements for service connection for PTSD. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between the current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. §§ 3.304(f), 4.125 (2016); see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). With regard to medical evidence of a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a), this regulation provides that, for VA purposes, all mental disorder diagnoses must conform to the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-V). The Veteran has contended several in-service stressors. In a November 2007 statement, he reported that he was on leave in Turkey during a time of anti-American sentiment with a friend. That friend was attacked, and his face was slashed with a knife. A second identified stressor was during the Veteran’s time in Korea. He stated that he was constantly on guard and alert along the Demilitarized Zone, causing stress which he did not deal with at the time. He noted that he felt like they could go into battle at any time, resulting in his mental health symptoms. Another identified stressor was during his time stationed in Germany. He stated that there was a lot of terrorist activity and he saw houses bombed and men burned. He also reported that when he was in Greece and Macedonia, he was in live fire situations. Finally, he reported that a friend with whom he joined the military died in a plane crash in December 1985 (after the Veteran’s separation from service). In February 2008, VA issued a formal finding that there was a lack of information to verify the claimed stressors. The Veteran’s service treatment records (STRs) are silent for any psychiatric complaints, symptoms, treatment, or diagnosis. At separation in March 1985, no psychiatric abnormalities were noted on clinical evaluation. On his report of medical history, the Veteran himself denied depression or excessive worry, nervous trouble, and frequent trouble sleeping. He has since described trouble with arguments, fights, and passive-aggressive behavior in the military which resulted in disciplinary problems, however, his military personnel records do not reflect any behavioral complaints. Personnel records also reflect that he did not receive combat decorations or medals. It was noted that he served in Korea from 1982 to 1983 and in Germany from 1983 to 1985. Post-service, the Veteran first sought VA psychiatric treatment in September 2006 when he was hearing voices, feeling depressed, and thinking he was “in the war.” He reported to clinicians that he had significant anger which he thought was the result of a friend being killed in an airplane crash and his childhood experiences in a dysfunctional family. A PTSD screen had positive results. VA clinicians diagnosed psychosis NOS secondary to polysubstance abuse; cocaine, marijuana, alcohol, and nicotine dependence; and malingering. The Veteran was hospitalized for a week due to hallucinations, erratic behavior, and homicidal intentions. He underwent several subsequent hospitalizations, largely focused on substance abuse treatment and related psychiatric symptoms. He stated that he had flashbacks of events that occurred during his service and he related his symptoms to a friend killed in a 1985 airplane accident and to a friend who died during Desert Storm. In September 2007, it was noted that he had symptoms of PTSD/schizophrenia and a PTSD screen was positive. Following a hospitalization in 2007, he was diagnosed with psychosis NOS, secondary to polysubstance abuse, and personality disorder NOS, along with polysubstance abuse is remission. Following Social Security Administration (SSA) psychiatric testing in February 2008, the Veteran was diagnosed with mood disorder NOS, personality disorder NOS, and polysubstance dependence. On the basis of the evaluation, he was awarded SSA disability benefits based on affective/mood disorders and personality/conduct disorders with a disability onset date of January 2006. In February 2008, July 2008, and November 2008, psychiatric testing was conducted by VA clinicians. It was noted that the test data was not suggestive of a diagnosis of PTSD. Instead, the Veteran was diagnosed with psychosis NOS, secondary to polysubstance abuse, resolved; dysthymic disorder; presence of anxiety symptoms below the threshold for a diagnosis of an anxiety disorder; alcohol, cannabis, opiod, cocaine, and benzodiazepine abuse in full, sustained remission (16-months of abstinence); and personality disorder NOS with self-defeating, schizoid, avoidant, schizotypal, paranoid, and antisocial traits. Periods of polysubstance abuse and sobriety continued. Any psychiatric symptomology was noted to be secondary to the Veteran’s polysubstance abuse and personality disorder NOS. Psychiatric testing was conducted again in January 2009 which revealed diagnoses of psychosis NOS, secondary to polysubstance abuse and personality disorder NOS, along with polysubstance abuse is remission. In July 2011, the Veteran was diagnosed by VA clinicians with mood disorder NOS, psychosis NOS, cocaine dependence, cannabis abuse, adjustment disorder component, anxiety disorder with features of PTSD, and rule out cocaine-induced mood disorder and psychosis. Subsequent private treatment records for other disabilities reflected a medical history of PTSD but contained no psychiatric testing or treatment. The Veteran was hospitalized in a private facility for psychiatric treatment in August 2011. Psychiatric evaluation resulted in diagnoses of major depressive disorder, recurrent and moderate, and alcohol abuse/cannabis abuse in remission. A June 2013 VA PTSD screen had negative results. In December 2014, VA clinicians stated that the Veteran’s psychosis with paranoia was likely schizoaffective. His current diagnoses subsequently included schizoaffective disorder. A review of the Veteran’s entitlement to SSA disability benefits was conducted in March 2015 which determined that the Veteran continued to be entitled to benefits due to a primary diagnosis of psychosis NOS and a secondary diagnosis of schizoaffective disorder. In August 2016, the Veteran stated that his pain was affecting his mood negatively. He noted in September 2017 that his mood was up and down due to pain. An August 2018 PTSD screen was negative. The most recent VA psychiatric treatment records reflected current and ongoing diagnoses of schizoaffective disorder, bipolar type; recurrent major depressive episodes, moderate; tobacco dependence, continuous; cocaine dependence, in remission; and other and unspecified alcohol dependence in remission. A VA examination was conducted in January 2020. The Veteran was diagnosed with schizoaffective disorder, bipolar type, and cocaine use disorder, severe but in remission since 2012. The examiner noted that his cocaine use previously accounted for severe symptoms and functional impairment and pre-dated the onset of his schizoaffective disorder. However, as he reported full sobriety now, his current noted symptoms and functional impairment were related solely to his schizoaffective disorder. The examiner determined that the Veteran described symptoms of schizophrenia and associated mood disturbance and anxiety, consistent with schizoaffective disorder. He also described a long history of drug and alcohol abuse pre-dating military service and continuing until 2012. With additional oversight and consequences, he was able to maintain sobriety since 2012, but it had clearly contributed to prominent functional impairments in the past. He described disorganized behavior and aggression and there were times when he would blow up and stab people and have random outbursts. This was often associated with drug or alcohol abuse but also with hallucinations/psychosis. He also endorsed symptoms of paranoia. He experienced depression for many years, worsening with numerous personal losses. Symptoms of fighting, killing others, and suicidal ideation subsided once he got sober. After a review of the Veteran’s pre-military, military, and post-military history and current clinical findings, the examiner determined that it was less likely than not that the Veteran’s psychiatric condition was incurred in or caused by his active service. In support, he stated that despite several notations in the record alleging symptoms were related to in-service events, the Veteran did not list any military traumas or stressors upon evaluation. Early treatment records revealed psychotic and mood symptoms in the context of substance abuse which was not directly related to military stressors. The examiner stated that the Veteran had been given a number of diagnoses in the record, however, many of these diagnoses overlapped and were redundant to his current diagnosis of schizoaffective disorder, bipolar type. His major depressive episodes were subsumed within the schizoaffective diagnosis. He did not show signs of a separate generalized anxiety disorder, but he did experience some anxiety with his schizoaffective disorder. He did not meet the criteria for PTSD based on his presentation on the current examination or review of the record, as well. The examiner also found that the Veteran’s psychiatric condition was less likely than not proximately caused or aggravated by his service-connected disabilities. In support, he stated that his symptoms were better accounted for by his substance abuse and later emerging schizoaffective disorder. He noted that the Veteran had a genetic predisposition for schizoaffective disorder and that his cocaine use precipitated the onset of that disorder. Several clinicians’ notations speculated a possible link between the Veteran’s psychiatric problems and chronic pain, but these were not full mental health evaluations and did not account for the extensive mental health history in its entirety, to include prominent psychotic symptoms in addition to possible depression and anxiety associated with schizoaffective disorder. Based on the foregoing, the Board finds that service connection for an acquired psychiatric disorder is not warranted. Although some private treatment records have PTSD noted as part of the Veteran’s medical history, there are no psychiatric evaluations of record diagnosing PTSD. With no current diagnosis, service connection for PTSD is not warranted. He does have a history of polysubstance abuse and psychosis and a current diagnosis of schizoaffective disorder, bipolar type. The STRs contained no complaints, symptoms, treatment or diagnosis of any psychiatric condition, to include the post-service diagnoses. The first evidence of psychiatric symptomology occurred in 2006, many years after separation, and in the context of polysubstance abuse. The Veteran described several military-related causes of his symptoms to clinicians, however they included events that occurred after his separation from service (i.e. a friend who died in a plane crash after the Veteran had separated, a friend who died in Desert Storm). The stressors he described for purposes of entitlement to service connection for PTSD could not be verified and there is no indication in the claims file that psychiatric symptomology resulted from the claimed incidents. The Board attaches significant probative weight to the VA opinion of record as it is well-reasoned, detailed, consistent with other evidence of record, and included consideration of the Veteran’s pertinent medical history. The examiner’s conclusions that the Veteran’s psychiatric condition was less likely than not related to active service or caused or aggravated by his other service-connected disabilities are consistent with the record and supported by adequate rationale. Accordingly, the preponderance of the evidence is against a finding that the Veteran’s acquired psychiatric disorder had its onset in service, is proximately caused or aggravated by service-connected disabilities, or is otherwise related to service. As such, service connection is not warranted. 2. Right Wrist Disorder The Veteran has contended that his right wrist disorder was proximately caused or aggravated by his service-connected residuals of burn, right forearm. The Veteran’s STRs are negative for complaints, symptoms, treatment, or diagnosis of a right wrist disorder. He experienced a burn to his right forearm in August 1982; however, treatment records do not indicate any involvement of the right wrist other than one notation describing the location of the burn. Post-service, the Veteran first noted pain in his right wrist in September 2006. A physical examination was normal. The Veteran underwent a VA examination in October 2006 in which he complained of right wrist pain, fatigability, and lack of endurance. An examination produced normal results and an x-ray revealed no significant osseous or articular findings. In a September 2007 VA treatment record, it was noted that the Veteran had numbness and tingling in his bilateral hands. He had decreased sensation consistent with carpal tunnel syndrome (CTS). Nighttime splinting was suggested. In January 2008, it was noted that the Veteran worked in laundry and complained of bilateral hand numbness, beginning at the wrist. Likely mild/moderate bilateral CTS was diagnosed, though it was noted that there were some atypical symptoms. Injections were prescribed. An x-ray of the right wrist conducted in October 2011 was negative. Photographs of the forearm burn injury added to the record in October 2011 indicated that the burn was on the right arm, above the wrist. Lay statements by the Veteran’s family members in September 2011 and December 2011 described pain in the right arm and weakness in the right hand. Another VA examination was conducted in August 2015. The Veteran was diagnosed with bilateral CTS. The examiner determined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected right forearm burn residuals. In support, she stated that the STRs showed that the Veteran sustained a superficial second-degree burn to the right forearm. At the examination, no hypersensitivity was noted, and the record reflected a diagnosis of bilateral CTS. It was less likely than not that the CTS was related to the superficial second-degree burn as CTS is caused by compression of the median nerve at the wrists. In the Veteran’s case, CTS was bilateral and more likely than not related to repetitive motion from his former occupations. Another VA opinion from the August 2015 examiner was obtained in April 2016. The examiner stated that the Veteran’s separation examination was negative for any peripheral nerve condition involving the right wrist and there was no documentation of a diagnosis within a year of discharge. The Veteran was not diagnosed with CTS until 2008, some 21 years after discharge. In the interim, he worked for extended periods as a machine operator, welder, furniture loader, and mechanic. The examiner determined that it was more likely than not that his CTS was the result of repetitive injury from post-military occupations. Another VA examination was conducted in April 2017. The Veteran was diagnosed with bilateral CTS. The examiner concluded that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected right forearm burn residuals. In support, she stated that burn of an arm is not a cause or contributing factor to the development of CTS according to the Mayo Clinic. The Veteran underwent another VA examination in June 2017. He was diagnosed with osteoarthritis of the right wrist. The examiner determined that the condition was less likely than not caused by the service-connected burn residuals. In support he stated that the burn scar was superficial and not over the wrist and could therefore not be the cause of degenerative joint disease (DJD) of the right wrist. The Veteran’s age (53) and obesity (weight of 228 pounds and BMI of 32.78) were risk factors associated with osteoarthritis, a disabling degenerative joint disorder, and were known to affect weight-bearing and nonweight-bearing joints. Both wrists had degenerative changes. If the right forearm burn scar was the cause of his condition, only the right wrist would have degenerative changes. Another examination was conducted in January 2020. The examiner determined that the Veteran’s right wrist disorder was less likely than not proximately caused or aggravated by his service-connected right forearm burn residuals. In support, he stated that the Veteran’s burn injury was to the top of his right forearm and a burn injury cannot anatomically or physiologically cause right wrist joint symptoms. The Board finds that the preponderance of the evidence is against a finding that the Veteran’s right wrist CTS and osteoarthritis is proximately caused or aggravated by his service-connected right forearm burn injury. There are no complaints, symptoms, treatment, or diagnosis of either condition during service or within a year of separation. Relevant symptoms were first noted many years after separation and following the Veteran’s participation in occupations involving repetitive motion. CTS was diagnosed bilaterally, not merely in the right wrist. The consensus of the VA examiners was that a burn like the superficial, second-degree burn the Veteran suffered in service could not cause or be a contributing factor to CTS or be anatomically or physiologically related to degenerative joint symptoms. The Board finds the examiners’ opinions to be highly probative as they are well-reasoned, consistent with other evidence of record, and included consideration of the Veteran’s pertinent medical history. The Board recognizes the Veteran’s belief that his right wrist disorder is related to his service-connected burn residuals, however, he has not been shown to have the requisite medical experience and knowledge to determine etiology of complex peripheral nerve or degenerative conditions. As such, his opinion on etiology is not probative. The preponderance of the evidence is against a finding that the Veteran’s right wrist disorder had its onset in active service or within a year of separation, is proximately caused or aggravated by a service-connected disability, or is otherwise related to service. As such, service connection is not warranted. REASONS FOR REMAND The August 2019 Board remand requested several VA examinations and opinions regarding the nature and etiology of the issues on appeal. The requested examinations were conducted in January 2020 and several opinions were provided. The Board finds that further remand is needed to ensure substantial compliance with the remand requests. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Left Ankle Disorder The VA examiner was asked to address entitlement to a left ankle disorder on a direct basis and as secondary to the Veteran’s service-connected right knee disability. It was specifically requested that relevant in-service notations from January 1983 and July 1983 showing diagnoses of a left ankle sprain and a February 2017 x-ray finding of a tiny osseous fragment adjacent to the top of the lateral malleolus likely due to a remote avulsion injury be considered by the examiner in his determinations. (The Board notes that the x-ray was mistakenly noted as occurring in June 2017 instead of February 2017). The January 2020 examiner did not list the February 2017 x-ray findings in his summary of relevant evidence and stated that the Veteran did not have a current diagnosis pertinent to the left ankle. Regarding direct service connection, the examiner determined that the claimed condition was less likely than not incurred in active service. In support, he stated merely that no medical records described left ankle symptoms at service discharge in 1985. Regarding secondary service connection, the examiner stated that the claimed condition was less likely than not caused or aggravated by the service-connected right knee disability. In support, he stated that the left ankle disorder was unrelated to the Veteran’s right total knee arthroplasty anatomically and physiologically. The Board finds that the remand requests were not fulfilled, as the in-service notations and February 2017 x-ray were not discussed, and the examiner did not provide complete rationales to support his findings. The Board finds that the opinion does not represent an adequate basis upon which to render a decision. Upon remand, the AOJ should obtain an addendum opinion which considers direct service connection in light of the two documented instances of left ankle sprains in service and the later x-ray findings suggesting a remote avulsion injury. Further, a new opinion addressing a secondary theory of entitlement supported by complete rationale should be obtained. 2. Left Knee Disorder The VA examiner was asked to provide an opinion supported by complete rationale as to whether the Veteran’s left knee disorder was proximately aggravated by his service-connected right knee disability. He was also specifically asked to address the October 2016 Disability Benefits Questionnaire (DBQ) completed by the Veteran’s treatment provider which found that his left knee disorder was likely exacerbated by his service-connected right knee disability. The January 2020 examiner determined that the claimed condition was less likely than not caused or aggravated by the service-connected right knee disability. In support, he stated only that the left knee disorder was unrelated to the Veteran’s right total knee arthroplasty anatomically and physiologically. As the examiner did not address the positive nexus opinion of record and did not provide a complete rationale for the opinions given, the Board finds that a new opinion is needed which considers all of the relevant evidence of record and which is supported by adequate rationale. 3. Right Hip and Thigh Disorders There are several VA opinions of record regarding the etiology of the Veteran’s right hip complaints. As noted in the August 2019 remand, none of the opinions offered a determination regarding aggravation by the Veteran’s service-connected right knee disability. Additionally, several other findings by VA examiners needed further explanation. A November 2016 examiner noted that, although the right knee disability would be a possible predisposing factor to trochanteric bursitis, his right knee injury occurred in 1984 and he did not have hip pain until 2016 after he was treated for sacroiliitis and bulging discs. The examiner failed to clearly explain the significance of the fact that the injury occurred many years prior to the reported hip pain. He also noted that a lower leg gait predisposed people to trochanteric bursitis, but failed to comment on the fact that the Veteran’s VA treatment records reflected that his gait was antalgic. See, e.g., November 2016 VA Physical Medicine Rehabilitation Consult. Additionally, in both the November 2016 opinion and a June 2017 opinion, examiners failed to adequately address whether the Veteran suffers from a disability or functional impairment associated with his right thigh. See Saunders v. Wilkie, 883 F.3d 1356 (Fed. Cir. 2018). Pursuant to the remand, the January 2020 VA examiner determined that the claimed condition was less likely than not caused or aggravated by the service-connected right knee disability. In support, he stated only that the right hip disorder and right thigh disorder were unrelated to the Veteran’s right total knee arthroplasty anatomically and physiologically. Another opinion was provided in February 2020. The clinician agreed with the June 2017 VA opinion which stated generally that the cause of the Veteran’s degenerative joint disease (DJD)/tendonitis in his claimed joints (wrist, hip, knee, ankle, and foot) were the result of aging and obesity, as he was 53 years old, 70 inches tall, and weighed 228 pounds with a BMI of 32.78. The February 2020 examiner determined that the Veteran’s trochanteric pain syndrome was less likely than not permanently aggravated beyond its natural progression by the service-connected right knee disability and at least as likely as not the result of a post-service process. He stated that no objective medical record or reputable medical literature evidence to indicate otherwise was found. There was no mechanism of action for cause or permanent aggravation beyond natural progression of the Veteran’s trochanteric pain syndrome by his service-connected right knee disability. His greatest risk factor for a right hip condition was a post-service process. The Board finds that a new VA opinion is needed regarding the etiology of the Veteran’s right hip and thigh disorders. Neither of the new opinions reconciled the findings from the November 2016 opinion with the record. The January 2020 opinion was not supported by a complete rationale and the February 2020 opinion employed a more restrictive standard than is required. The Court of Appeals for Veterans Claims (Court) issued a precedential decision in Ward v. Wilkie, 31 Vet. App. 233 (2019), holding that a “permanent worsening” of a nonservice-connected disability is not required to establish secondary service connection on the basis of aggravation. Accordingly, a new opinion should be sought upon remand. 4. Bilateral Lower Legs (Bilateral Calf) Disorders The August 2019 remand listed numerous notations in the claims file relevant to the bilateral lower legs. The January 2020 VA examiner did not discuss any of the pertinent in-service and post-service records and merely found that the left leg disorder was less likely than not directly related to service as no medical records described left leg symptoms at service discharge in 1985. He determined that there was no right leg disorder found on examination, and it was less likely than not directly related to service as the Veteran’s symptoms were normal postoperative symptoms that caused no functional issues. He also concluded that a left leg disorder was not caused or aggravated by the right knee disability as it was unrelated to the disability anatomically and physiologically. He provided negative causation and aggravation opinions for the right leg, as he found no disorder upon examination other than normal postoperative symptoms that caused no functional issues. The Board finds that a new VA opinion is needed which addresses the identified radiological findings of record and reports of relevant symptomology and which is supported by adequate rationale. 5. Bilateral Foot Disorders The August 2019 remand requested a VA opinion which addressed both a theory of direct service connection for the left foot and secondary theories of entitlement for the bilateral feet. The examiner was also asked to discuss a June 2017 examiner’s finding that the Veteran’s bilateral hallux valgus was due to a congenital predisposition. The January 2020 VA examiner did not discuss a July 1983 notation that the Veteran injured his left foot while playing basketball nor a February 1985 note that he suffered a cold injury to his left foot. The examiner merely stated that a left foot condition was less likely than not related to active service because no medical records described left foot symptoms at service discharge in 1985. He also determined that the left and right foot disorders were less likely than not caused or aggravated by the right knee disability as they were unrelated to his right total knee arthroplasty anatomically and physiologically. The Board finds that a new VA opinion is needed which addresses both of the direct and secondary theories of entitlement, discusses the relevant evidence of record, and is supported by adequate rationale. The matters are REMANDED for the following action: 1. Obtain addendum opinions from an appropriate VA medical professional regarding the claims on appeal. The need for in-person examinations is left to the clinician providing the opinions. The clinician should review the entirety of the evidence and specifically address all evidence highlighted herein. The clinician is asked to address: Regarding the left ankle disorder: (a.) Identify any current diagnoses regarding the left ankle. The Veteran’s reports of relevant symptomology should be discussed. (b.) Whether the claimed condition is at least as likely as not (50 percent probability or greater) the result of active service, specifically to include the January 1983 and July 1983 diagnoses of left ankle sprains. The clinician should discuss the in-service notations and the February 2017 x-ray finding of a tiny osseous fragment adjacent to the top of the lateral malleolus likely due to a remote avulsion injury. The clinician is reminded that a negative nexus opinion based solely on the lack of a noted condition at separation is not an adequate basis to determine entitlement to benefits. (c.) Whether it is at least as likely as not (50 percent probability or greater) that any currently-diagnosed left ankle disorder was caused or aggravated by his service-connected disabilities, to include his service-connected right knee disability. The Board emphasizes that causation and aggravation are two separate inquiries which should be answered by the clinician. If aggravation is found, the clinician should address the baseline manifestations of the disorder found prior to aggravation. The clinician is advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms. (d.) All findings should be reported in detail and all opinions should be accompanied by a clear rationale. Regarding the left knee disorder: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any currently-diagnosed left knee disorder was caused or aggravated by his service-connected disabilities, to include his service-connected right knee disability. The Board emphasizes that causation and aggravation are two separate inquiries which should be answered by the clinician. If aggravation is found, the clinician should address the baseline manifestations of the disorder found prior to aggravation. The clinician is advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms. (b.) The clinician is specifically asked to address the findings of the October 2016 DBQ. (c.) All findings should be reported in detail and all opinions should be accompanied by a clear rationale. Regarding the right hip and right thigh disorders: (a.) Identify any relevant diagnoses of the right hip and right thigh. If there is no current diagnosis regarding the right thigh, the clinician is asked to determine whether the Veteran suffers from a disability or functional impairment associated with his right thigh. (b.) Whether it is at least as likely as not (50 percent probability or greater) that any currently-diagnosed right hip or thigh disorder was caused or aggravated by his service-connected disabilities, to include his service-connected right knee disability. The Board emphasizes that causation and aggravation are two separate inquiries which should be answered by the clinician. If aggravation is found, the clinician should address the baseline manifestations of the disorder found prior to aggravation. The clinician is advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms. Evidence of permanent worsening is not required. (c.) The clinician is specifically asked to address the findings of the November 2016 VA examiner including to explain the significance of the fact that the right knee injury occurred in 1984 and right hip pain was first reported in 2016 and to explain the finding that a lower leg gait predisposed people to trochanteric bursitis in light of the fact that the Veteran’s VA treatment records reflected that his gait was antalgic. (d.) All findings should be reported in detail and all opinions should be accompanied by a clear rationale. Regarding impairment of the bilateral lower legs (bilateral calf disorders): (a.) Identify any current diagnoses regarding the bilateral lower legs. The Veteran’s reports of relevant symptomology should be discussed. (b.) Whether the claimed conditions are at least as likely as not (50 percent probability or greater) the result of active service, specifically to include the December 1982 report of a pulled muscle in his left leg after straining his leg backward while playing basketball and the October 1984 notation of the presence of right tibial shelf tenderness. The clinician is reminded that a negative nexus opinion based solely on the lack of a noted condition at separation is not an adequate basis to determine entitlement to benefits. (c.) Whether it is at least as likely as not (50 percent probability or greater) that any currently-diagnosed impairment of the right lower extremity or left lower extremity was caused or aggravated by the Veteran’s service-connected disabilities, to include his service-connected right knee disability. The Board emphasizes that causation and aggravation are two separate inquiries which should be answered by the clinician. If aggravation is found, the clinician should address the baseline manifestations of the disorder found prior to aggravation. The clinician is advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms. (d.) The clinician is specifically asked to address the following notations: 1. May 2011: MRI of the right knee revealing subchondral reactive changes at the femoral condyle that could possibly represent insufficiency related to the insertion for gastrocnemius (calf muscle); 2. May 2016: private treatment record noting the presence of subarticular cysts at the tibial eminence of the left leg; 3. September 2016: MRI of the right knee revealing small subchondral cysts at the tibial attachment likely due to chronic mechanical stress and high-grade partial tear of the proximal attachment of the medial head of the gastrocnemius; 4. October 2018: VA record noting the Veteran’s report of severe pain in his right lower leg; 5. January 2019: right ankle x-ray revealing mild bone spur formation at the front and rear aspects of the large long bone of the lower leg; and 6. May 2019: VA record noting that sensation to light touch and pinprick was decreased in the Veteran’s left lateral calf. (e.) All findings should be reported in detail and all opinions should be accompanied by a clear rationale. Regarding the bilateral foot disorders: (a.) Identify any current diagnoses regarding the bilateral feet. The Veteran’s reports of relevant symptomology should be discussed. (b.) Identify whether any condition is a congenital or developmental disease or defect. (c.) If any foot disability is a congenital or developmental defect, whether the condition was subject to superimposed disease or injury in service, to include the July 1983 treatment for left foot pain and February 1985 assessment of a left foot cold injury. (d.) If any foot disability is a congenital or developmental disease, whether such disease clearly and unmistakably preexisted service, and if so, whether it was aggravated beyond natural progression during service. (e.) If any current foot disability is not a congenital or developmental defect or disease, whether the claimed condition at least as likely as not (50 percent probability or greater) the result of active service, specifically to include the July 1983 treatment for left foot pain and February 1985 assessment of a left foot cold injury. The clinician is reminded that a negative nexus opinion based solely on the lack of a noted condition at separation is not an adequate basis to determine entitlement to benefits. (f.) Whether it is at least as likely as not (50 percent probability or greater) that any currently-diagnosed left ankle disorder was caused or aggravated by his service-connected disabilities, to include his service-connected right knee disability. The Board emphasizes that causation and aggravation are two separate inquiries which should be answered by the clinician. If aggravation is found, the clinician should address the baseline manifestations of the disorder found prior to aggravation. The clinician is advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms. (g.) All findings should be reported in detail and all opinions should be accompanied by a clear rationale. 2. Readjudicate the claims. MICHAEL KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, Associate 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.