Citation Nr: 21001858 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 10-32 901 DATE: January 12, 2021 ISSUES 1. Entitlement to service connection for a lung disability, to include post-operative pulmonary emphysema and alpha-1 antitrypsin deficiency, and variously claimed as residuals of a lung condition with right lung surgery, bilateral lung condition with air pockets. 2. Entitlement to service connection for a disability manifested by facial sweating, variously claimed as secondary to a lung disability. 3. Entitlement to service connection for a right knee disability, variously claimed as secondary to a service-connected lumbar spine disability. 4. Entitlement to service connection for a left knee disability, variously claimed as secondary to a service-connected lumbar spine disability. ORDER Entitlement to service connection for a right knee disability, variously claimed as secondary to a service-connected lumbar spine disability, is denied. Entitlement to service connection for a left knee disability, variously claimed as secondary to a service-connected lumbar spine disability, is denied. REMANDED Entitlement to service connection for a lung disability, to include post-operative pulmonary emphysema and alpha-1 antitrypsin deficiency, and variously claimed as residuals of a lung condition with right lung surgery, bilateral lung condition with air pockets, is remanded. Entitlement to service connection for a disability manifested by facial sweating, variously claimed as secondary to a lung disability, is remanded. FINDINGS OF FACT 1. A right knee disability was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 2. A left knee disability was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. CONCLUSIONS OF LAW 1. A right knee disability was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 2. A left knee disability was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 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 October 1979 to December 1986, with subsequent service in the Virginia Army National Guard. This matter is before the Board of Veterans Appeals (Board) on appeal from March 2009 and May 2009 Rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. These claims were previously remanded by the Board in September 2016, November 2017, and December 2019. Additional development was completed, and the claims have now been returned to the Board for further adjudication. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97 (2008). As discussed in the Remand section below, some additional development is still needed for compliance with all of the December 2019 Remand directives. The Board observes that during the pendency of the appeals, a September 2020 Rating decision granted service connection for focal papillary carcinoma, claimed as thyroid cancer. This represents a full grant of that benefit sought. AB v. Brown, 6 Vet. App. 35, 38 (1993). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran’s July 2010 VA Form 9 contains lay statements and recitations of VA’s duties under the governing statutory law. We have considered these below. The Veteran was sent an October 2020 Supplemental Statement of the Case (SSOC) informing her of the critical evidentiary requirements necessary to substantiate her claims. The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection To establish service connection a Veteran must generally show: “(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.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). 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.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). We note that organic disease of the nervous system is a chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Under 38 C.F.R. § 3.303 (b), service connection may be established by demonstrating continuity of symptomatology. Continuity may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. The provisions of 38 C.F.R. § 3.303 (b) only apply to diseases recognized by VA as “chronic.” See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a). Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for a right knee disability, variously claimed as secondary to a service-connected lumbar spine disability 2. Entitlement to service connection for a left knee disability, variously claimed as secondary to a service-connected lumbar spine disability By way of background, the Service Treatment Records (STRs) include a June 1979 Report of Medical Examination from enlistment. It disclosed a clinically normal evaluation of the lower extremities, spine, other musculoskeletal system, and neurologic system. The October 1985 Report of Medical Examination as part of a retention examination disclosed a clinically normal evaluation of the lower extremities, spine, other musculoskeletal system, and neurologic system. A June 1986 STR shows a complaint of bilateral knee pain, with limited mobility. The problems began about one week prior. There were some signs of tendonitis. The Veteran was advised against running. The November 1986 Report of Medical Examination from separation disclosed a clinically normal evaluation of the lower extremities, spine, other musculoskeletal system, and neurologic system. In the contemporaneous Report of Medical History, the Veteran denied arthritis, rheumatism, or bursitis, trick or locked knee, and neuritis. Later, although the Veteran was noted to have pes planus in a September 1990 examination related to her post-active duty National Guard service, the examiner noted that she had “no debility.” She could wear combat boots without symptoms. Years later, ongoing April 2004 private treatment records from Dr. Z. at Adult and Pediatric Neurosurgery, P.C. indicate that the Veteran reported low back pain radiating down her left leg which had caused her to limp again. A July 2006 private treatment record indicates that the Veteran had degenerative changes of the lumbar spine and that she “may have radicular symptoms consistent with nerve root compression or a leaking disc.” Ongoing private treatment records show that in November 2006, the Veteran was diagnosed with chondromalacia of the patella on the left side. October 2007 private treatment records from an October 10, 2007 steroid injection for the lumbar spine indicate that the Veteran has a history of chronic back pain and leg pain in the setting of degenerative disc disease of the lumbar spine with an annular tear. These were later received by VA along with the February 8, 2010 Notice of Disagreement (NOD). Next, the Veteran was afforded a January 2009 VA knees examination. The Veteran reported that she began experiencing pain in the retropatellar areas of both knees in 2005. She attributed this to the “wear and tear of physical training” in the Army. The Veteran reported pain. Still, the VA examiner ultimately found, “For the claimed condition of ‘bilateral knee condition,’ there is no diagnosis as there is no pathology on today’s examination.” Contemporaneous imaging was negative for both knees. The Veteran perfected her appeals in July 2010. The Veteran asserted, “I believe that my left and right knee conditions began while I was on active duty, because of the continuous running I did on concrete surfaces in the Army, which spanned a period of many years.” She also emphasized that her Military Occupational Specialty (MOS) required climbing telephone poles. She wrote that she would often be on top of them for hours, later jumping onto Army trucks. She began experiencing shin splints in service and was prescribed motrin. The Veteran cited various statutes governing VA’s duties and principles of service connection. Later, a January 12, 2011 VA Pulmonary Consult Note shows that a review of systems revealed joint pain, including in the back and knees. It shows that the Veteran reported that she was a police officer who did desk work. Next, a January 29, 2015 VA treatment record shows in part, “Pt able to ambulate with cane in left hand to support right knee pain w/o undue difficulty or fatigue.” More than one year later, the Veteran was afforded a November 2016 VA knee examination with medical opinion. The VA examiner reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. The VA examiner diagnosed bilateral knee tendonitis from the date of the VA examination. The VA examiner documented a lay history from the Veteran. The Veteran reported that she endured running on concrete while serving on active duty. She ran for sport after separation until her back gave out in the mid-1990s, but was able to still pass the physical requirements for the reserves and police officer occupation until at least 2006. She is now a retired police officer. The VA examiner identified that the Veteran was seen for bilateral knee tendonitis with swelling after overuse in 1986 while on active duty. The Veteran explained that she was given an ASA slip for no PT for 5 days. Since that time, she was told that her cartilage was thinning. Her last treatment for knee pain was a steroid injection from around 2006. She uses heat and ice for symptoms. The VA examiner recognized that imaging had not shown degenerative or traumatic arthritis. There was no degenerative joint disease (DJD). The VA examiner wrote, “Current sx: intermittent knee pains without swelling but stiffness reported. Known pes planus PTE.” The VA examiner recorded various test results. Next, the November 2016 VA examiner went on to render a negative nexus opinion for direct service connection. The VA examiner reasoned: Quadriceps Tendinitis is an overuse phenomena demonstrated by “Pain around the top of the kneecap during and after exercise. There may be pain when simply contracting the quadriceps muscles or pressing in along the top of the knee where the muscle attaches to the patella. The patient is likely to feel stiffness the day after training and have pain when standing from a crouched position.” The veteran was seen on a single occasion for obvious inflammation of the entire knee with diffuse swelling but this was not confined to the area of quadriceps cenesthopathy noted on today’s XR. The veteran has long standing and uncorrected pes planus with accompanying gait abnormality which would contribute to the enesthopathy shown in imaging. She was able to run for fitness and meet the physical demands of the reserves as well as police officer for many years post the single mention of bil knee problems during active duty. The enesthopathy that is enough to be seen on XR is cumulative across time. There is a difference between enesthopathy and tendinopathy. The enesthopathy is associated with the swelling of the joints at the point of attachment of ligaments or muscles to the bones. Tendinitis is a swelling of tendon only and typically is an acute rather than chronic finding associated with overuse. The VA examiner cited other factors, including weight. The VA examiner cited medical literature to support the findings. The VA examiner concluded, “Based on the above facts, although within the realm of medical possibility, the examiner believes it less likely than not that the current knee pain is related to the 1986 episode of bil tendinitis.” Turning to secondary service connection, the November 2016 VA examiner also rendered a negative nexus opinion. This implicitly encompassed all theories of secondary service connection, including proximate cause and aggravation. The VA examiner distinguished: This veteran has an MRI that shows multilevel DJD of the lumbar spine along with multiple annular tears. This indicates trauma severe enough to split the annulus that encloses the lumbar disc but age of the damage is indeterminate. The XR of bil knees show enestopathic changes rather than degenerative changes. Enesthopathy indicates a swelling and inflammation at the site of the tendon insertion while tendinitis is a swelling and inflammation of the tendon itself. It is highly unlikely that the tendonitis treated in 1986 is still present today and did not require care for more than 20 years. Tendinitis is an acute finding, generally associated with over use or trauma. The VA examiner observed, “In summary, [the] veteran has a genetic disease with resultant inflammation which appears to have caused the enesthopathy of both knees shown on imaging and while within the realm of medical possibility, it appears less likely than not that the current knee disability actually has a nexus to her medical service to include her back problem and limping.” Next, the Board performed a preliminary evidentiary review as part of the November 2017 Remand. The Board identified various theories of entitlement and medical questions to be resolved. The Board questioned the basis for the November 2016 VA examiner’s conclusions because, “it is not clear that the Veteran actually has alpha-1 antitrypsin deficiency.” The Board discussed, “Additionally, a February 2010 [lumbar spine] examination report noted that guarding of the thoracolumbar spine ‘“produces an abnormal gait.’” This could be indicative of secondary knee disability, and the Board found that additional development was needed. Next, the Veteran was afforded a February 2018 VA knees examination with medical opinion. The VA examiner reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. The VA examiner ultimately rendered a negative nexus opinion for the bilateral knees. The VA examiner provided similar reasoning to the November 2016 VA medical opinions. The VA examiner carefully explained: Shin splints are a self limiting problem once the activity ceases. “Shin splints normally require that you take a break from certain physical activities and give your legs time to rest. The discomfort will usually resolve completely in a few hours or at most in a few days with rest and limited activity. The suggested amount of downtime is typically about two weeks.” The various activities cited by the veteran while on active duty could cause acute overuse syndromes such as tendinitis or shin splints but once the activity stops, the body will repair itself. In the case of this veteran, she was seen for her knee problems about 20 years post active duty in December of 2006 at Jordan Young Institute. Chondromalacia was diagnosed, not tendinitis or shin splints. The VA examiner went on to describe other factors, including a potential cause of chondromalacia. The VA examiner echoed the findings of the November 2016 VA examiner. The VA examiner concluded, “So while the veteran believes that sitting on telephone poles for long periods/running on concrete/carrying heavy weight on active duty caused her chondromalacia, the above medical literature does not support that belief.” Turning to secondary service connection, the February 2018 VA examiner similarly rendered negative nexus opinions. The separate opinions provide supporting detail regarding all theories of proximate cause and aggravation. For proximate cause, the VA examiner concluded, “Based on the research, limping gait appears more with other structure abnormalities than the lumbar spine.” The VA examiner cited medical literature and anatomical principles of ambulation. For aggravation, the VA examiner remarked in part: There is some inconsistency in history of the back problem noted. There is a progress note dated 1/30/86 where the veteran complained of “back problems before coming to service x 8 yr.” This would make the onset of back pain prior to entry into the military. In 1986, veteran underwent PT for her back where hypomobility of the spine was thought to be the source of the pain. The straight leg lift was negative and XR negative, therefore herniated disc less likely. In summary, while within the realm of medical possibility, the examiner believes the preponderance of the evidence does not support her knee disability as aggravated or caused by her back disability and that records from the aprox 1999 MVA with major trauma might be helpful in determining the exact source of her current back disability/DJD. Later, in December 2019, the Board dissected the VA examinations of record and remanded the claims for additional development. The Board held, “After thorough review of the most recent VA opinion, the Board finds that the February 2018 opinion to be incomplete, and another remand is required.” See December 2019 Board Remand, p. 3. First, the Board identified that the VA examiner failed to discuss private treatment records from after separation. The Board went on to discuss, “Additionally, the Board notes that with regards to the Veteran’s claim of secondary aggravation, the VA examiner failed to provide an adequate rationale with regards to any relation between the Veteran’s back disability and h[er] knees.” The claims were then remanded for a new VA examination with medical opinion. Recently, in January 2020, the Veteran was afforded a fresh series of VA examinations with medical opinions. The VA examiner reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. Upon clinical examination, the VA examiner identified patellofemoral pain syndrome in both knees. The details of the onset show, “No trauma or injury. States they just hurt. States that when she has back pain she tends to favor different sides and that has caused her pain. She does relay that running on concrete while in service and had some pain. Has been evaluated and has had steroid injections in both. Knee pain is indicated in the kneecaps. Walking and standing for prolonged periods causes pain. Takes Nucynta.” The VA examiner identified that no arthritis had been documented in either knee. Next, the January 2020 VA examiner rendered a series of negative nexus opinions encompassing all theories of direct, presumptive, and secondary service connection. The VA examiner reviewed the claims file, including private treatment records, and considered lay statements. The VA examiner rendered a negative nexus opinion for direct and presumptive service connection. The VA examiner also rendered a negative nexus opinion for all theories of secondary service connection, including aggravation. The VA examiner remarked: Veteran in her lay statements complains of limp and altered gait due to her back being causal of in this case bilateral knee pain. Physiologically and biomechanically that is inconsistent with the gait mechanism. Back pain can cause intermittent changes in biomechanics due to pain, however these are typically not lasting of duration long enough effect damage to the lower extremity. Furthermore, the changes in gait (if of enough duration) would not result in bilateral pathology as that in and of itself conflicts with the compensatory mechanism that the limp and altered gait would be based. Therefore, given no pathophysiologic/biomechanical correlation no causality between her back and knee pain is reasonable. Additional ongoing VA and private treatment records show post-service treatment for bilateral knee pain. They are substantially the same. The Veteran contends that she is entitled to service connection for right and left knee disabilities, to include as secondary to the service-connected lumbar spine disability. The Veteran is competent to provide evidence of that which she experiences, including her symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report knee pain, including worsening aches, following events during and after service. The Veteran is also competent to relate what she has been told by a professional. She is competent to report when she was diagnosed with chondromalacia and patellofemoral pain syndrome. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s own lay opinions as to the diagnosis and cause of any bilateral knee disability are not probative evidence, although the Veteran’s observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran’s lay opinion beyond a description of her symptoms is of limited probative value. Here, the most probative evidence is the contemporaneous treatment records, including the STRs, and the medical opinions of the November 2016 and January 2020 VA examiners. First, the STRs do not show any knee disability, including any neurological manifestations, at separation. There is one notation from June 1986 which shows that it was only tendonitis impairing the knees. Later, the separation examination disclosed a clinically normal evaluation of the lower extremities, neurologic system, and spine, other musculoskeletal system. In the contemporaneous Report of Medical History, the Veteran denied arthritis, rheumatism, or bursitis, trick or locked knee, and neuritis. Years later, the Veteran presented to private treatment providers around 2004 primarily concerning her lumbar spine disability, but with complaints of radiating pain in her legs. A July 2006 private treatment record indicates that the Veteran has degenerative changes of the lumbar spine and that she “may have radicular symptoms consistent with nerve root compression or a leaking disc.” October 2007 private treatment records from an October 10, 2007 steroid injection for the lumbar spine indicate that the Veteran has a history of chronic back pain and leg pain in the setting of degenerative disc disease of the lumbar spine with an annular tear. Subsequent VA treatment records show complaints of back pain, and the use of a cane. The Board assigns substantial probative weight to the contemporaneous treatment records. In short, there is post-service pain, but no nexus. There is no diagnosed arthritis in the bilateral knees. Second, the Board also assigns substantial probative weight to the comprehensive medical opinions of the November 2016 and January 2020 VA examiners. The VA examiners reviewed the entire claims file, and provided detailed reasons and bases in support of negative nexus opinions. First, the November 2016 VA examiner rendered negative nexus opinions for all theories of direct and secondary service connection for the bilateral knees, which considered all neurological manifestations. There was no finding of arthritis. The negative nexus opinions are supported by the objective evidence in the claims file, as cited to by the VA examiner. The VA examiner highlighted that the Veteran’s own lay history placed the onset of the claimed disability to after service, but for one brief notation in the STRs. Based upon the VA examiner’s medical expertise, this type of injury is unrelated to the service-connected lumbar spine disability. The VA examiner reasoned: The veteran was seen on a single occasion for obvious inflammation of the entire knee with diffuse swelling but this was not confined to the area of quadriceps cenesthopathy noted on today’s XR. The veteran has long standing and uncorrected pes planus with accompanying gait abnormality which would contribute to the enesthopathy shown in imaging. She was able to run for fitness and meet the physical demands of the reserves as well as police officer for many years post the single mention of bil knee problems during active duty. The enesthopathy that is enough to be seen on XR is cumulative across time. There is a difference between enesthopathy and tendinopathy. The enesthopathy is associated with the swelling of the joints at the point of attachment of ligaments or muscles to the bones. Tendinitis is a swelling of tendon only and typically is an acute rather than chronic finding associated with overuse. The negative nexus opinions that followed are supported by sound reasons and bases. Therefore, we assign substantial probative weight to the negative nexus opinions of the November 2016 VA examiner. Recently, and following a thorough review by the Board, the Veteran was afforded a January 2020 VA examination. The general practitioner, holding a doctorate-level medical degree, reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. The VA examiner recognized that no arthritis had been documented in either knee. Next, the January 2020 VA examiner rendered a series of negative nexus opinions. The VA examiner reviewed the entire claims file and considered lay statements. The negative nexus opinions encompass all theories of direct, presumptive, and secondary service connection. The VA examiner explained: [The] Veteran in her lay statements complains of limp and altered gait due to her back being causal of in this case bilateral knee pain. Physiologically and biomechanically that is inconsistent with the gait mechanism. Back pain can cause intermittent changes in biomechanics due to pain, however these are typically not lasting of duration long enough effect damage to the lower extremity. Furthermore, the changes in gait (if of enough duration) would not result in bilateral pathology as that in and of itself conflicts with the compensatory mechanism that the limp and altered gait would be based. Therefore, given no pathophysiologic/biomechanical correlation no causality between her back and knee pain is reasonable. Consistently, the February 2018 VA examiner also rendered negative nexus opinions. The VA examiner concluded, “So while the veteran believes that sitting on telephone poles for long periods/running on concrete/carrying heavy weight on active duty caused her chondromalacia, the above medical literature does not support that belief.” None of the VA examinations suggest a positive nexus, and they variously cite medical principles suggesting otherwise. These November 2016 and January 2020 VA examinations are the most probative evidence of record, in addition to the contemporaneous treatment records. Here, regarding direct and presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. Right and left knee disabilities were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what she has been told by her physician and to report being told by her physician that she has various knee diagnoses, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as patellofemoral pain syndrome, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented reports of chronic conditions many decades after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and VA medical opinions does not demonstrate such continuity. The VA examiners described the Veteran’s medical history showing the remote onset of the claimed disease entities several decades after separation. There is no link between one brief mention in service and complaints of pain approximately two decades after separation. Consequently, we find that service connection on a direct and presumptive basis for right and left knee disabilities is not warranted. Next, it appears the Veteran’s theory of entitlement to service connection for right and left knee disabilities is also one of secondary service connection. More specifically, she contends that these right and left disabilities are secondary to her service-connected lumbar spine disability and functional impairment. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that right and left knee disabilities are not related to service, and are less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the November 2016 and January 2020 VA examiners supported the negative nexus opinions for secondary service connection with comprehensive reasons and bases citing to accepted medical knowledge and evidence in the claims file. For example, the November 2016 VA examiner reasoned: The XR of bil knees show enestopathic changes rather than degenerative changes. Enesthopathy indicates a swelling and inflammation at the site of the tendon insertion while tendinitis is a swelling and inflammation of the tendon itself. It is highly unlikely that the tendonitis treated in 1986 is still present today and did not require care for more than 20 years. Tendinitis is an acute finding, generally associated with over use or trauma. Importantly, the Veteran was afforded yet another VA examination in January 2020. The VA examiner considered the Veteran’s lay statements, the previous findings, and the entire claims file. The VA examiner rendered negative nexus opinions for all theories of secondary service connection. The VA examiner reasoned, “Back pain can cause intermittent changes in biomechanics due to pain, however these are typically not lasting of duration long enough effect damage to the lower extremity.” The VA examiner concluded, “Therefore, given no pathophysiologic/ biomechanical correlation no causality between her back and knee pain is reasonable.” The VA examiner based this upon her medical expertise and a consideration of this particular Veteran’s circumstances. Implicit in the indications of review of the entire claims file is a review of the private treatment records from after separation. Any previously identified shortcomings in the February 2018 VA medical opinion have been cured. The January 2020 VA examiner fully discussed any claimed aggravation. Moreover, all of the VA examiners considered and reconciled lay reports of running in service. Miller v. Wilkie, 32 Vet. App. 249 (2020). The medical opinions contain complete rationales. In short, we find these VA examinations with medical opinions to be the most probative evidence. On the other hand, there is also no competent and probative evidence establishing that any right or left knee disability is due to any service connected disease or injury. Private treatment records show lumbar spine pathology and treatment related to possible knee or leg pain, but do not establish a nexus. We have considered the Veteran’s lay statements to the extent that she is competent to relate current pain in the bilateral knees. Her lay reports are outweighed by the medical findings of the VA examiners based upon all of the evidence in the claims file. In this regard, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). The Federal Circuit found that the term “disability” as used in 38 U.S.C. § 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability.” The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). We note that Saunders was in the context of the musculoskeletal system, though it does not explicitly hold that it is limited to such circumstances. Regardless, there is no additional functional impairment due to pain alone as is addressed by Saunders related to service. It follows that the weight of the evidence is against any indication of a relationship to service for any neurological manifestations of a bilateral knee disability. Therefore, even after considering Saunders, service connection for a bilateral knee disability is not warranted. In sum, the Board has assigned the most probative weight to the contemporaneous medical records, including the STRs, and the findings of the November 2016 and January 2020 VA examiners. The VA examiners reviewed the STRs, VA treatment records, imaging results, private treatment records, and considered the Veteran’s lay history. The VA examiners rendered negative nexus opinions for all theories of entitlement. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. Any tendonitis in service was acute, transitory, and resolved by separation. The most probative evidence establishes the remote onset of any knee impairment. There is also no nexus to lumbar spine or other service-connected disability. 38 C.F.R. § 3.310. We considered any organic disease of the nervous system. However the repeated examinations and imaging have not documented arthritis in the knees. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, we considered Saunders for all theories of entitlement. We note other factors. There is no probative evidence to the contrary. There is no doubt to resolve, and the Veteran has been afforded an ongoing series of VA examinations considering every theory of entitlement. Therefore, service connection for right and left knee disabilities is not warranted. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Although the Board regrets any possible delay, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran’s claim so that she is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Stegall, supra. 1. Entitlement to service connection for a lung disability, to include post-operative pulmonary emphysema and alpha-1 antitrypsin deficiency, and variously claimed as residuals of a lung condition with right lung surgery, bilateral lung condition with air pockets, is remanded. The Board incorporates its discussion from the sections above by reference. We note that bronchiectasis is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board observes that a Veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012). “Clear and unmistakable evidence” means that which cannot be misunderstood or misinterpreted; it is that which is undebatable. Vanerson v. West, 12 Vet. App. 254 (1999). A preexisting injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Where a preservice disability underwent an increase in severity in service, there is a presumption of aggravation; clear and unmistakable evidence is required to rebut the presumption of aggravation. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306 (2018). The Court has held that temporary or intermittent flare-ups of a preexisting condition during service are not sufficient to be considered “aggravation in service” unless the underlying condition, as opposed to its symptoms, has worsened. See Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). By way of background, the Service Treatment Records (STRs) include a June 1979 Report of Medical Examination from enlistment. It disclosed a clinically normal evaluation of the head, face, neck, and scalp, mouth and throat, and lungs and chest. Importantly, the Veteran reported recurrent throat infections that were treated with penicillin. In the contemporaneous Report of Medical History, the Veteran denied shortness of breath. The examination is blank, or the scan is illegible, though it does not show that she endorsed chronic cough. There is a notation of a recurrent sore throat. A May 1985 STR shows that the Veteran reported shortness of breath, with pain worse by cough. She had pain in the center of her chest. There is a notation of possible bronchitis. The lungs were clear. Below is a notation of “A-Bronchitis – green sput—(illegible).” The October 1985 Report of Medical Examination for the purposes of retention disclosed a clinically normal evaluation of the nose, sinuses, mouth and throat, and lungs and chest. The Report of Medical Examination from separation from November 1986 disclosed a clinically normal evaluation of the head, face, neck, and scalp, mouth and throat, and lungs and chest; except for a notation of a nodular thyroid. There is also a notation of a bullae in her right upper lung. Next, the Veteran was afforded a series of August 2008 VA examinations related to this appeals stream. The VA examiner elicited a lay history from the Veteran. The examination shows in part: Concerning the bilateral lung condition with air pockets, the veteran states that in 1983 she had a bad cold. She was eventually seen by physician who told her that she had air pockets in her lungs. She was also told to stop smoking at that time, however she states she continued and stopped only four months ago. Currently, she states she has shortness of breath when she has a cold or with running or physical activity such as climbing stairs. Regarding the condition of lung condition (sic) with right lung surgery, the veteran states that her lungs became very bad in 2004. At that time, she had a partial resection of the right upper middle and lower lobes. This improved her breathing for some period of time. The VA examiner ultimately diagnosed status right post resection of the right upper, middle, and lower lobes for pulmonary emphysema with residual scar. The VA examiner also diagnosed bilateral pulmonary emphysema. The impairment is described as decreased pulmonary reserve. The Veteran perfected her appeals in July 2010. She provided an explanation of her theory of entitlement. The explanation includes the contention that she has continuously had a lung disability since serving on active duty. Years later, the Veteran was afforded a series of November 2016 VA medical opinions, previously characterized as December 2016 based upon their date of print. The VA examiner rendered a negative nexus opinion for the lungs. The VA examiner reasoned: At the time of her entrance physical for MEPS at age 18, veteran gave history of recurrent throat infections in presence of 4+ tonsillar hypertrophy, vision problems, an S1 split in her heart sounds and she began a pattern of cough with URI sx within 2 weeks of entering the USA. According to NIH, “The first lung-related symptoms of alpha-1 antitrypsin (AAT) deficiency may include shortness of breath, less ability to be physically active, and wheezing. These signs and symptoms most often begin between the ages of 20 and 40. Other signs and symptoms may include repeated lung infections, tiredness, a rapid heartbeat upon standing, vision problems, and weight loss.” So, in hind sight, there were some clues to her genetic illness around the time of her entrance into the military. Since it is genetic, there is clear and unmistakable evidence of the disease which runs in her family per hematology notes submitted by the veteran. The disease itself has a downward progression that was worsened by her smoking, a well documented and research driven fact that is found in most medical articles on A1 alpha tryptan deficiency. “Smoking is the leading risk factor for life-threatening lung disease if you have AAT deficiency.” per NIH. Physical activity, healthy diet and ongoing medical care are the other things that affect the course of the disease and these were present while on active duty, therefore the disease was not worsened by her military service. It is less likely than not that the disease had its onset during military service as the genetic aberrancy was present at birth and has no etiology that would tie it to her active duty or military service. Hematology records show the familial tendency and veteran’s co morbid coagulopathy is also noted in others within the family. The lung condition of emphysema was the cause for the lung biopsies and had been present since the bullae found in 1986. “Congenital bullae” was ruled out with positive testing for the protease inhibitor deficiency. In addressing this medical opinion in November 2017, the Board previously found in part, “Additionally, there are several private treatment records which document ‘bullous’ emphysema with a history of ‘congenital bullous emphysema’ and as presenting with ‘large air sacs.’ Accordingly, the rationale provided by the examiner is not sufficient for adjudicatory purposes.” Following the November 2017 Remand, the Veteran was afforded a new February 2018 VA examination with medical opinion. The VA examiner documented that a review of a laboratory finding from March 24, 2015 shows negative findings for A1AT. The VA examiner described the Veteran’s early history: The bullous disease found early in her military service was thought to be congenital in origin per radiology notes (if not A1AT deficiency)in 1986. Her bullae were noted in ER visit in 1985. Her 2010 pulmonary consult with Dr E at Hampton VAMC included consideration of outside records submitted by the veteran including path reports which showed scars, evidence of smoking, and the blebs/bullae. She was treated for acute exacerbation of COPD at that time. Tobacco abuse for 20 years was noted. A 2015 pulmonary consult by Dr. S noted smoking from age 16 to 53 with stopping that week in the presence of severe emphysema. Restart of smoking noted at admission to acute care later that year. Her PFTs were noted to show RAW (reactive airways). Pulmonary HTN (long standing vascular hypertension) was also dx and treated with Bipap during episode or respiratory failure in October of 2015. She was later in December found to have sleep apnea in presence of obesity and her other risk factors. The February 2018 VA examiner elaborated: The veteran’s bullous lung disease is a disease, not a defect, as the rate and extent of growth of the bullae are highly variable. (Clinical Advisor, Bullous Lung Disease, Melamed and Barjaktarevic). They can be isolated incidental findings or advance such as in this case. The symptoms demonstrated by the veteran after entry into service were due to a natural progression of the congenital bullae. Her frequent URI symptoms prior to military were likely the first sign of the condition. Her smoking contributed to the progression of bullous disease. The VA examiner concluded, “In summary, the COPD, congenital bullae, pulmonary HTN, sleep apnea are not causally or etiologically related to the veteran’s military service.” Next, in December 2019, the Board revisited and remanded the issue again. Prior to this Remand, the attorney and VLJ made several observations. We note these for transparency. The Remand raised the issue of the adequacy of the February 2018 VA examination. The Remand reads in part: The Board finds this analysis unpersuasive and inadequate. It is unclear who or what “Canada’s OSHA” refers to and no citation to this “statement” was provided. This makes it impossible for the Board to determine if the examiner’s rationale is consistent with the evidence she cited as support. Furthermore, despite asserting that asbestos exposure would cause scarring in the lower lungs, she went on to discuss how the body prevents dust from reaching the lower lungs, but did not reconcile this with her statement that the Veteran’s pathology reports showed scarring in the lungs. As such, the Board finds the VA opinion obtained in the last remand to be incomplete, and remand is required for the VA to fulfills its duty to the Veteran. See December 2019 Board Remand, p. 2. The Remand directives went on to repeat that the September 2005 lay statement regarding exposure to toxic substances must be discussed. Id. at p. 7. Most recently, the Veteran was afforded a January 2020 VA respiratory examination with medical opinion. In compliance with Board’s remand directives, this was performed by an examiner with a D. O. degree (doctorate level). The VA examiner reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. The VA examiner identified bullous emphysema with a date of diagnosis of 2020. There is an additional diagnosis from 2020 of Alpha 1 Antitrypsin disease. The VA examiner wrote “unknown” for the date of onset. Later in the examination, for the possibility of multiple respiratory disorders, the VA examiner wrote, “They are largely the same thing - as A1AD results in emphysema.” The VA examiner described the onset: History of bullae and lobectomy secondary too. She has had numerous lung sicknesses of PNA and bronchitis. She is a prior smoker 15-20 years history. Never treated for asthma or lung condition as child or adult until the surgery. States she came down with a cough for a long time and couldn’t shake it. Was evaluated and then found the bullae. O2 3LNC since being diagnosed with CHF - not directly due to the lungs but secondary to lung effusion from CHF. She is however on Spiriva for her lungs, as well as albuterol, Symbicort. All since her surgery. Next, the VA examiner then rendered a series of medical opinions. The VA examiner first opined: Veteran STR and RMH of 11/6/86 reflect report of emphysematous lung bullae. Veteran testing in 2016 was also significant for alpha1 antitrypsin deficiency. This deficiency is a genetic disorder that commonly results in lung diseases to include recurrent infections asthma, COPD as well as other organ damage. Emphysematous bullae are common pathology related to this due to deterioration and weakness of the lung tissue. Given that she has positive testing for A1A and this is a congenital disorder, no nexus with service is reasonable. The VA examiner provided additional opinions regarding any secondary relationship, including to surgery or facial sweating. The VA examiner ultimately determined: MEDICAL OPINION 7 OF 7) A) RESPIRATORY DISORDER - Veteran hx states that she developed unilateral facial sweating, predominantly left sided, after undergoing lung surgery for emphysematous bullae. She relays that follow up with surgeon was performed with no resolution and that a referral to neurologist was met with hypothesis that perhaps a nerve was injured during her lung surgery. Her symptoms, although not visualized on exam, nor seemingly throughout any evaluation, have some correlation with Horner syndrome, is a rare condition characterized by miosis (constriction of the pupil - which is not present or noted in any reports), ptosis (drooping of the upper eyelid - not present or reported), and anhidrosis (absence of sweating of the face). It is caused by damage to the sympathetic nerves of the face, which is not commensurate with the procedure she underwent. Previous DBQ have dx Hemi-facial hyperhidrosis - with causal etiology of cervical disc herniation myelopathy. However disc herniation and is correction have very little impact on the direct sympathetic chain and very low likelihood of causing this pathology. Therefore neither the lung surgery, nor in the previous examiner[’s] case the cervical surgery[,] have likely correlation to this reported condition. The rationale is the same for a second heading of “B) ALPHA-1 ANTITRYPSIN DEFICIENCY.” Unfortunately, the January 2020 VA examiner then provided a series of inconclusive responses. Regarding any superimposed disability, the VA examiner rendered an opinion that this was unknown. The VA examiner wrote, “Unknown. To answer, childhood records would be needed. Frequent wheezing, shortness of breath, bronchitis, PNA or any pulmonary irregularities would have to be matched with service complaints. RMH of veteran at discharge does reflect a singular bullae, but this in a vacuum is just representative of a lung weakness that can be manifested by common respiratory disease.” (emphasis added.) Regarding any increase in severity during service, the VA examiner opined, “Again this question is making many assumptions. Any person who has long history of smoking is likely to develop COPD or emphysema. The lung irritant itself will cause pathology. Superimposing that onto a congenitally weakened lung is going to exacerbate the pathology. The congenital disease alone can manifest into severe pulmonary condition any other comment on progression or correlation would be purely speculative.” In short, although thorough in parts, the VA examination does not fully address the detailed December 2019 Remand directives regarding any superimposed disability or disability not preexisting service. It also now represents another opinion in the record requiring clarification. Although there is a thorough rationale in some respects, the VA examiner does not fully discuss the September 2005 lay report. The Board observes that the basis for the December 2019 Remand of this issue was an incomplete medical opinion. In remanding this particular issue, the Board emphasized its duty to assist. The January 2020 VA examiner also identified that childhood medical records would be needed to answer whether any manifestations of the congenital disease preexisted service. The Board is mindful that a Veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. Here, a remand is necessary for additional development in light of the Board’s thorough December 2019 Remand directives. These directives included that a VA examination be obtained that addressed the threshold issue of the rebuttal of the presumption of soundness, superimposed disability, and aggravation. This VA examination is necessary to understand the relationship between lung pathology and service, including a consideration of whether clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by service. Pursuant to the November 2017 and December 2019 Remand directives, the September 2005 lay statement regarding exposure to toxic substances must be discussed. See “Military Personnel Record,” received by VA on February 16, 2006. The Board observes that compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. For an opinion to be adequate, it must include consideration of the Veteran’s statements, be based on accurate factual premises, and contain a rationale sufficient to support its conclusions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). Such determinations require medical expertise. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). For compliance with Stegall, we have incorporated the same directives from the December 2019 Board Remand below. On remand, the Veteran should be sent a VA development letter for childhood medical records related to any congenital lung disability. Therefore, a remand is warranted. 2. Entitlement to service connection for a disability manifested by facial sweating, variously claimed as secondary to a lung disability, is remanded. We note that arthritis is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310 (b). By way of background, the Service Treatment Records (STRs) include the June 1979 Report of Medical Examination from enlistment. It disclosed a clinically normal evaluation of the skin, lymphatics. Scars were noted on the upper left thigh, right forehead, lower left abdomen, and left arm. The October 1985 Report of Medical Examination disclosed a clinically normal evaluation of the head, face, neck, and scalp, and skin, lymphatics. The Report of Medical Examination from separation from November 1986 disclosed a clinically normal evaluation of the head, face, neck, and scalp, and skin, lymphatics; except for a nodular thyroid. Years later, the Veteran perfected her appeals in July 2010. She averred that she has facial sweating on the right side of her face whenever she eats food. She explained, “When my lung surgery healed, it caused nerve damage which causes this facial sweating condition.” The issue of entitlement to service connection for a disability manifested by facial sweating is inextricably intertwined with the service connection for a lung disability claim being remanded for additional development. Therefore, a final decision on this issue cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Hence, a remand of this issue is also warranted. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran’s VA treatment records, and associate them with the Veteran’s claims folder. 2. Send the Veteran a VA Form 21-4142, Authorization and Consent to Release Information to VA, and with her consent, obtain any additional childhood medical treatment records regarding a lung disability, as identified by the Veteran or her representative. 3. Obtain a medical opinion from a different VA examiner. The examiner should be an appropriate medical doctor who is able to assess the etiology of the Veteran’s current respiratory conditions and any alpha-1 antitrypsin deficiency. The examiner must review the claims file and should note that review in the report. (a.) The VA examiner should diagnose all current respiratory disorders and should also address any service, private, or VA treatment records that indicate that the Veteran’s current respiratory disorders are “congenital” or “bullous” in nature. (b.) Then the VA examiner should provide the following etiology opinions for each diagnosed respiratory condition(s) and/or alpha-1 antitrypsin deficiency: a. The examiner should state whether the disorder is a congenital defector a congenital disease. (To assist the examiner, for VA adjudication purposes, “disease” generally refers to a condition considered capable of improving or deteriorating, whereas “defect” generally refers to a condition not considered capable of improving or deteriorating. (As an example, VA considers sickle cell anemia as congenital “disease” for VA purposes, whereas refractive error is considered a congenital “defect.”)) i. For any congenital defect, the examiner should state whether there is any evidence of superimposed disease or injury during service. ii. For any congenital disease, the examiner should state whether manifestations of the disease preexisted the Veteran’s service. iii. If so, the examiner should state whether there was an increase in the severity during service. If the evidence reflects such an increase, the examiner should indicate whether any increase was due to the natural progression of the disorder or whether it represented a chronic worsening of the underlying pathology. b. For each diagnosis identified that is not congenital and/or did not preexist service, the examiner should opine as to whether it is at least as likely as not that the disorder is causally or etiologically related to the Veteran’s military service, to include any symptomatology therein. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) c. The Veteran’s September 2005 lay statement with regard to in-service exposure to toxic substances to include dust, plaster, and asbestos should be considered in responding to the above inquiries. See “Military Personnel Record,” received by VA on February 16, 2006. d. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state so and provide a rationale for this conclusion, including an explanation of whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion. (Continued on the next page.) 4. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and her representative an appropriate supplemental statement of the case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Bodi, 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.