Citation Nr: 20052955 Decision Date: 08/10/20 Archive Date: 08/10/20 DOCKET NO. 18-46 327 DATE: August 10, 2020 ORDER Entitlement to an increased rating in excess of 10 percent for right knee arthritis is denied. Entitlement to an increased rating in excess of 10 percent disabling for right lower extremity radiculopathy is denied. Entitlement to an increased rating in excess of 10 percent disabling for left lower extremity radiculopathy is denied. Entitlement to service connection for a right upper extremity peripheral disability is denied. Entitlement to service connection for a left upper extremity peripheral disability is denied. REMANDED Entitlement to service connection for a heart disorder, to include supraventricular arrhythmia and chest palpitations, is remanded. FINDINGS OF FACT 1. The Veteran’s right knee arthritis is not productive of ankylosis; slight recurrent subluxation or lateral instability; dislocated or removed symptomatic semilunar cartilage; flexion functionally limited to 30 degrees or less; extension functionally limited to 10 degrees or more; an impairment of the tibia and fibula; or genu recurvatum. 2. The Veteran’s radiculopathy of the right lower extremity more nearly approximates mild incomplete paralysis of the sciatic nerve. 3. The Veteran’s radiculopathy of the left lower extremity more nearly approximates mild incomplete paralysis of the sciatic nerve. 4. The Veteran’s right upper extremity peripheral disability did not have its clinical onset in service and is not otherwise related to active duty. 5. The Veteran’s left upper extremity peripheral disability did not have its clinical onset in service and is not otherwise related to active duty. CONCLUSIONS OF LAW 1. The criteria for a schedular rating in excess of 10 percent for right knee arthritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5256-63. 2. The criteria for entitlement to an increased rating for radiculopathy, right lower extremity, currently evaluated as 10 percent disabling have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8520. 3. The criteria for entitlement to an increased rating for radiculopathy, left lower extremity, currently evaluated as 10 percent disabling have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8520. 4. The criteria for service connection for a right upper extremity peripheral disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a left upper extremity peripheral disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty for training from April 1991 to May 1991 and active duty service from October 2001 to September 2002. Increased Rating Disability ratings are determined by comparing a veteran’s present symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an increased rating in excess of 10 percent for right knee arthritis The Veteran’s right knee arthritis is evaluated as 10 percent disabling under DCs 5010-5260 for arthritis and limited leg flexion. 38 C.F.R. § 4.71a. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis, which will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DCs 5003 and 5010. Under DC 5260 where flexion is limited to 45 degrees, a 10 percent rating is assigned. When flexion is limited to 30 degrees, a 20 percent rating is assigned; and when flexion is limited to 15 degrees, a 30 percent rating is assigned. 38 C.F.R. § 4.71a. Separate ratings may be assigned for disability of the same joint under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg). See VAOPGCPREC 9-04. Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Under DC 5261, where extension is limited to 10 degrees, a 10 percent rating is assigned. When extension is limited to 15 degrees, a 20 percent rating is assigned; when limited to 20 degrees, a 30 percent disabling is assigned; when limited to 30 degrees, a 40 percent rating is assigned and when extension is limited to 45 degrees, a 50 percent rating is assigned. 38 C.F.R. § 4.71a. Normal range of motion in the knee is 0 degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71a, Plate II. VA received a claim by the Veteran for an increased rating for her right knee on June 5, 2017. VA had issued a rating decision regarding an increased rating for the right knee in October 2015. The Veteran did not appeal this decision and it became final. Thus, the period on appeal is determined by the June 2017 claim for an increased rating. In a May 2017 VA treatment record, the Veteran reported numbness in her feet, legs, and hands. She also reported having intermittent knee pain for the past few months. She explained that she tried pool therapy, but it increased her pain. The August 2017 VA examination was mainly directed towards the Veteran’s left knee disability, thus no diagnosis for the right knee was assigned at that moment. During the examination, the Veteran reported that she began having right knee pain in addition to the constant dull to sharp pain in her left knee. The Veteran reported that she did not have flareups of her knees or lower legs, but that she is unable to stand or walk for long periods of time due to her knee disabilities. Upon initial range of motion (ROM) measurements for the right knee flexion was limited to 55 degrees with no limitation of extension. The examiner noted that the ROM itself contributed to a functional loss since the Veteran has a limited ability to climb stairs. The Veteran reported moderate to severe pain at the anterior location and was due to unclaimed tendinopathy. There was evidence of pain with weight bearing but there was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions for her right knee and there was no additional loss of function or ROM after the repetitions. The Veteran was not examined immediately after repetitive use over time and the examiner explained that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner noted that pain significantly limited the Veteran’s functional ability with repeated use over a period of time. While the examiner was unable to describe the functional loss in terms of ROM, the examiner explained that the assessment was based on the Veteran’s subjective report of functionality after repetitive use over time. The Veteran was not examined during a flare up. The examiner noted that disturbance of locomotion and interference with standing were additional contributing factors of the disability. The Veteran had normal muscle strength in his right knee and did not have any muscle atrophy. The examiner also noted that the Veteran did not have ankylosis, any joint instability, a history of recurrent subluxation, a history of lateral instability, or a history of recurrent effusion. The Veteran did not report ever having a meniscus condition but did report regularly wearing a brace for his left knee. There was objective evidence of pain when the right knee was used in non-weight bearing, passive ROM measurements were the same as the active ROM, and the pain on passive ROM was the same with active ROM. In another VA examination from September 2017, the Veteran was diagnosed with right knee osteoarthritis. The Veteran reported that her current symptoms included constant sharp to throbbing pain in the right knee. It also locks up and gets stiff. The Veteran did not report experiencing flare ups regarding his knees but did explain that he suffers from functional impairment which is reflected by his inability to sit, stand, or walk for long periods of time. The initial ROM measurements include flexion limited to 40 degrees and no limitation of extension. The ROM itself contributes to a functional loss since she cannot climb things. She exhibited pain on the examination with rest when conducting flexion and extension movements. The examiner noted that there was objective evidence of moderate localized tenderness or pain on palpation of the right knee joint at the anterior, medial, and lateral area due to the osteoarthritis. There was no pain with weight bearing but there was evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or ROM after the repetitions. The Veteran was not being examined after repetitive use over time or during a flareup and the examiner opined that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time or with a flareup. The examiner explained that there was no conceptual or empirical basis for making such a determination without directly observing function under these conditions. The examiner noted that disturbance of locomotion, interference with sitting, and interference with standing were additional contributing factors of disability for the right knee. Flexion of the right knee exhibited active movement against some resistance. The Veteran did not have muscle atrophy, ankylosis, a history of recurrent subluxation, a history of lateral instability, or a history of recurrent effusion. The Veteran was unable to conduct joint stability testing since she was unable to flex her knee to appropriate testing level. The Veteran reported that she had shin splints in the past and that they did not affect the ROM of her right knee or ankle. The Veteran reported using a brace regularly for her right knee. The examiner noted that the Veteran’s knee disabilities impact her ability to perform occupational tasks since she has an inability to sit, stand, or ambulate for extended periods of time and she is a temporary administrative assistant. The examiner also noted that there was objective evidence of pain on passive ROM testing and when the joint was used in non-weight bearing. In a March 2019 VA treatment record, the Veteran did not report any weakness in her lower extremities. Based on the evidence of record, the Veteran’s right knee disability does not warrant a rating higher than 10 percent. Although she exhibits loss of flexion, even with complaints of pain, the results from the VA examinations do not show sufficient limitation of flexion (to 30 degrees) or extension (to 10 degrees) sufficient to warrant a separate 10 percent or an increased 20 percent evaluation under DCs 5261 or 5260, respectively. 38 C.F.R. § 4.71a. There is no evidence to show that any worsening after repetitive use, with weight bearing, or during flare ups would be severe enough to limit the right knee motion to 30 degrees of flexion or 10 degrees of extension to warrant a separate 10 percent or an increased 20 percent evaluation under DCs 5261 or 5260, respectively. 38 C.F.R. § 4.71a. Given that his complaints do not prevent him from achieving substantial measured range of motion for the right knee they do not support a finding of additional functional loss for higher ratings. The Veteran’s complaints have been taken into consideration, but there is no evidence that her right knee disability suffer significant or additional functional loss beyond that contemplated by the assigned 10 percent evaluation. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board has also considered whether the Veteran would be entitled to a higher or separate rating under any other diagnostic code, but other analogous ratings are either not applicable to the Veteran’s case or do not offer a higher disability rating based on the symptomatology exhibited. In other words, there is no evidence of ankylosis, recurrent subluxation, lateral instability, meniscus impairment, nonunion of the tibia/fibula, or genu recurvatum. See 38 C.F.R. § 4.71a, 5256, 5257, 5258, 5259, 5262, 5263. Accordingly, there is no basis for a higher rating. A preponderance of the evidence is against the claims, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). 2. Entitlement to an increased rating in excess of 10 percent disabling for right lower extremity radiculopathy 3. Entitlement to an increased rating in excess of 10 percent disabling for left lower extremity radiculopathy Disability ratings with respect to neurological conditions ordinarily are assigned in proportion to the impairment of motor, sensory, or mental function. 38 C.F.R. § 4.12. In evaluating peripheral nerve injuries, attention therefore is given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory. Id. Special consideration is given to complete or partial loss of use of one or more extremities and disturbances of gait. 38 C.F.R. § 4.124a. The Veteran is assigned 10 percent evaluations for the peripheral neuropathy of the left and right lower extremity under Diagnostic Code 8520. Diagnostic Code 8520 pertains to paralysis of the sciatic nerve and provides that a 10 percent rating is warranted for mild incomplete paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. Moderately severe incomplete paralysis merits a 40 percent rating. A rating of 60 percent requires severe incomplete paralysis with marked muscle atrophy. The maximum rating of 80 percent is reserved for complete paralysis shown by manifestations such as: the foot dangles and drops, no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. At the outset, the Board notes that the Veteran’s bilateral lower extremity has not been manifested by muscle atrophy or complete paralysis at any point during the appeal period. Therefore, entitlement to ratings of 60 and 80 percent for incomplete and complete paralysis, respectively, under Diagnostic Code 8520, are not warranted. The preface to 38 C.F.R. § 4.124a states that when the involvement is wholly sensory, the rating should be for the mild, or at the most, the moderate degree. In addition, the preface states that the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. The Board acknowledges that the terms “mild,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of terminology such as “moderate” or “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. After a review of the record, the Board finds that the weight of the evidence is against a finding the Veteran’s bilateral lower extremity radiculopathy warrants an increased rating in excess of the currently assigned 10 percent. In a May 2017 VA treatment record, the Veteran reported numbness in her feet, legs, and hands. She explained that she was having intermittent knee pain for a few months and that pool therapy did not help. In the August 2017 Back VA examination, the Veteran was diagnosed with right lower extremity radiculopathy with an August 2017 diagnosis date. When provided the sensory examination, the results reflected decreased sensation to light touch for the right lower leg, ankle, foot, and toes. There was no decreased sensation for the left lower extremity. Moreover, the examiner noted that the Veteran experienced mild numbness in his right lower extremity, but everything was normal for the left lower extremity. The examiner noted that the L4, L5, S1, S2, and S3 nerve roots were involved and affected the right side. The examiner also indicated that the Veteran experienced mild radiculopathy for the right side, and everything was normal for the left side. In the January 2018 Muscle Injuries VA examination, the examiner did not diagnose the Veteran with any muscle injury or muscle cramps. The examiner noted that there was no objective evidence of a muscle injury or muscle cramps on physical examination and that muscle cramps are a symptom and not a diagnosable condition. The Veteran reported that she developed bilateral leg cramps after separation from service and that she was unsure of whether they were a symptom of her low potassium levels. She further reported that the cramps have worsened over time and that she still experienced bilateral leg cramps. The Veteran also reported that she did not have any muscle injury to her foot, leg, or thigh. Muscle strength testing for her bilateral lower extremities all came out normal. The examiner opined that the Veteran did not have a diagnosis of muscle cramps and thus it was at least as likely as not incurred in or caused by service. The Veteran reported a long history of bilateral leg cramps that began after service, but there was no objective evidence of a muscle injury or cramping during the examination. The examiner further explained that muscle cramps are a symptom and not a diagnosable condition. The examiner claimed that the muscular exam was unremarkable. Additionally, because there is no objective evidence of a muscle injury documented in the record, there is insufficient evidence to establish a nexus to service. In the January 2018 Peripheral Nerves Conditions VA examination, the Veteran was diagnosed only with right and left lower extremity radiculopathy of the sciatic nerve associated with degenerative arthritis of the spine. The Veteran explained that she began to feel tingling in her legs, arms, fingers, and toes after separation from service. She did not know if these symptoms were due to her hypertension or low potassium levels. She denied taking any medication for her tingling, but her tingling symptoms have worsened since onset. The Veteran reported mild paresthesias and/or dysesthesias and mild numbness for both lower extremities. Muscle strength testing came out normal for the bilateral lower extremities. Sensation testing for light touch came out normal for the lower extremities, the Veteran did not have any trophic changes attributable to peripheral neuropathy, and her gait was normal. When tested for the severity for lower extremity nerves, the Veteran had mild incomplete paralysis of the sciatic nerve on both sides. The examiner opined that the Veteran does not have a diagnosis of tingling in her limbs that is at least as likely as not incurred in or caused by service. In a March 2019 VA treatment record, the Veteran reported no weakness, numbness, or tingling in her lower extremities. In summary, the relevant evidence of record shows that the Veteran’s bilateral lower extremity radiculopathy symptomatology has been no more than mild in severity during the appeal period. Thus, the Board finds that a rating in excess of 10 percent for left lower extremity radiculopathy, and 10 percent for right lower extremity radiculopathy is not warranted. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303 (a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303 (d). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for cardiovascular-renal disease and myocarditis if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 4. Entitlement to service connection for right upper extremity 5. Entitlement to service connection for left upper extremity The Veteran asserts that her bilateral upper extremity disability is related to her active service. She also asserts that the bilateral arm and hand tingling was affected by low potassium and muscle cramps. Service treatment records (STRs) are silent for treatment for or diagnosis of any upper extremity disability. Post-service medical records reflect subjective complains of bilateral upper extremity numbness; however, the Veteran has not been objectively diagnosed with a bilateral upper extremity radiculopathy. Moreover, there are no positive etiologic opinions in the record. In a May 2017 VA treatment record, the Veteran reported numbness in her feet, legs, and hands. In the January 2018 Muscle Injuries VA examination, the examiner did not diagnose the Veteran with any muscle injury or muscle cramps. Additionally, the Veteran reported that she did not have any muscle injury to her shoulder girdle, arm, forearm, hand, or neck. Muscle strength testing for her bilateral upper extremities all came out normal. The examiner opined that the Veteran did not have a diagnosis of muscle cramps and thus it was at least as likely as not incurred in or caused by service. The Veteran reported a long history of bilateral leg cramps that began after service, but there was no objective evidence of a muscle injury or cramping during the examination. The examiner further explained that muscle cramps are a symptom and not a diagnosable condition. The examiner claimed that the muscular exam was unremarkable. Additionally, because there is no objective evidence of a muscle injury documented in the record, there is insufficient evidence to establish a nexus to service. In the January 2018 Peripheral Neves Conditions VA examination, the Veteran was diagnosed only with right and left lower extremity radiculopathy of the sciatic nerve associated with degenerative arthritis of the spine. The examiner explained that there was no objective evidence of a peripheral nerve condition to the upper extremities pertaining to the claimed condition of tingling in limbs and that further diagnostic testing would be required to assess the Veteran’s reported symptom. The examiner explained that tingling is a symptom and not a diagnosable condition in and of itself. The examiner explained that she began to feel tingling in her legs, arms, fingers, and toes after separation from service. She does not know if these symptoms are due to her hypertension or low potassium levels. She denied taking any medication for her tingling, but her tingling symptoms have worsened since onset. The Veteran reported mild paresthesias and/or dysesthesias of the bilateral upper and lower extremity. While the Veteran experienced numbness in her bilateral lower extremities, she did not experience numbness in her bilateral upper extremities. The examiner explained that while the Veteran subjectively reported experiencing bilateral upper extremity tingling, her symptoms could not be reproduced on examination. Muscle strength testing came out normal for the bilateral upper extremities. Sensation testing for light touch came out normal for the upper extremities, the Veteran did not have any trophic changes attributable to peripheral neuropathy, and her gait was normal. When tested for the severity or upper extremity nerves and radicular groups, everything came out normal. When tested for the severity for lower extremity nerves, the Veteran had mild incomplete paralysis of the sciatic nerve on both sides. The examiner opined that the Veteran does not have a diagnosis of tingling in her limbs that is at least as likely as not incurred in or caused by service. The examiner explained that while the Veteran subjectively reported experiencing tingling to all four extremities, examination of the upper extremities was unremarkable and that further diagnostic testing would be required to determine the etiology of the Veteran’s symptoms. The examiner also explained that literature does not support a relationship between peripheral nerve conditions and low potassium, and thus, without objective evidence of an upper extremity peripheral nerve condition, no diagnosis or nexus can be made. Upon consideration of the above evidence, the Board finds that the preponderance of the evidence is against the claims of service connection for bilateral upper extremity disability. Post-service treatment reflects only subjective complaints of tingling in the upper extremities, but even after physical examination, there was no objective evidence of a bilateral upper extremity peripheral disability. Furthermore, the Board finds persuasive the opinion of the VA examiners regarding whether there is a link between the Veteran’s current disability and her time in service. There is no medical evidence in the record supporting a finding of an etiological relationship between the Veteran’s service and her claimed disabilities. The Board has considered the Veteran’s lay statements that her claimed bilateral upper extremity peripheral disability is related to military service, but finds that she is not competent to opine as to the etiology of her claimed disorders, as she has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As such, her lay statement concerning nexus between her claimed disabilities and active service does not constitute competent medical evidence and lacks probative value. Based on the foregoing, the Board finds that there is no evidence of an in-service event related to the Veteran’s claimed disabilities and no nexus between her claimed disabilities and military service. The preponderance of the evidence is against the claims for service connection for bilateral upper extremity peripheral disability. The benefit of the doubt doctrine is not applicable, and the claims must be denied. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND 1. Entitlement to service connection for chest palpitations is remanded. The Veteran contends that her heart disorder began in service, specifically that she began to experience heart flutters in 2000. Service treatment records (STRs) are silent for any symptom, treatment, or diagnosis of a heart disorder. The Veteran’s entrance and exit examinations reflect that she had no heart disorders. In a May 2003 Reserve Component Health Risk Assessment, when asked if the Veteran ever had irregular heartbeats that concerned her, it was noted that she “felt funny” on May 13, 2003. In an April 2011 EKG, the results showed a normal sinus rhythm. In May 2017, the Veteran discussed her potassium results and denied having any symptoms and claimed that she was doing fine. In the January 2018 VA examination, the Veteran was diagnosed with supraventricular arrhythmia with a diagnosis date of January 22, 2018. The examiner noted that palpitations are a symptom and not a diagnosable condition, thus there is no diagnosis warranted specifically for chest palpitations. The Veteran explained that she began to experience heart flutters in 2000. She explained that she sought medical attention and was given an EKG, but that was all the medical treatment she received while in service. She further reported that around 2016 she had bloodwork completed and was informed of her low potassium levels. She furthered that she was last seen for her palpitations in October and reported that she did not receive any treatment following this appointment. She denied having a diagnosis of a heart condition or that she took any medications for her heart. The examiner noted that the Veteran’s heart conditions do not qualify within the generally accepted medical definition of ischemic heart disease. When asked to provide the etiology of the Veteran’s heart condition, the examiner explained that the Veteran’s sinus arrhythmia was caused by her hypokalemia. The examiner further reported that the Veteran had constant sinus arrhythmia which was documented through an EKG. The EKG showed sinus bradycardia with marked sinus arrhythmia. During the physical examination, the Veteran had a regular rhythm and had normal heart sounds. The Veteran denied experiencing palpitations related to physical activity. The examiner opined that the Veteran’s heart condition did not impact her ability to work. The examiner opined that the Veteran does not have a diagnosis of palpitations that is at least as likely as not incurred in or caused by service. The examiner also opined that the Veteran has a diagnosis of sinus arrhythmia, but that it is less likely as not incurred in or caused by service. The examiner explained that the Veteran subjectively reported experiencing heart flutters, but that she denied having a diagnosed heart condition. The examiner noted that the Veteran was diagnosed with hypokalemia 14 years after service. The examiner further explained that the record indicates that the Veteran had an EKG performed in April 2011 and that the result was of normal sinus rhythm. The examiner noted that there was no objective evidence of palpitations or treatment for heart-related complaints, including hypokalemia, in the record. The examiner explained that literature indicates that hypokalemia can cause heart arrhythmia. Without objective evidence of a heart condition or hypokalemia in the STRs, the examiner found that there was insufficient evidence to establish a nexus to service. In a February 2018 VA treatment record, the Veteran denied any chest pain, shortness of breath, or palpitations. The examiner explained that the Veteran’s hypokalemia was resolved. In March 2019, the Veteran reported again that she was not experiencing any palpitations. The Board finds that the January 2018 VA examiner did not provide an adequate reasoning to the opinions provided. The examiner did not address that the Veteran mentioned that she “felt funny” when asked if she experienced any irregular heartbeats that made her concerned in 2003, which is within a year since her separation from active duty. As such, VA must provide an adequate VA examination and with a thorough rationale behind the given nexus opinion. (Continued on the next page)   The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any heart disability. The examiner must opine 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. The examiner must address the 2003 notation that the Veteran “felt funny” when asked whether she experienced any irregular heartbeats that made her concerned. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Imam, 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.