Citation Nr: 21001346 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 14-34 621A DATE: January 7, 2021 ORDER Service connection for arthritis of the cervical spine is granted. Service connection for arthritis of the lumbar spine, based on service aggravation, is granted. An initial rating higher than 10 percent for a right foot bunionectomy is denied. An initial rating higher than 10 percent for a left foot bunionectomy is denied. An initial 10 percent rating for bilateral hand eczema is granted, subject to controlling regulations governing the payment of monetary awards. REMANDED Service connection for a right shoulder disorder. Service connection for a left shoulder disorder. Service connection for right hand numbness. Service connection for left hand numbness. Service connection for a right knee disorder. Service connection for a left knee disorder. An initial rating higher than 10 percent for hypertension. FINDINGS OF FACT 1. The Veteran is presumed sound at service entrance in May 2004 with respect to the cervical spine; arthritis of the cervical spine had its onset during or within the initial year of separation. 2. The Veteran’s lumbar spine disability that preexisted service entrance in May 2004, was aggravated by such service. 3. The Veteran’s right and left foot bunionectomies are currently assigned the maximum disability rating. 4. The Veteran’s bilateral hand eczema, at most, affects at least 5 percent, but less than 20 percent, of the entire body or exposed areas, and requires topical therapy. CONCLUSIONS OF LAW 1. The criteria for service connection for arthritis of the cervical spine are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for arthritis of the lumbar spine, based on service aggravation, are met. 38 U.S.C. §§ 1110, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306. 3. The criteria for a rating higher than 10 percent for a right foot bunionectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5280. 4. The criteria for a rating higher than 10 percent a left foot bunionectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, DC 5280. 5. The criteria for a 10 rating, but no higher, for eczema of the bilateral hands, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.118, DC 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1978 to May 1981 and from May 2004 to May 2006. The case is on appeal from a March 2012 rating decision. In September 2015, the Veteran testified at a Board hearing. In May 2018, the case was remanded for additional development. By rating decision in April 2020, the ratings for right and left foot bunionectomies were each increased to 10 percent. In November 2020, the Veteran’s representative waived initial RO consideration of the additional evidence associated with the claims file since the most recent April 2020 supplemental statement of the case (SSOC). See 38 C.F.R. § 20.1305(c). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection A. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Thus, when no preexisting condition is noted upon entry into service, a veteran is presumed sound. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during that service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Analysis 1. Service connection for a cervical spine disorder. The Veteran seeks service connection for a cervical spine disability. He maintains that his current neck disorder had its onset during his second period of active duty. Initially, a report of magnetic resonance imaging (MRI) reflects a diagnosis of osteoarthritis of the cervical spine. See May 2020 private treatment records. As such, the element of current disability is met. In addition, if, as in this case, the entrance examination report is missing, the Veteran is presumed to have been sound at service entrance. Quirin v. Shinseki, 22 Vet. App. 390, n. 5 (2009). To rebut this presumption, there must be clear and unmistakable evidence that the Veteran had a cervical spine disability that pre-existed the period of service beginning in May 2004 and was not aggravated by any incident of this service. In that respect, and although Reserve records reflect neck symptoms prior to service entrance in May 2004, to include cervical strain in December 1988 and neck pain in July 1997, see May 2014 service treatment records (STRs), the evidence does not show a diagnosis arthritis of the cervical spine prior to service entrance. The Board notes that as the Veteran was ordered to active duty and served for two years, it may reasonably be assumed that at service entrance, any pre-existing neck injury or disorder was non-disqualifying/asymptomatic. Moreover, consistent with the Veteran’s assertion, a January 2007 letter from the service department specifically states that the Veteran’s neck disorder was sustained or aggravated in the line of duty during his mobilization in June 2004. See May 2012 Third Party Correspondence; May 2014 Correspondence; December 2013 SPRs. The Board emphasizes that clear and unmistakable evidence is an “onerous” evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be “undebatable.” Cotant v. Principi, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993)). A finding of “insufficient evidence” of aggravation does not meet VA’s burden, only affirmative evidence proving that there was no aggravation does. Horn v. Shinseki, 25 Vet. App. 231 (2012). As the evidence does not clearly and unmistakably show cervical spine arthritis at active duty service entrance during the second period in May 2004, the presumption of soundness has not been rebutted. Pursuant to the Board’s May 2018 remand, the Veteran was afforded a VA examination in October 2019. The report of examination reflects that the diagnosis of cervical spine arthritis noted in the Veteran’s STRs in November 2004 was confirmed by x-ray examination of the cervical spine shortly after separation, the impression of which was degenerative changes with spondylosis and marginal osteophytosis at multiple levels shortly after separation. As noted above, the service department specifically determined that the Veteran’s neck disorder was sustained or aggravated in the line of duty while on active duty. The Board notes that a service department finding that an injury occurred in the line of duty will be binding on the VA unless it is patently inconsistent with the requirements of laws administered by the VA. 38 C.F.R. § 3.1(m); see Kinnaman v. Principi, 4 Vet. App. 20, 28 (1993). Insofar as there is evidence against the claim, specifically, the October 2019 VA opinion that the Veteran’s cervical spine disability is less than likely related to service, the opinion was based, in part, on a finding of no diagnosis of a neck disorder in the Veteran’s STRs. However, as reflected above, arthritis of the cervical spine was noted during service in November 2004. Therefore, the Board finds the opinion is based, at least in part, on an inaccurate factual premise, and accordingly, is of diminished probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion based on an inaccurate factual premise has no probative value.); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (“If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely.”). In addition, the examiner did not address the Line of Duty determination. As such, the Board affords this opinion limited probative weight. The Board therefore concludes that, with the benefit of the doubt resolved in the Veteran’s favor, service connection for arthritis of the cervical spine is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Service connection for a lumbar spine disorder. The Veteran also seeks service connection for a back disorder. He maintains that his current back disorder is related to his second period of active duty. Initially, the February 2011 VA examination report reflects a diagnosis of lumbar spine strain with disc bulge. As such, the element of current disability is met. As noted in the decision above, the entrance examination report for the Veteran’s second period of active duty is missing, and thus, the Veteran is presumed to have been sound at service entrance in May 2004. Quirin, 22 Vet. App. at 390, n. 5. To rebut this presumption, there must be clear and unmistakable evidence that the Veteran had a back disability that pre-existed the period of service beginning in May 2004 and was not aggravated by any incident of this service. Although the entrance examination report for the Veteran’s second period of active duty is missing, Reserve records reflect a history of back symptoms prior to service entrance in May 2004, an August 2006 Reserve record notes that the Veteran sustained a back injury in October 2005 during training for combat missions, and the impression of MRI in October 2006 was L5-S1 disc bulge. See May 2014 STRs. Further, a June 2006 service department MEMORANDUM states that the Veteran was mobilized on June 1, 2004, and that the line of duty determination, initiated on May 8, 2006, was that degenerative lumbar spondylosis-lumbar disc protrusion was aggravation of a pre-existing condition. See December 2013 SPRs; see also May 2012 Third Party Correspondence. Further, a July 2007 Reserve Report of Investigation Line of Duty and Misconduct Status indicates aggravation as a result of wearing a weighted flakvest for long periods of time. See April 2013 SPRs; see also 38 C.F.R. § 3.1(m); Kinnaman, 4 Vet. App. at 28. In this case, after careful review of the evidence, the Board finds that service connection for a lumbar spine disability is warranted, based on service aggravation. The medical evidence in favor of and against the claim is considered probative with consideration of the relevant facts and supported by adequate rationale. Therefore, after reviewing the conflicting medical opinions and after resolving reasonable doubt in favor of the Veteran, the Board finds the Veteran’s pre-existing back condition was aggravated by service. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In sum, the Board finds that there was an in-service increase in severity of his pre-existing back condition. Accordingly, because there was an increase in severity, a rebuttable presumption of aggravation of the Veteran’s pre-existing back condition has been established. See 38 C.F.R. § 3.306(b). The Board notes that although the October 2019 VA examiner opined that the Veteran did not have a current back disability, in addition to the February 2011 VA examination report, an August 2010 Physical Evaluation Board (PEB) report reflects degenerative arthritis of the lumbar spine. See December 2013 SPRs. The Board notes that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain v. Nicholson, 21 Vet. App. 319 (2007). Moreover, the opinion was based, in part, on a finding that the Veteran’s in-service back pain was transient and self-limiting, and resolved without chronic residuals, noting no diagnosis of a back disorder in the Veteran’s STRs. However, as reflected above, the record reflects the Veteran sustained a back injury on active duty in October 2005. Further, the examiner did not address the Line of Duty Determination. Therefore, the Board finds the VA opinion is based, at least in part, on an inaccurate factual premise, and accordingly, is of diminished probative value. See Reonal, 5 Vet. App. at 461 (A medical opinion based on an inaccurate factual premise has no probative value.); see also Monzingo, 26 Vet. App. at 107 (“If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely.”). Finally, the current back disability is shown to be the same disease or process from service. There is no indication that the Veteran’s current lumbar spine disability is a different condition from that which was in shown in service. Therefore, service connection for the Veteran’s arthritis of the lumbar spine is warranted based on service aggravation. Increased Rating A. Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). The regulations pertaining to rating skin disabilities were revised, effective August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria from that date, and whatever criteria is more favorable to the Veteran will be applied from that date. As such, both the old and new criteria are for consideration. Under the rating criteria in effect prior to August 13, 2018, DC 7806 governed eczema ratings. A 10 percent rating was assigned for at least 5 percent, but less than 20 percent, of the entire body or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating was assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating was assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Under the new criteria, a note preceding 38 C.F.R. § 4.118 provides that, for the purposes of this section, “systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin.” DC 7806 continues to apply to dermatitis or eczema but is rated under the General Rating Formula for the Skin (Formula). Under the Formula, a 10 percent rating is warranted where at least one of the following is present: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted where at least one of the following is present: Characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Under DC 5280, pertaining to hallux valgus (bunion), the maximum rating is 10 percent. 38 C.F.R. § 4.71a, DC 5280. B. Analysis 3. A rating higher than 10 percent for a right foot bunionectomy. 4. A rating higher than 10 percent for a left foot bunionectomy. Pursuant to the Board’s May 2018 remand, the Veteran was afforded a VA foot examination in October 2019. Based on the examination report reflecting resection of the metatarsal heads, the RO assigned 10 percent ratings for the right and left foot bunionectomies under DC 5280 throughout the rating period on appeal. Thus, the Veteran is currently in receipt of the maximum schedular rating for right and left foot bunionectomies. Thus, no higher rating is available for his disabilities under DC 5280. The Board has conducted a thorough review of the evidence and finds that a higher rating is not warranted under another DC. There is no evidence of weak foot, claw foot, hammer toes, metatarsalgia, malunion or nonunion of the metatarsal bones, rated under the remaining potentially applicable DCs. In addition, the maximum rating for hallux rigidus under DC 5281 is 10 percent. The Board notes that DC 5284 does not apply to the eight foot conditions specifically listed in the rating schedule under DCs 5276-5283. DC 5284 refers to “other” foot injuries and applies to foot disabilities for which there is not already a specific DC. It has been held that when a when a condition is specifically listed in the Schedule, it may not be rated by analogy under DC 5284. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). As the Veteran is service connected for his hallux valgus, DC 5284 is not for application. Further, DCs 5170, 5171, 5172, and 5173 address amputation of toes. Under DC 5171, amputation of the great toe with removal of the metatarsal head warrants a 30 percent rating, and without metatarsal involvement merits a 10 percent rating. In this case, however, the great toes have not been amputated. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran’s service-connected foot disability is not warranted based on functional loss due to pain or weakness, as the Veteran’s symptoms are supported by pathology consistent with the 10 percent rating assigned under DC 5280. The October 2019 VA foot examiner reported mild to moderate symptoms, noting the Veteran denied having any functional loss or functional impairment due to the service-connected right and left bunionectomies. In sum, the Board does not find ratings higher than 10 percent are supported for right and left foot bunionectomies. The preponderance of the evidence is against the claims; the benefit of the doubt doctrine is not applicable; and ratings higher than 10 percent for right and left foot bunionectomies are therefore not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board is remanding other claims for additional development, remand is not necessary with respect to these claims, as there is no reasonable possibility that further assistance would substantiate the claims. See 38 C.F.R. § 3.159(d). 5. A compensable rating for bilateral hand eczema. The Veteran seeks a compensable rating for bilateral hand eczema. He maintains that his symptoms including during flare ups warrant a compensable rating. The Veteran’s eczema is rated under DC 7806, which pertains to dermatitis or eczema. After review of the record, the Board finds that a 10 percent rating, but no higher, is warranted. As noted above, both the old and revised criteria are for consideration in this case based on the date of claim. With regard to the meaning of “systemic therapy” prior to the new definition of the term in the revised criteria, the Court in Johnson v. McDonald, 27 Vet. App. 497, 505 (2016) held that use of a topical steroid constituted “systemic therapy” within the meaning of DC 7806. In Johnson v. Shulkin, 862 F.3d 1351, 1356 (Fed. Cir. 2017), the Federal Circuit reversed this decision and determined that “constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs” under DC 7806 is generally not inclusive of topical corticosteroids. The Federal Circuit found that “systemic therapy” means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means “treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.” Id. at 1355. Thus, according to the Federal Circuit, all applications of topical corticosteroids do not constitute systemic therapy. The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. 30 Vet. App. 286, 289-93 (2018). Pursuant to the Board’s May 2018, the Veteran was afforded a VA examination in October 2019. The report of examination reflects the Veteran’s history of recurring eczema approximately every three months corresponding with changes in weather. Topical use of a corticosteroid medication (fluocinonide) for 6 weeks or more but not constant, and the Veteran stated the eczema resolved after using the topical for approximately two to three weeks. Although the examiner reported that the Veteran’s eczema was not active, pictures provided were noted to reflect peeling layers of skin on the Veteran’s hands consistent with private treatment records in July 2020 noting peeling skin of the hands and/or hypopigmented scaling patches of the hands. Although the Veteran indicated eczema affected his feet as a result of training in wet boots for many hours during his second period of active duty, see September 2015 Board hearing testimony, there is no evidence that eczema affects his feet. The Veteran is competent to report his symptoms, to include skin symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). The Board considered the lay statements and the clinical findings of record. The Board attributes greater probative value to the clinical findings which do not reflect bilateral hand eczema affects more than 5 percent of exposed areas affected. The medical evidence shows that the Veteran has required topical treatment for his bilateral hand eczema. The Veteran has not required systemic therapy throughout the rating period on appeal. However, resolving reasonable doubt in the Veteran’s favor, the Board finds that throughout the period on appeal, his eczema more closely approximates the criteria for 10 percent rating under the old criteria. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Therefore, a 10 percent rating is warranted throughout the period on appeal. As reasonable doubt was already applied in finding that the evidence supports a 10 percent rating for bilateral hand eczema, an even higher rating is clearly not warranted. Although the Board is remanding other claims for additional development, remand is not necessary with respect to this claim, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d).   REASONS FOR REMAND 1. Service connection for a right shoulder disorder. 2. Service connection for a left shoulder disorder. 3. Service connection for left hand numbness. 4. Service connection for left hand numbness. Pursuant to the Board’s May 2018 remand, the Veteran was afforded VA shoulder and hand examinations in October 2019. Although the shoulder and hand conditions were not related to service, the examiner may not have completely considered the Veteran’s lay statements as to onset of symptoms and functional impairment during service. See October 2010 VA 21-526c Pre-Discharge Compensation Claim. In addition, the opinions were based, at least in part, on the absence of documentation of the conditions the Veteran’s STRs. A medical opinion based solely on the absence of documentation in the service treatment records or that fails to take into account lay statements is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (VA examiner’s opinion inadequate that relied on the absence of contemporaneous medical evidence); see also Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran’s report of in-service injury but relied on the service medical records to provide a negative opinion). As such, the examinations are not completely adequate. Thus, a new VA examination is warranted with respect to the right and left shoulder conditions and hand numbness with consideration of whether the conditions are secondary to the newly service-connected arthritis of the cervical spine.   5. Service connection for a right knee disorder. 6. Service connection for a left knee disorder. Pursuant to the Board’s May 2018 remand, the Veteran was afforded a VA knee examination in October 2019. Although the right and left knee disorders were not related to service or found to be aggravated by service, the opinions were based, at least in part, on the absence of right knee symptoms in the Veteran’s STRs, as well as resolved, transient self-limiting left knee pain. However, the Veteran’s STRs reflect knee symptoms in November 2004, the impression of (MRI) in October 2005 was quadriceps tendon with postsurgical changes versus intrasubstance tear, and a May 2006 record notes knee pain. See May 2014 STRs; May 2012 SPRs. In addition, as noted in the prior remand, the Veteran described that the wear and tear of active duty and an accident to the left knee while playing basketball caused the disabilities. As above, a medical opinion based solely on the absence of documentation in the service treatment records or that fails to take into account lay statements is inadequate. As such, the opinion and accompanying rationale are not completely adequate. Thus, a new VA examination is warranted. 7. A rating higher than 10 percent for hypertension. The October 2019 VA hypertension examination report states that hypertension impacted the Veteran’s ability to work. However, the examiner did not provide any detail as to that impact. As such, the opinion is not completely adequate. Thus, an addendum opinion is warranted. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination (or telehealth interview, records request, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of knee right and left shoulder, hand, and knee disorders. The claims file and a copy of this remand, as well as the May 2018 remand, must be made available to and reviewed by the clinician. Any indicated studies should be performed, and all findings should be reported in detail. (a) The examiner should first identify the Veteran’s current shoulder, hand, and knee conditions. The examiner should provide an opinion as to whether any shoulder, hand, or knee condition clearly and unmistakably (undebatable from a medical perspective) preexisted either period of the Veteran’s active duty service. If the examiner finds it did clearly and unmistakably preexist service, the examiner should provide an opinion as to whether it was clearly and unmistakably not aggravated by service. Aggravation is an increase in severity beyond the natural progress of the disease or temporary flare-up. If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner should then opine whether it is at least as likely as not (a 50 percent or greater probability) that a right or left shoulder, hand, or knee condition had its onset during service, within one year of service, or is otherwise related to, including physical training during monthly drills. Consideration should be given to, and the examiner is requested to comment on: (1) service records MRI in October 2005, and a May 2006 record noting knee pain, as well as Reserve records including a June 2006 Statement of Medical Examination and Duty Status; a July 2007 Report of Investigation Line of Duty and Misconduct Status; and an August 2010 PEB; (2) the Veteran’s lay statements; and (3) post service VA and private treatment records, as well as VA examination reports. A complete rationale should be provided for any opinions reached. If the examiner cannot provide some or all of such opinions, the examiner must make clear that he or she has considered all relevant, procurable data, but that any member of the medical community at large could not provide such an opinion without resorting to speculation. 2. Obtain an addendum opinion from an appropriate clinician regarding the impact hypertension has on the Veteran’s ability to work. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Taylor 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.