Citation Nr: 21002014 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 14-19 615 DATE: January 12, 2021 ORDER Entitlement to service connection for left ear hearing loss disability is granted. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for gout is denied. Entitlement to service connection for a bilateral knee disability is denied. REMANDED Entitlement to service connection for sinus problems (claimed as sinusitis) is remanded. Entitlement to service connection for a back disability is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his left ear hearing loss is at least as likely as not related to noise exposure in service. 2. The preponderance of the evidence is against finding that the Veteran’s sleep apnea is secondary to service-connected bipolar disorder and is not otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that the Veteran’s gout began during active service, or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran’s bilateral knee disability began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for left ear hearing loss have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for gout have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1988 to March 1989 and from October 1989 to November 1991. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from September 2011 and October 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In April 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ); a transcript is associated with the claims folder. The Board remanded the issues on appeal for additional development in December 2017 and again in September 2019. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a left ear hearing loss disability is granted. The Veteran contends that his left ear hearing loss is related to acoustic trauma from service, to include noise exposure as an infantryman from vehicles, explosions, and artillery fire. See October 2016 VA Form 9; April 2017 Board Hearing. The Veteran also testified that his hearing loss began in service. Alternatively, he contends that his hearing loss is secondary to sinus problems. For VA compensation purposes, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The presumption of soundness applies in this claim. In general, every veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated. Only such conditions as are recorded in examination reports are considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). When no pre-existing medical condition is noted upon entry into service, a Veteran is presumed to have been sound upon entry. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227; VAOPGCPREC 3-03 (July 16, 2003) A National Guard enlistment examination in May 1988 for entrance onto active duty for training noted no audiological abnormality. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 5 15 25 LEFT 35 25 10 15 15 The audiologic findings do not constitute impaired hearing for VA purposes. In addition, a score of 1 was reported for H on the PUHLES physical profile, demonstrating non-defective hearing at this time. Service treatment records include an audiological evaluation conducted in October 1989. Pure tone thresholds, in decibels, from these evaluations do not reflect a hearing loss disability for VA disability purposes. PUHLES showed a hearing loss profile of H-1. A May 1991 medical evaluation board noted hearing within normal limits. A left ear hearing loss disability was note noted at discharge. At separation in June 1991 audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 10 10 LEFT 30 30 10 10 20 The Veteran’s DD Form 214 show that his military occupational specialty was in combat signal specialist. Based on the examination report at induction, the Veteran is presumed to have been sound upon entrance to active duty as defective hearing was not noted upon examination. The post-service treatment and VA examinations demonstrate a current diagnosis of left ear hearing loss which meets the criteria for a hearing disability for VA purposes. 38 C.F.R. § 3.385. See April 2011, October 2015, and December 2019 VA examinations. Given the current diagnosis and the noise exposure in service, the question before the Board is whether the Veteran has a current disability that began during active service or is related to in-service injury or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). On this question, there are probative opinions in favor of and against the claim. The evidence against the claim includes the April 2011 VA examination report. The examiner opined that the Veteran’s left ear hearing loss is less likely than not related to in-service noise exposure as service treatment records did not show a significant threshold change in either ear while in service. The examiner also noted that the Veteran’s left ear hearing loss is conductive in nature and not induced by high frequency noise. VA obtained another examination report in October 2015. The examiner indicated the entrance examination revealed mild hearing loss in the left ear and subsequent hearing exams showed stable puretone thresholds throughout active service. Further, the records showed perforation from a myringotomy tube that was placed after service and never closed properly. Thus, the examiner concluded that the Veteran’s hearing left ear hearing loss is more likely attributable to that pathology. The evidence in favor of the claim includes the most recent VA examination report obtained in December 2019. Although the examiner noted that the Veteran’s mild hearing loss was present in the left ear at time of enlistment with no significant changes in thresholds on separation exam, the examiner also opined that the Veteran’s claimed left ear hearing loss is at least as likely as not incurred in or caused by service. In reaching this conclusion, the examiner noted that the Veteran had a high probability for hazardous noise exposure given his military occupational specialty as “combat signaler,” lay statements, and other circumstances of service. The examiner also noted that the Veteran’s hearing loss is at least as likely as not due to his sinus/middle ear pathology given the abnormal findings on tympanogram, middle ear fluid, and air bone gaps present. Upon review of the record, the Board finds the VA examination reports to be probative. Each report was authored by an audiologist, with the appropriate training, expertise, and knowledge to evaluate the claimed disability. The examiners provided a thorough and cogent rationale for their findings and opinions. Given the above, the evidence to at least be in equipoise as to whether the Veteran’s current left ear hearing loss is related to hazardous noise exposure service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for left ear hearing loss is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for sleep apnea is denied. The Veteran asserts that his diagnosed sleep apnea is secondary to his service-connected psychiatric disorder. See October 2016 VA Form 9. At the April 2017 Board Hearing, the Veteran testified that his condition was related to exposure in the Gulf War or is a Gulf War illness. The Veteran also indicated that soon after his separation from service, the Veteran’s spouse told him that he was snoring, had night sweats, and would stop breathing during sleep. Generally speaking, 38 C.F.R. § 3.317 provides that a veteran of the Persian Gulf War may be entitled to VA benefits on a presumptive basis if he or she exhibits a “qualifying chronic disability” that manifests to a certain degree before December 31, 2021, and that cannot be attributed to any known clinical diagnosis. Atencio v. O’Rourke, 30 Vet. App. 74, 80 (2018). A qualifying chronic disability means a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(2). Service treatment records are silent for diagnosis, symptoms, or treatment for sleep apnea. The Veteran did complain of being sleep deprived as related to his bipolar disorder, the decreased need for sleep, and feeling not nearly sleeping at all. See May 1991 service treatment records. Nonetheless, issues related to sleep apnea were not noted on the Veteran’s June 1991separation examination and his June 1991 report of medical history. Post-service, the Veteran reported excessive daytime drowsiness, snoring, gasping, and witnessed episodes where he stopped breathing during sleep in the July 2014 VA treatment records. In August 2014, the Veteran completed a sleep study questionnaire. He reported symptoms that included insomnia, waking up coughing, and choking, which had been ongoing for a while. After completion of a September 2014 sleep study, the Veteran was diagnosed with obstructive sleep apnea. Pursuant to the Board’s Remand, the Veteran was afforded a VA examination in January 2020, with an accompanying VA medical opinion in January 2020. At the examination, the Veteran reported having had onset in the 1990s with sleep problems since he separated from service with nightmares and night sweats. The Veteran also reported that when he married in 1995, his wife complained of his snoring and that he quit breathing during his sleep. In the medical opinion, the examiner concluded that the Veteran’s sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the obstructive sleep apnea is due to physical obstruction of the airway. There is no medical evidence that establishes that burn pits cause such obstruction. Moreover, the Veteran’s sleep apnea was not caused by service-connected bipolar disorder as there is no medical evidence that his psychiatric disorder causes obstruction of airway while sleeping. In addition, the Veteran’s sleep apnea is effectively controlled by CPAP treatment, and thus it is not aggravated by any service-connected condition. Finally, the examiner noted that the Veteran’s lay statements are insufficient to establish onset of sleep apnea in service, noting that the Veteran stated that sleep apnea started approximate in time to his 1995 marriage, after his active duty term. The Board concludes that, while the Veteran has a current disability of sleep apnea, the preponderance of the evidence is against finding that the Veteran’s disability is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability, or related to an in-service injury or illness. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The Board finds the opinion of the January 2020 examiner to be probative because the examiner has the appropriate training, expertise and knowledge to evaluate the claimed disability. The examiner provided a thorough and cogent rationale for her findings and opinions, which included consideration of the Veteran’s reported symptoms both during and after service, and the post-service clinical history. Furthermore, there are no competent opinions to the contrary. Although the Veteran believes his sleep apnea had onset in service, is related to exposures in service, or is proximately due to or aggravated beyond its natural progression by service-connected bipolar disorder, he is not competent to opine on the matter. Although the Veteran is competent to report symptoms he observed in service and thereafter, he is not competent to relate the symptoms to his current diagnosis. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the January 2020 VA examination report. Finally, the Veteran has also asserted that service connection for sleep apnea is warranted as due to a “Gulf War illness.” In this regard, he is shown to have served in Southwest Asia. See DD 214. Therefore, he is shown to meet the criteria for a Persian Gulf veteran. See 38 C.F.R. § 3.317 (d). However, with regard to the application of 38 C.F.R. § 3.317, the Board finds that the provisions of the law regarding Persian Gulf War veterans are inapplicable. Sleep apnea is a known, medically diagnosed disease and therefore not an undiagnosed illness or manifestation of a medically unexplained multi-symptom illness, or included on the list of presumptive infectious diseases, and has been found to be less likely than not the result of his involvement in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317 (a)(1)(i)-(ii). In conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. As such, his claim for entitlement to service connection for sleep apnea must be denied. 3. Entitlement to service connection for gout is denied. The Veteran seeks service connection for gout, as manifested by debilitating pain. See April 2017 Board Hearing. Service treatment records are silent for complaints or symptoms related to gout. A June 1991 clinical evaluation noted no abnormalities of the lower extremities, spine, or other musculoskeletal. In the June 1991 report of medical history, the Veteran checked “no” to having had swollen or painful joints, and arthritis, rheumatism or bursitis. Although the Veteran complained of general joint pain in June 1993, the examination noted specific right foot swelling and tenderness associated with bumping against a van. The examination revealed no other musculoskeletal abnormality. Moreover, the post-service treatment records show the Veteran first had elevated uric acid levels many years after service. See e.g. July 2007 VA treatment record. Gout appeared on the Veteran’s list of medical problems in September 2005. See March 2015 VA treatment records. Similarly, in June 2012 VA treatment records, the Veteran reported taking medication for gout in the last five years (2007). The Board notes that intervening September 1996 VA general medical conditions examination was silent for gout or elevated uric acid levels. The Veteran was afforded a VA examination in May 2018. As noted in the Board’s prior remand, the examiner offered a negative opinion based on the inaccurate factual premise that there was no current condition. Thus, the Board remanded the claim for an adequate addendum opinion. Pursuant to the Board’s Remand, VA obtained an addendum opinion in January 2020. The examiner concluded that the Veteran’s gout is less likely than not related to service, to include as exposure to burn pits. The examiner reasoned that gout is a common inflammatory arthritis caused by elevated uric acid levels related to diet or lack of ability to excrete uric acid. There is no medical evidence to support environment exposures as a cause of elevated uric acid. Further, the examiner noted that there was no diagnosis of gout in service or within one year of service. Service connection is not warranted in this case. The service treatment records are negative for gout. A diagnosis of gout was not noted in service or within a year of discharge, and there was not continuity thereafter. The Veteran’s testimony did not establish with any specificity chronicity in service or continuity of symptoms since separation from service. Accordingly, 38 C.F.R. § 3.303 (b) does not provide an avenue of service connection based on chronicity or continuity of symptomatology. Service connection for arthritis may also not be presumed as a chronic disease under 38 C.F.R. §§ 3.307, 3.309(a). Moreover, the Board finds the January 2020 opinion is probative evidence against the claim. The examiner has the appropriate training, expertise and knowledge to evaluate the claimed disability. The examiner provided a cogent rationale for her finding and opinion. The claims file otherwise contains no competent opinions linking gout to service. To the extend the Veteran contends that his gout is related to service or had onset in service or within one year of separation, the Board accords more probative value to medical clinicians trained to perform testing and interpret testing results in relation to the diagnosis of gout. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Notably, the distinction between general complaints of pain and manifestation of gout require the ability to interpret diagnostic testing and knowledge of the musculoskeletal system. As noted above, the Veteran does not have the training or education to competently opine on the matter. In sum, the evidence weighs against a nexus between the Veteran’s current gout and active military service. Accordingly, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service connection is not warranted. 4. Entitlement to service connection for a bilateral knee disability is denied. The Veteran asserts that his knee disability began in service due to constantly wearing boots, running, carrying a rucksack and or 60 to 80 pounds of equipment, air assault jumps, and repelling. See April 2017 Board Hearing. Service treatment record notes a complaint related to his knees. In November 1988service treatment records, the Veteran complained of knee pain which had onset at least three weeks prior. He was given an assessment of knee pain. The Veteran’s June 1991 separation examination noted no abnormalities of the lower extremities. In the June 1991 report of medical history, the Veteran checked “no” to having had trick or locked knee, swollen or painful joints, or arthritis, rheumatism or bursitis. Post-service, the Veteran reported knee pain in December 1996. At that time, the Veteran reported knee pain that had been ongoing for three years, with no history of trauma. The impression was right knee degenerative joint disease and a recommendation for X-rays. Subsequent January 1997 X-rays showed no evidence of fracture, abnormality or effusion. The impression was of a negative right knee. Similar, negative findings were made in March 1998 imaging of both knees, March 2005 imaging of both knees, March 2009 imaging of the left knee, April 2011 imaging of both knees, and June 2014 imaging of both knees. It was not until May 2018 that imaging showed a diagnosis of mild patellofemoral and medial compartment degenerative arthropathy bilaterally, and small bilateral joint effusions. Nonetheless, the Veteran reported chronic knee pain with onset in service and was noted to have crepitus in June 2012. The Veteran was also given a diagnosis of chondromalacia patellae, which was associated with the Veteran’s medical records in March 1998. See September 2014 VA treatment records. The Veteran was afforded a VA examination in April 2011, May 2018 and January 2020. At the April 2011 VA examination, the examiner opined that it is unlikely that the Veteran’s minimal supratellar bursa effusion is related to military service as there was no documented complaint or treatment. As the Board noted in its December 2017 Remand, the opinion did not reflect adequate consideration of the Veteran’s report that knee symptoms began in service and continued thereafter. The May 2018 VA examination and opinion also offered a negative causal nexus opinion on the basis that there was no current findings. As noted in the Board’s September 2019 Remand, the medical opinion was based upon an inaccurate factual premise. The Veteran was most recently afforded a VA examination in January 2020. The examination noted diagnoses of left knee instability and bilateral suprapatellar bursitis. The Veteran reported that the symptoms of bilateral knee pain had onset in 1995 with progressive course since onset. In the accompanying January 2020 VA opinion, the examiner again relied on an inaccurate factual premise. In this instance, the examiner noted that the Veteran was already service-connected for bilateral knee condition diagnosed as suprapatellar bursitis and the current instability is a progression of the service connected condition. In doing so, the examiner noted that there is no objective evidence of degeneration at this time. VA obtained an addendum opinion in September 2020. The examiner opined that the current knee conditions of degenerative arthritis and left knee instability were less likely than not incurred in service. The examiner indicated that the Veteran was not diagnosed during service or within one year of discharge from service. The examiner noted that imaging in the years after service were negative, and complaints of general knee or toe pain were attributable to gout. Moreover, the examiner noted that the Veteran was engaged in laborious and physically demanding post-service occupation. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report having experienced symptoms of knee pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of his current diagnosis. The issue is medically complex, as it requires knowledge of the musculoskeletal system and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Moreover, the competent and objective post-service treatment records and imaging showed no findings consistent with his current diagnosis for years after service. Consequently, the Board gives more probative weight to the medical records and September 2020 VA opinion. Accordingly, the Board finds that the preponderance of the evidence weighs against a causal nexus between the Veteran’s knee disabilities and service. As such, the benefit of the doubt doctrine does not apply, and service connection is not warranted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND 1. Entitlement to service connection for sinus problems (claimed as sinusitis) is remanded. The Veteran asserts that his sinus problem is due to environmental exposures in the Gulf War. The Veteran testified that he had problems while deployed and has had continuing difficulties since onset in service. See April 2017 Board Hearing. Pursuant to the Board’s Remand, VA obtained a January 2020 examination and a January 2020 medical opinion. The examination report reflects the following information in Section II- Medical History, Details of onset: “The veteran stated that he had sinus trouble and rhinitis while he was deployed in 1990, exposed to burn pits.” On the same page, the following information is noted: “Date of onset: 1994. The veteran was unsure of when his symptoms started but according to a C&P exam dated 9-4-1996, the veteran stated that he had sinus trouble for the past 2 years and was going to have sinus surgery soon.” In the nexus opinion, examiner opined that the Veteran’s condition was less likely than not related to service. In particular, the examiner relied on the Veteran’s uncertainty as to onset at the current examination and the statements made at the September 1996 examination of sinus trouble since 1994. Consistent with the examiner’s findings, the Board notes that service treatment records do not reflect complaints of sinusitis. However, the examiner did not fully explain the clinical significance of the absence of such complaints in service/contemporaneous to burn pit exposure as it relates to determining causal nexus. Rather, the rationale appears to be limited solely to the absence of sinusitis complaints during service. On remand, the examiner is asked to provide an addendum opinion that explains the significance of the delayed onset of sinusitis symptoms as it relates to the current diagnosis of sinusitis and environmental exposures during the Gulf War. 2. Entitlement to service connection for a back disability is remanded. The Veteran asserts that his back disability is due to the rigors of service. See April 2017 Board Hearing. Specifically, the Veteran testified that he constantly wore combat boots, ran, carried a rucksack, made air assault jumps, and repelled in service. At the May 2018 VA examination, the Veteran reported that back pain had onset in service and continued thereafter. Upon review of the evidence, the Board notes that May 2018 imaging showed mild to moderate degenerative disc disease and degenerative joint disease. As noted in the prior Board Remand, the May 2018 and May 2019 VA examinations considered the Veteran’s low back pain and diagnosis of lumbar strain. However, the examination reports did not sufficiently consider the Veteran’s diagnoses of degenerative disc disease and degenerative joint disease, shown in May 2018 imaging. As such, the Board remanded the claim for an addendum opinion that considered the Veterans’ other diagnoses, to include degenerative disc disease and degenerative joint disease. VA obtained an examination in January 2020 and an addendum opinion in January 2020. The examiner concluded that the Veteran’s claimed lumbar spine degenerative arthritis was less likely than not incurred in service. In doing so, the examiner indicated that she found no X-ray report which indicated the presence of degenerative disease process of his spine. There is no specific reference to the May 2018 imaging. This indicates that the examination report was not based on the full and accurate facts/history of this case. Upon remand, VA should obtain an opinion that is based on the full and accurate history of the case. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s sinus disability. The examiner is asked to indicate whether it is at least as likely as not (50 percent or better probability) that the Veteran’s sinus conditions, to include sinusitis and rhinitis, had onset in service or are otherwise related to service, to include environmental exposures during the Gulf War. In discussing the rationale, the examiner is asked to address the significance, if any, of the delayed onset of sinusitis/rhinitis symptoms as it relates to the current diagnoses and the Veteran’s environmental exposures (burn pits) during the Gulf War. 2. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s back disability. The examiner should review the claims file and a copy of this remand. The examiner is advised that the VA treatment records include May 2018 lumbar spine imaging where findings included, “1. Mild to moderate DDD and DJD at T10-11 and L5-S1. 2. Mild DDD and DJD extending from the T11-12 through the L4-5 disc levels.” (a) The examiner is asked to indicate whether it is at least as likely as not (50 percent or better probability) that the Veteran’s current lumbar degenerative disc and joint disease is related to service, to include as due to rigors of military service which reportedly included wearing boots, running, repelling and often carrying 60 to 80 pounds of equipment. (b)The examiner should also opine as to whether it is at least as likely as not that the Veteran’s lumbar degenerative joint disease (arthritis) had onset in service or manifested within one year of service discharge. A complete rationale for the requested opinions should be provided. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Vuong, 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.